Lower respiratory tract Infection

1. Bronchitis 2.Bronchiectasis 3.Cystic fibrosis

1.Bronchitis

Bronchitis is inflammation of the breathing tubes. These airways are called bronchi. This
inflammation causes increased mucus production and other changes.

Bronchitis is an inflammation of the bronchial tubes, the airways that carry air to your lungs. It
causes a cough that often brings up mucus. It can also cause shortness of breath, wheezing, a low
fever, and chest tightness.

Common symptoms: fever, cough, sputum production, and rarely croup- like features (an
infection of the upper airway).

Bacterial agents Viral agents

1. B. pertussis 1. Influenza viruses

2. B. parapertussis 2. Adenoviruses

3. Mycoplasma pneumonia 3. Rhinoviruses

4. Chlamydophila pneumonia 4. Coronaviruses

There are two main types of bronchitis:

1. Acute bronchitis 2. Chronic bronchitis

1. Acute bronchitis
Acute bronchitis may also be called a chest cold. Most symptoms of acute bronchitis last for upto
2 weeks. The cough can last for up to 8 weeks in some people.

Causes of acute bronchitis:

 Viral infection
 Bacterial infection
 Physical or chemical agents (dusts, allergens, and strong fumes, including those from
chemical cleaning compounds or tobacco smoke.)
 A common cold or other viral infections in the upper respiratory tract.
 People with chronic sinusitis
 Allergies
 With enlarged tonsils and adenoids (the adenoids are a mass of soft tissue behind the
nasal cavity)
  It can be serious in people with lung or heart diseases.

Complications:
Acute bronchitis can worsen and progress to chronic bronchitis or pneumonia.
Pneumonia is a complication that can follow bronchitis.

Symptoms:

1. Back and muscle pain 7. Runny nose

2. Cough, first dry (non-productive), later, 8. Slight fever
a lot of mucus is produced 9. Shortness of breath
3. Chest soreness 10. Sore throat
4. Chills 11. Watery eyes
5. Feeling tired and achy 12. Wheezing
6. Headache

Diagnosis:
Chest X-rays: Are normal in acute bronchitis.
A chest X-ray can help determine if you have pneumonia or another condition that may explain
your cough.
Pulse oximetry: The pulse oximeter, or Pulse Ox, is an electronic device that measures the
saturation of oxygen carried in red blood cells.
Cultures of nasal discharge and sputum: A sputum culture is a test that checks for bacteria or
another type of organism that may be causing an infection in your lungs or the airways.

Pulmonary function tests: PFT's are noninvasive tests that show how well the lungs are working.
The tests measure lung volume, capacity, rates of flow, and gas exchange.

Arterial blood gas:

Treatment:

1. Acute bronchitis is usually mild 7. Quitting smoking

2. No need of antibiotic 8. Avoiding exposure to secondhand
3. Rest, fluids, and aspirin (for adults) smoke
4. Increased fluid intake 9. Avoid antihistamines because they
5. Analgesics and anti-pyretic , such as dry up the secretions and can make
acetaminophen (tylenol) the cough worse.
6. A humidifier or steam

2.Chronic bronchitis:

Chronic bronchitis is long-term inflammation of the bronchi. It is common among smokers.

People with chronic bronchitis tend to get lung infections more easily. They also have episodes
of acute bronchitis, when symptoms are worse.
This is clinical disorder characterized by productive cough on most of the days for at least three
consecutive months for more than two successive years.

People with chronic bronchitis have chronic obstructive pulmonary disease (COPD). This
large group of lung diseases includes chronic bronchitis. These diseases can block airflow in the
lungs and cause breathing problems.

The two most common conditions of COPD are chronic bronchitis and emphysema.

Causes:

1. Main cause of chronic bronchitis is cigarette smoking.

2. Secondhand smoke
3. Air pollution
4. Chemical fumes or dusts from the environment or workplace.
5. Rarely, a genetic condition called alpha-1 antitrypsin deficiency. (AATD is a rare,
inherited condition, which can cause lung and liver problems.)

