Lower Respiratory Tract Infections (LRTIs)

BRONCHITIS

Bronchitis is a self-limited inflammation of the bronchi. Acute bronchitis must be

distinguished from chronic bronchitis where patients have a cough for more than 3
months.
Pathophysiology

The coughing is so characteristic of bronchitis, it is an attempt to clear the mucus

produced by the inflammatory response to viral infection. Bronchitis occurs more
often in the winter months than in the summer. Smoking predisposes to bronchitis
(and pneumonia) by damaging the cilia in the bronchi, leading to an inability to clear
mucus from the respiratory tract. Bronchitis is self-limited and usually resolves in 1 to
2 weeks. However, cough may persist for several more weeks due to airway
hyperreactivity.

Clinical Manifestations

Cough, Symptoms of an upper respiratory infection ( nasal congestion, scratchy sore

throat, and perhaps a low-grade fever) and expiratory wheezes. However, if cough
persists for more than 5 days and pneumonia has been ruled out, acute bronchitis
should be suspected.

Pathogens

 Respiratory viruses
1. Influenza A and B
2. Parainfluenza virus
3. Coronavirus
4. Rhinovirus
5. Respiratory syncytial virus [RSV]
6. Human metapneumovirus.
 Bacterial pathogens are not play a significant role in acute bronchitis.

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Diagnosis and treatment

The diagnosis is primarily made clinically. Sputum cultures are typically not done.

In patients with chronic cardiorespiratory disease, a rapid antigen test for influenza
virus may be useful because Tamiflu can shorten the duration and intensity of
symptoms.

Treatment of both upper respiratory infections and acute bronchitis is largely

supportive. So, It is very important clinically to distinguish acute bronchitis (usually
viral) from pneumonia (mainly bacterial), which does require antimicrobial therapy. A
chest radiograph may be performed to determine whether pneumonia is present.

Treatment involves reassurance and symptom relief with agents such as nonsteroidal
anti-inflammatory drugs and/or a bronchodilator. If influenza is diagnosed, Tamiflu
may reduce the length and severity of symptoms. Antibiotics should be used only in
those for whom a bacterial etiology has been clearly demonstrated.

Prevention

Influenza vaccine can prevent bronchitis and pneumonia caused by influenza A and B
viruses

. Tamiflu should be given to unimmunized‫ غ<<ير المطعمين‬individuals with chronic

cardiorespiratory disease.

Handwashing is recommended to reduce the carriage of respiratory viruses.

2- BRONCHIOLITIS

Bronchiolitis is inflammation of the bronchioles with a diameter of less than 2mm.

Pathophysiology

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Particularly among children under 2 years of age, viruses can directly damage the
epithelial cells of the terminal bronchioles, causing inflammation and obstruction of
the small airways. Prematurity is an important predisposing factor.

Clinical Manifestations

Usually children initially have symptoms consistent with an upper respiratory tract
infection and then are noticed to have increased respiratory distress. Children under 2
years old in particular may have tachypnea, wheezing, nasal flaring, and chest
retractions. In severe cases, hypoxia, apnea, and respiratory failure may ensue. In most
cases, recovery occurs in 1 to 2 weeks.

Pathogens

In children, viruses are the main etiology of bronchiolitis. Bacteria are not thought to
be involved. The main viral causes are

1. RSV is the most common pathogen.

2. influenza virus
3. parainfluenza virus
4. adenovirus
5. coronavirus
6. rhinovirus
7. human metapneumovirus.
In adults, the causes are more varied and range from viruses, to inhaled toxic
chemicals in the workplace, to idiopathic causes. Bronchiolitis caused by RSV occurs
primarily in the winter months.

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Diagnosis

The diagnosis is primarily clinical. Upper respiratory tract infection symptoms

followed by lower respiratory tract symptoms and signs (e.g., nasal flaring‫حرقة‬,
wheezing) in a young child during the fall ‫خريف‬and winter would be very suggestive
of bronchiolitis. Chest radiograph typically shows hyperinflation of the lungs. An
enzyme immunoassay (EIA) for RSV antigen in respiratory secretions. A polymerase
chain reaction (PCR) assay that detects the RNA of RSV .

Treatment

Because this is a self-limited disease in most cases, general supportive measures are
adequate in most cases. Patients with moderate or severe respiratory distress will
require hospitalization. Ribavirin, delivered by aerosol into the lungs, is approved for
severe disease caused by RSV, but its use is limited to hospitalized infants. Inhaled
bronchodilators (albuterol or epinephrine) may be useful.

Prevention

1. Handwashing to minimize transmission of pathogens is an important strategy.

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2. Infection control procedures should be instituted in hospitalized patients to

prevent the spread of viruses to others.
3. monoclonal antibody against the RSV F (fusion)
4. There is no viral vaccine against RSV.

3- PNEUMONIA

Pneumonia is an inflammation of the lung parenchyma affecting the alveoli. There are
different types of pneumonia and it is important to consider the type to help determine
the spectrum of potential pathogens that differs based on setting. More importantly,
because empiric therapy is often given in pneumonia, therapeutic interventions differ
based on the different populations. Pneumonia may include:

Community-acquired pneumonia(CAP)

CAP is a serious illness. It is a most common cause of death it is caused by the typical
bacterial pathogens. It is an acute infection of lung tissue with onset outside of hospital
or within 48 hours of admission to hospital. The British Thoracic Society Definitions
for diagnosis are:

In community
• Cough PLUS one other lower respiratory tract symptom
• New focal chest signs on examination Focal chest signs: decreased chest expansion,
dullness on percussion, decreased entry of air, bronchial breathing, and crackles

