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Summary Pulmonology- Internal Medicine
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Pulmonology for medical students.
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1. Acute bronchitis. Tracheobronchitis. Bronchiolitis.Acute bronchitis
De nition: Short term in ammation of the bronchi.
Etiology:
- pathogens
- viruses: respiratory syncytial virus, rhinovirus, in uenza
- bacteria ( uncommon): M. pneumoniae, Chlamydophila pneumoniae, Bordetella pertussis,
Streptococcus pneumoniae, H. in uenzae
Pathophysiology:
- Damage caused by irritation of the airways leads to in ammation and leads to neutrophils
in ltrating the lung tissue.
- Mucosal hypersecretion is promoted by a substance released by neutrophils.
- Further obstruction to the airways is caused by more goblet cells in the small airways. This is
typical of chronic bronchitis.
- Although infection is not the reason or cause of chronic bronchitis, it is seen to aid in sustaining
the bronchitis.
Clinics:
- productive cough that may be purulent
- retrosternal chest pain
- dyspnea
- wheezing
- upper respiratory tract infections often precede acute bronchitis: headache. nasal congestion,
sore throat
Diagnosis:
Physical examination
- auscultation: wheezes, decreased intensity of breath sounds, rhonchi, prolonged expiration
- percussion: dullness suggests disease extension beyond bronchi
Radiology:
- chest x- ray to exclude pneumonia: common in patients with fever, tachycardia and tachypnea
Labs:
- sputum sample: neutrophil granulocytes; culture: pathogenic microorganisms
- blood test: increased leukos, increased CRP
Treatment:
- self resolution in a few weeks
- salbutamol as bronchodilator
- NaCl inhalation ( 3%)
- mucolytics ( e.g ACC)
- antibiotics in superinfection
- fever: paracetamol; NSAIDS
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, Tracheobronchitis
De nition: In ammation of the trachea and bronchi.
Etiology:
- pathogens
- viruses: in uenza, rhinovirus, adenovirus, parain uenza, measles
- bacteria (uncommon): Chlamydia pneumoniae, Mycoplasma, Bordetella pertussis
- in patients with already existing pulmonary diseases (e.g. COPD) a superinfection through a
bacterium ( strept. pneumoniae, haemophilus in uenzae, moraxella catarrhalis) follows a viral
infection
Clinics:
- dry cough
- retrosternal chest pain
- hoarseness-> laryngitis
- hypersecretion after a few days leading to productive cough ( purulent) and hemopytsis
- green productive cough is an indicator for superinfection
Diagnosis:
Physical examination
- auscultation: wheezes, rhonchi, prolonged expirium
Labs
- sputum: pathogens
- blood test: increased leukos, increased CRP
Radiology:
- chest x- ray to exclude pneumonia
Treatment:
- self resolution in 8- 10 days
- painful and dry cough: codeine
- productive cough: mucolytics (e.g. ASS)
- bacterial superinfection: antibiotics
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, Bronchiolitis
De nition: Blockage of the small airways in the lungs due to a viral infection. It usually occurs in
children less than 2 years of age.
Etiology:
- viruses: respi. syncytial virus, metapneumovirus, in uenza, parain uenza, coronavirus,
adenovirus, rhinovirus and mycoplasma
Risk factors:
Children are at an increased risk for progression to severe respiratory disease if they have any of
the following additional factors:
- Preterm infant (gestational age less than 37 weeks)
- Younger age at onset of illness (less than 3 months of age)
- Congenital heart disease
- Immunode ciency
- Chronic lung disease
- Neurological disorders
- Tobacco smoke exposure
Clinics:
- fever
- rhinorrhea
- cough
- wheezes
- tachypnea
- increased work of breathing
- severe:
- poor feeding (less than half of usual uid intake in preceding 24 hours)
- signi cantly decreased activity
- history of stopping breathing
- respiratory rate >70/min
- presence of nasal aring and/or grunting
- severe chest wall recession (Hoover's sign)
- bluish skin
Diagnosis: typically made by clinical examination!
Physical examination
- auscultation: wheezes, rhonchi
Labs: following are not routine but used in kids with comorbidities.
- blood testing
- electrolyte analysis
Radiology:
- chest x- ray to exclude bacterial pneumonia
DD:
- Asthma and reactive airway disease
- Bacterial pneumonia
- Congenital heart disease
- Heart failure
- Whooping cough
- Allergic reaction
- Cystic brosis
- Chronic pulmonary disease
- Foreign body aspiration
- Vascular ring
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, Treatment:
Treatment of bronchiolitis is usually focused on the hydration and symptoms instead of the
infection itself since the infection will run its course and complications are typically from the
symptoms themselves. Without active treatment, half of cases will go away in 13 days and 90% in
three weeks. Children with severe symptoms, especially poor feeding or dehydration, may be
considered for hospital admission. Oxygen saturation under 90%-92% as measured with pulse
oximetry is also frequently used as an indicator of need for hospitalization. High-risk infants,
apnea, cyanosis, malnutrition, and diagnostic uncertainty are additional indications for
hospitalization.
Most guidelines recommend su cient uids and nutritional support for a ected
children.Measures for which the recommendations were mixed include nebulized hypertonic
saline, nebulized epinephrine, and nasal suctioning. Treatments which the evidence does not
support include salbutamol, steroids, antibiotics, antivirals, heliox, continuous positive airway
pressure (CPAP), chest physiotherapy, and cool mist or steam inhalation.
- oxygen may be applied
- diet: nasogastric tube or i.v. uids to sustain hydration
- hypertonic saline
- bronchodilators
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