Bronchitis, Pneumonia, and Pleural Empyema Katay Bouttamy DO Tintinalli Chapter 63

Acute Bronchitis Definition: an acute respiratory tract infection with cough being the predominant feature Usually lasts 1 to 3 weeks, peaks between October and March Viruses cause the vast majority of cases: Influenza A and B, parainfluenza, and RSV are the most common

Acute Bronchitis Bordetella pertussis, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella species are reported in 5-25% of cases Clinical features: cough and wheezing are the strongest positive predictors, less than 10% of patients are febrile

Acute Bronchitis Diagnosis: (1) acute cough less than 1-2 weeks (2) no prior lung disease (3) no auscultatory abnormalities that suggest pneumonia Treatment: studies have failed to show significant improvement with Abx therapy and at best may decrease duration of cough, decrease purulent sputum production and return patients to work < 1 day each

Acute Exacerbation of Chronic Bronchitis Two-thirds are bacterial in origin (H. flu, Strep pneumo, M. Catarrhalis) High risk patients are the elderly and those with poor lung function and with comorbid conditions Characterized by increased dyspnea, increased cough and sputum production and purulence with underlying COPD Treatment includes doxycycline, extended spectrum cephalosporin, macrolide, augmentin or fluoroquinolone

Pneumonia CAP is 6th leading cause of death Studies of both inpatients and outpatients with CAP fail to identify a specific pathogen in 40-60% of patients but when found pneumococcus is still the most common

Pneumonia Typical presentation of pneumococcal pneumonia is sudden onset of fever, rigors, dyspnea, bloody sputum production, chest pain, tachycardia, tachypnea and abnormal findings on lung exam Some of the atypicals are associated with headache and GI illness

Other bacterial pneumonia Staph aureus is a consideration in patients with chronic lung disease, laryngeal CA, immunosuppressed patients, NH patients; chest Xray usually shows extensive disease with empyema, effusion or multiple areas of infiltrate

Other bacterial pneumonia Klebsiella occurs in patients at risk at aspiration, alcoholics, elderly and other patients with chronic disease; may develop abscesses but often have lobar infiltrates Pseudomonas not a typical cause of CAP and usually associated in patients who have prolonged hospitalization, have been on broad-spectrum Abx, high-dose steroids, structural lung disease or NH patients

Other bacterial pneumonia H. flu seen in elderly and should be considered in patients with COPD, sickle cell disease or immunocompromised disorders M. catarrhalis similar to H. flu

Atypical Pneumonia Legionella should be considered in cigarette smokers, persons with COPD, transplant patients and immunosuppressed patients; commonly complicated by GI symptoms including abdominal pain, vomiting and diarrhea Chlamydia usually causes a mild subacute illness with sore throat, mild fever, and NP cough

Atypical Pneumonia Mycoplasma occurs year round and causes a subacute respiratory illness and occasionally causes extrapulmonary symptoms including bullous myringitis, rash, neurologic symptoms, arthritis, hematologic abnormalities and rarely renal failure

Pneumonia in Special populations Alcoholics: Strep pneumo still most common but Klebsiella and H. flu are important pathogens Diabetics: patients between 25-64 are 4 times more likely to have pneumonia Pregnancy: more likely to experience preterm labor, preterm delivery and deliver a low birthweight infant

Pneumonia in Special populations Elderly: 3 times more likely to have pneumococcal bacteremia, mortality is 3-5 times greater than those younger than 65, have atypical symptoms (afebrile, c/o weakness, falling, GI symptoms, delirium, confusion) and up to 1/3 will not manifest leukocytosis

Nursing-Home acquired Pneumonia Patients are less likely to have productive cough or pleuritic chest pain and more likely to be confused and have poorer functional status and more severe disease 8 independent predictors of pneumonia: increased pulse, RR>30, T>100.4, somnalence or decreased alertness, acute confusion, lung crackles, absence of wheezes and increased WBC

Treatment Outpatient: doxycycline, newer macrolide or fluoroquinolone Hospitalized: evidence indicates that early administration (within 8 hrs of presentation) leads to lower mortality rate and hospital stay, therapy should be initiated with 2-3rd generation cephalosporin or PCN plus beta-lactamase inhibitor, with a macrolide. Coverage can also be provided with newer fluoroquinolone.

Disposition Estimated 75% of patients with CAP do not require hospitalization, many factors influence prognosis and outcome Fine’s prediction rules can be used to estimate risk of death and ICU placement (does not include patients from NH or hospital setting and HIV patients)

Disposition PSI score of I, II, III generally have low mortality and mortality jumps between III and IV Forest study looked at clinical judgement vs PSI alone to determine need for hospitalization: many people with low PSI need to be admitted for other reasons (noncompliance, inability to eat or drink, unmet social needs, failed outpatient Tx)

Empyema Pleural effusions are present on X-ray of 20-60% of patients with bacterial pneumonia and often resolve with antibiotic therapy Risk factors: aspiration, immunocompromised patients with gram neg bacteria, fungal infections, TB or malignancy

Empyema Exudative stage: free flowing pleural fluid, very amenable to treatment with closed tube drainage Fibrinopurulent stage: formation of fibrin strands through the pleural fluid resulting in loculations, makes adequate drainage with single chest tube unlikely Organizational stage: fibrosis is much more extensive forming a pleural peel that restricts expansion even if fluid can be evacuated

Empyema Decub films will be helpful in determining if fluid is free flowing or loculated Pleural fluid that is gross pus with positive cultures or gram stain is considered empyema along with other findings: pH<7.1, glucose<40 and LDH>1000

Empyema Treatment: drainage of pus by chest tube, reexpansion of lung and eradication of the infection. Treatment of organizational stage requires surgical intervention with removal of the fibrous peel

Questions 1. All are true of Acute Bronchitis except: a. Peaks from October and March b. Viruses are the majority of cause c. Strep pneumo is a major cause if it is bacterial in etiology d. Less than 10% of patients are febrile

Questions 2. A 45 yo male presents with sudden onset of fever, rigors, shortness of breath and rust colored sputem. The most likely cause is: a. H. Flu b. Legionella c. Strep pneumo d. M. catarrhalis

Questions 3. The most common cause of CAP in an HIV patient is: a. Strep pneumo b. Tuberculosis c. H. Flu d. Pneumoncystis carinii

Questions 4. T or F: Klebsiella is the most common cause of CAP in alcoholics. 5. A 57 yo male presents with nonproductive cough, fever of 102, dyspnea and diarrhea. His labs show a WBC of 18,000 and Na of 129. The most likely cause is: a. H. Flu b. Strep pneumo c. Mycoplasma d. Legionella

Answers 1. C 2. C 3. A 4. False 5. D