One systemic symptom
• No other explanation
In hospital (<48 hours)
• Symptoms and signs consistent with pneumonia
• New chest X-ray shadowing

Clinical Features

Respiratory symptoms and signs Systemic symptoms

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• Cough
• Shortness of breath
• Purulent sputum • Fever
• Chest pain • Sweats
• Chest signs of consolidation
  - Reduced chest movement • Shivers
  - Dull percussion • Aches
  - Bronchial breathing
  - Increased tactile vocal fremitus & • Pains
vocal resonance
In Children

• Fever
• Increased respiratory rate
• Cough
• Recession
• Chest pain or pain referred to abdomen
Assessment of Severity
C = Confusion (new)
U = Urea >7mmol/L
R = Respiratory Rate >30/min
B = Blood pressure <90mmHg systolic OR 60mmHg diastolic
65 = Age >65 years
Score = 1 each per criteria e.g. C + R + >65 = 3

Common Causes

• Staphylococcus aureus
• Streptococcus pneumoniae
• Haemophilus influenzae
• Mycoplasma pneumoniae
• Legionella pneumophila (especially if travelled)
• Chlamydia pneumoniae
• Viral e.g. Influenza Virus, Parainfluenza Virus, Respiratory Syncytial
Virus (RSV), Adenovirus and Coronavirus.

Note that the causes of pneumonia in a neonate are those acquired during passage

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through the birth canal. The main cause of pneumonia in an infant, Chlamydia
trachomatis, is also acquired during passage through the birth canal but is a less
aggressive pathogen so its onset in delayed.
If history of COPD, as above plus:
• Pseudomonas aeruginosa
If aspiration, as above plus:
• Anaerobes e.g. Bacteroides  sp., Fusobacterium  sp.
If zoonotic
• Chlamydiapsittaci (from parrots and budgerigars), MERS, 2019-nCoV
If empyema
• Staphylococcus aureus
• Streptococcus pneumoniae
• Streptococcus anginosus group

Diagnosis and treatment

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Total Duration
7 days
Empyema requires drainage and 2-4 weeks total treatment
Up to 40% of patients with Streptococcus pneumoniae reactivate Herpes
Simplex Virus (HSV) leading to cold sores.
Switch to Oral Therapy : Improvement in cough and dyspnea
AMOXICILLIN Capsules: 250 mg or 500 mg (as trihydrate)
TRIMETHOPRIM-SULFAMETHOXAZOLE(COTRIMOXAZOLE)

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Note: Adverse Reactions of TRIM; CNS: Headache; depression; seizures.

GI: Nausea; vomiting; anorexia; abdominal pain; diarrhea; Stevens-Johnson syndrome

Prophylaxis and Prevention

-No roll for antibiotics to prevent recurrence.
-Vaccine against Streptococcus pneumoniae
-Vaccination of children reduces exposure and hence infection in adults by
decreasing reservoir of bacteria in community

Hospital-acquired pneumonia (HAP)

HAP, also called nosocomial pneumonia, is a lung infection acquired after

hospitalization for another illness or procedure. Hospitalized patients have a variety of
risk factors for pneumonia, including mechanical ventilation, prolonged malnutrition,
underlying cardiac and pulmonary diseases, achlorhydria and immune disorders.
These pathogens include resistant aerobic gram-negative rods, such as Pseudomonas ,
Enterobacter and Serratia, resistant for Antibiotics used for hospital-acquired
pneumonia include aminoglycosides, fluoroquinolones, carbapenems, and
vancomycin. Gram positive cocci, such as MRSA. 

Rout of infection: Inhalation, aspiration and hematogenous spread.

Aspiration Pneumonia

This type of pneumonia can occur during inhalation of food, drink, vomit, or saliva
from mouth into lungs. This may happen in cases such as a brain injury, swallowing
problem, or excessive use of alcohol or drugs. Aspiration pneumonia can lead to a
lung abscess.

Atypical Pneumonia

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Several types of bacteria—Legionella pneumophila (Legionnaire's

disease), mycoplasma pneumonia, and Chlamydophila pneumoniae—cause atypical
pneumonia, a type of CAP. Atypical pneumonia is passed from person to person

Predisposing factors are:

 Exposure to a virulent organism or inhalation of a large number of organisms

from the environment
 aspiration of organisms from the oropharynx
 defect in host immunity including the extremes of age (the very young and very
old), chronic obstructive pulmonary disease (COPD) and chronic bronchitis,
diabetes mellitus, cystic fibrosis, and congestive heart failure. Injection drug
users who overdose, alcoholics, and patients with seizure disorders because they
can aspirate organisms into the lung when unconscious.
 People exposed to water aerosols, especially from air conditioners, are at risk
for pneumonia caused by Legionella. Hospitalized patients in the intensive care
unit are at risk for ventilator-associated pneumonia (VAP) caused by gram
negative rods such as Escherichia coli, Pseudomonas, and Acinetobacter.

Clinical Manifestations

Symptoms include cough that may be productive of sputum, fever, chills, chest pain,
and shortness of breath. “Rusty” sputum is a well-known finding in pneumococcal
pneumonia. Sputum that has a “currant jelly” appearance occurs in pneumonia caused
by Klebsiella because the organism is heavily encapsulated. Physical examination
findings include tachypnea, rales, and rhonchi. If the lung is consolidated, dullness to
percussion may be detected. Patients who are intubated and who acquire a nosocomial
pneumonia may only have fever as a presenting sign, which may be accompanied by
increased respiratory secretions or increased oxygen requirements. Pneumonia may be
complicated by an infected pleural effusion or a pleural empyema. A pleural empyema
is a walled-off collection of pus in the pleural space.

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