Pneumonology

Chronic obstructive pulmonary disease

• chronic cough

• dyspnea

• Sputum production

• airflow limitation

Usually on smokers > 40yo

Chronic bronchitis

• chronic inflammation - mucociliary dysfunction - increased globet cell amount and secretion - excessive mucous production

• Chronic obstruction - during respiration less O2 comes in and less CO2 comes out - decreased O2 in blood and increased CO2

• Alveolar hypoxia - constriction of pulmonary vessels to shunt blood to healthier alveoli - pulmonary hypertesion:

  • backflow of blood to right side of the heart - right sided heart failure - cor pulmonale - increased JVP

  • decreased LV output - decreased circulatory volume - activation of RAAS - more fluid retention (even though there’s no lack of fluid in the body)

Emphysema

• Inflammatory response - elastin breakdown - loss of alveolar integrity (air trapping)

• Proteases (from macrophages and neutrophils) break down elastin - decrease in elastic recoil (low ventilation) and destruction of capillary beds (low perfusion):

  • Matched V/Q defecide- low O2 high CO2

  • low elastic recoil (loss of alveolar integrity and desctruction of alveolar wall) - increased work of breathing - dyspnea and cachexia

• alpha 1 antitripsin deficiency - increased proteases - …

Common symptoms: exertional dyspnea, chronic cough w/ mucoid sputum, fatigue, weight loss in advanced stages

Exacerbations: intermittent worsening of symptoms, triggered by infections or environmental factors

heterogenous disease of chronic airway inflammation:

• wheezing

• dyspnea

• chest tightness

• cough that varies in intensity over time

• airflow limitations

• Intermittent

  • Symptoms: <2/week

  • Night symptoms: <2/month

• Mild persistent

  • Symptoms: <7/week

  • Night symptoms: 3-4/month

• Moderate persistent

  • Symptoms: everyday

  • Night symptoms: 5+/month

• Severe persistent

  • Symptoms: continuous

  • Night symptoms: frequent

• Allergic asthma

• Non-allergic asthma

• adult-onset asthma

• asthma w/ persistent airflow limitation

• asthma in obesity

• Mild

  • Status: Controlled

  • Step: 1 and 2

• Moderate

  • Status: Controlled

  • Step: 3 and 4

• Severe

  • Status: Uncontrolled

  • Step: w/ ICS-LABA

Inflammatory condition of the lung primarily affecting the alveoli of infectious etiology

• Community acquired pneumonia (CAP)

  • Typical or atypical

• Hospital acquired pneumonia (HAP)

  • early or late

• Ventilator-associated pneumonia (VAP)

  • >48H after intubation

• Healthcare associated pneumonia (HCAP)

  • healthcare facilities or nursing homes

• Lobar pneumonia

  • dense alveolar infiltration in one or 2 lobes

• Interstitial pneumonia

  • infiltratation of interstitium

  • bilateral reticular or micronodular changes

• Bronchopneumonia

  • Alveoli and bronchioles

  • patchy infiltrate

• Thromboemboliti pneumonia

• Viral

  • Influenza, COVID-19, etc.

• Bacterial

  • Typical: S. pneumonia, H. influenzae, S. aureus, K. pneumoniae

  • Atypical: Mycoplasma pneumoniae, L. pneumophilia, chlamidia pneumoniae, tuberculous pneumonia

• Fungal

  • aspergilus species

Complaints:

• Dyspnea, tachypnea, cough (productive or dry)

• Fever

• Sputum: yellow, green, brown, bloody

• Severe malaise, pleuritic chest pain

On examination:

• Crackles, pleural effusion, diminished lung sounds, dumm percussion

PNEUMONIA SEVERITY INDEX

• estimates mortality in adults based on risk factors

CURB-65

• estimates if treatment should be in or outpatient

• Anamnesis and physical exam

• Labs

  • Inflammatory markers (CRP, ESR, serum procalcitonin in bacterial…)

  • CBC, urea, glucose, Na+, Liver function, albumin

  • ABG: respiratory insufficiency susp.