Bronchitis symptoms often happen with other lung diseases, such as:

1. Asthma 4. Sinusitis
2. Pulmonary emphysema 5. Tuberculosis
3. Scarring of the lungs (pulmonary 6. Upper respiratory infections
fibrosis)

Symptoms:

 Cough, often called smokers cough

 Coughing up mucus (expectoration)  Chest discomfort

 Wheezing

Other symptoms may include:

 Bluish fingernails, lips, and skin  Swollen feet

because of lower oxygen levels  Heart failure
 Wheezing and crackling sounds with
breathing

Diagnosis
1. Spirometry. 
2. Peak flow monitor: A peak flow meter is a portable, easy-to-use device that measure the
amount of air blown out of the lungs.

3. Arterial blood gas

4. Pulse oximetry
5. Chest X-ray: shows increased interstitial markings especially at bases. Diaphragm are not
flattened.
6. CT scan: it is usually not so helpful in diagnosis of CB.

Treatment:

 Quitting smoking
 Staying away from secondhand smoke and other lung irritants
 Bronchodilators and steroids
 Getting oxygen from portable containers
 Humidifying the air
 Having lung reduction surgery to take out damaged areas of the lung
 Getting a lung transplant, in rare cases
 Pulmonary rehab to help you learn how to live with your breathing problems and stay
active. (Chest physiotherapy and different breathing exercises)

2. Bronchiectasis

Bronchiectasis is abnormal, irreversible and permanent dilatation of the bronchioles. This in turn
leads to impaired clearance of bronchial secretions. Accumulation of secretions lead to persistent
bacterial infection and bronchial inflammation. It may be localized to a lobe or generalized
throughout the bronchial tree.

Causes: Pulmonary tuberculosis is the major cause of bronchiectasis.

In adults (acquired in In children (acquired in Congential

adults) children)

 Chronic pulmonary Secondary to:  Cystic fibrosis

tuberculosis
 pneumonia
 Suppurative
pneumonia  Adenovirus
 Lung abscess  influenza virus
 Bronchial distension
 Aspiration pneumonia
(resulting from
 Endobronchial accumulation of pus
beyond the lesion
obstruction
lymphadenopathy in
 AIDS primary tuberculosis.)
 Alpha1 anti trypsin
deficiency
 Ciliary dysfunction
syndrome
 Primary
Hypogammaglobinemia
Hypogammaglobulinem
ia (hypo- + gamma +
globulin + -emia) is a
problem with the immune
system in which not
enough gamma globulins
are produced in the blood.
This results in a lower
antibody count, which
impairs the immune
system, increasing risk of
infection.

Clinical features:

1. Chronic productive cough (usually worsen in morning, or by change of posture)

2. Recurrent chest infections
3. Severe disease thick, foul-smelling green sputum.
4. Hemoptysis
5. Breathlessness
6. Wheeze
7. Clubbing of fingers in severe disease.

On examination: Physical signs may be unilateral or bilateral. In the presence of large amount
of secretions numerous coarse crepitation (crackles) will be heard over the affected area, usually
the lung bases.
Investigations
Chest X-ray: Cystic bronchiectacic spaces may be visible in gross bronchiectasis at the base of
lungs (honeycomb appearance in advanced cases). In mild bronchiectasis x-ray may be normal
and diagnosis requiring CT scan.

High-resolution CT scanning (is the gold standard for diagnosis).

Bronchiectatic cavities may not be apparent on x-ray in mild to moderate cases; therefore, high
resolution CT scan is the diagnostic study of choice.
CT shows dilated bronchi with wall thickening crowded together in parallel when seen
longitudinally the airways appear as "tram tracks" and when seen in cross section they produce
"ring shadow".

Bronchoscopy: It is sometimes required to evaluate cause of hemoptysis, to remove retained

secretions and to rule out obstructive airway lesion

Pulmonary function test: PFTS show obstructive pattern due to diffuse bronchiectasis or
associated COPD.

Sputum culture: It is essential during an infective exacerbation.

Further investigations: e.g. serum immunoglobulins, sweat test in patients where an underlying
cause is suspected.

Management:

1. Smoking cessation
2. Respiratory physiotherapy: Promotes mucociliary clearance and sputum production.
Techniques are the active cycle of breathing technique (ACBT), postural drainage and chest
percussion.
3. Antibiotic therapy:
In mild cases : cefaclor 500 mg, Amoxilline 500 TDS, Augmentin 625 mg 8 hourly
In moderate to severe cases: Augmenten 1.2 g ,8 hourly
Specific antibiotics, e.g. ceftazidime 1 g 8 hourly
ciprofloxacin (alternative) 250 to 750 mg BD for 5-10 days
Flucloxacillin is the best treatment (Staph. Aureus)
Long-term antibiotics.
4. Bronchodilators: β2 agonists and/or anticholinergics may provide symptomatic relief even
without an objective improvement in FEV1. Bronchdilators such as Ventolin are effective to
improve obstruction and aid in clearance of secretion.
5. Inhaled or oral steroids: can decrease the rate of progression.
6. Surgery: is reserved for the very small minority with localized disease.
7. Heart–lung transplantation: Severe disease sometimes requires lung or heart–lung
transplantation.
Prevention:

 Adequate treatment of whooping cough, Measles, Primary tuberculosis.

 Early detection of bronchial obstruction.

Complications:

 Recurrent hemoptysis (may be  Pleurisy

massive)  Pleural effusion or empyema.
 Pneumonia  Respiratory failure
 Lung abscess

3. Cystic fibrosis (CF)

Cystic fibrosis (CF) is an autosomal recessive condition that occurs as a result of mutations
affecting a gene located on long arm of chromosome 7.
Pathogenesis:

 CF occurs when a person inherits a mutated (abnormal) copy of the CFTR gene (cystic
fibrosis transmembrane conductance regulator) from each parent
 This faulty CFTR protein leads to the dysregulation of salt and water transport.
 In the lungs, the build-up of chloride ions inside the epithelial cell pull in both sodium
ions and water via osmosis and diffusion from the airway surface liquid & mucus gel
layer outside the cell, adversely effecting mucociliary transport, causing repeated lung
infections etc.

Risk factors: Family history & Race

Clinical features:

Respiratory features Gastrointestinal features

Although the lungs of babies born with CF are
structurally normal at birth, frequent respiratory
infections soon develop and are the presenting
feature.
1. Recurrent bronchopulmonary infection especially
Bronchiectasis presenting with cough, sputum,
decrease exercise tolerance and hemoptysis.
2. Airflow limitation and eventually respiratory
failure.
3. Finger clubbing (due to presence of pus in lungs).
1.Pancreatic dysfunction: leads steatorrhea
(Increased in fat excretion in stools)
2.Cholesterol gall stones
3.Cirhosis of liver
4.Increase peptic ulceration
Other feature:
Malnutrition and malabsorption lead to
increased pulmonary sepsis.
Puberty and skeletal maturity delayed.
4. Sinusitis and nasal polyps occur in most patients. Diabetes and joint disease occur.

Pathophysiology:

Diagnosis :

 Evaluation for CF is indicated in patients with suggestive symptoms or signs, or a

sibling with the disease
 Sweat sodium measurement is the initial investigation. This must be performed in a
laboratory regularly undertaking testing. A value ≥ 60 mmol/L is diagnostic. Lower
values but above the normal range still require DNA analysis
 Blood DNA analysis of the gene defect
 Radiology showing features of CF.

Management:
Postural drainage: and chest physiotherapy for clearance of lower airways secretion.
Antibiotics: for infection (common organism: staph.aureus, H.influenzae)
Inhaled bronchodilators: such as salbutamol (Ventolin)
Inhaled corticosteroid: to reduce inflammation.
Vaccination: for pneumococcal infection and annual influenza vaccination.
Lung transplantation: heart -lung transportation last option in severe cases.
Genetic screening: of family members.