• X ray (CT if inconclusive)

• Microbiological diagnosis

  • Blood cultures, sputum cultures, throat swabs, BA lavage

  • Urine antigens: legionella and S. pneumoniae

In europe:

• Outpatient: amoxicillin

• Inpatient not in ICU; moderate severity: Amoxicillin plus macrolide

• Inpatient in ICU; high severity: β-lactamase stable β-lactams¶ plus macrolide

• vaccination

• hygiene protocols

• screening for MRSA

• early mobilization and extubation

• prevent aspiration: upright position after meals

• decontamination of GI tubes

Lungs are unable too efficiently exchange gases:

• hypoxemia (decreased O2)

• hypercapnia (elevated CO2)

Hypoxemia:

PaO2 <60mmHg

Hypercapnia:

PaCO2 >50mmHG

TYPE 1 ARF

• Partial respiratory insufficiency

• Low O2+ low or normal CO2

• pO2 <60mmHg

• Impaired gas exchange at the alvelar-capillary memebrane

TYPE 2 ARF

• Global respiratory insufficiency

• Low O2 + high CO2

• pCO2 >50mmHg

• Inadequate alveolar ventilation

Supportive measures:

• Correction of hypoxemia

  • Goal: PaO2 = 60mmHg or SpO2 of 90%

• Correction of hypercapnia

  • treat underlying cause

• Ventilation support

  • invasive or non-invasive

• Permissive hypercapnia

  • allows CO2 levels to remain elevated to minimize ventilator-associated lung injury

expectoration of blood:

• bronchial arteries

• pulmonary arteries

Pulmonary artery circulation

• Low pressure system - supplies lung parencyma (alveoli)

• Majority of non-life-threatening hemoptysis

Bronchial artery circulation

• High pressure system - supplies endotracheal tree (airways and bronchial structures

• Majority of life-threatning hemoptysiss

Non-life-threathning hemoptysis

• Acute bronchitis (during flair ups)

• Bronchiectasis (during flair ups)

• Bronchial neoplasms (later stages)

Life-threatening hemoptysis

• bronchiectasis (if ruptured bronchial artery)

• tuberculosis

• fungal infections

• bronchogenic carcinoma (especially if large centrally located tumor)

Build up of fluid in between the pleural layers (pleural space)

• Transudate (watery)

  • gradual start, dyspnea, cough, edema, ascitis

  • imbalance in hydrostatic and osmotic pressures

• Exudate (protein rich)

  • acute or subacute start, pain, fever, dyspena, cough

  • changes in pleura, inflammation, damage, infections, cancer

Transudative pleural effusion

• Heart failure

• liver cirrhosis

• nephrotic syndrome

• peritoneal dialysis

• hypoalbuminuria

• pulmonary embolism

Exudative pleural effusion

• pneumonia

• cancer

• tuberculosis

• pulmonary embolism

• trauma

• autoimmune diseases

LIGHT’S CRITERIA

For transudative: diuretics, thoracentesis, manage Ex

Exudative: a/b, thocacostomy, fibrinolytic therapy, pleurodesis, surgery

restrictive intrinsic diffuse parenchymal of unknown ex

chronic, progressive lung disease of unknown ex: (restrictve lung disease)

• lung scarring (fibrosis)

• Interstitial pneumonia pattern on chest imaging

• >60yo

May result from repeated injury to the lung tissue with improper healing

immunologically driven lung condition - repeated inhalation of organic or chemical agents:

• damaged alveoli, bronchioles, lung interstitium

• untreated: irreversible lung damage

• avian protein

• fungi

• mucobacterium avium complex

• male rat urine protein

• aquatic animal protein

• molds

prednisolone

Small clusters of cells (granulomas) form in organs

• can cause inflammation and tissue damage

• 20-60yo