0071643192.pdf

■ Recurrent aspiration (eg, severe GERD, disordered swallow)

■ Lower airway obstruction with tumor

SYMPTOMS

Patients often have cough productive of yellow or green sputum together with

dyspnea and hemoptysis.

EXAM

■ Lung exam reveals crackles and wheezes.

■ Acute exacerbations typically include changes in sputum production, ↑

dyspnea,↑cough and wheezing, fatigue, low-grade fever, ↓pulmonary

function, changes in chest sounds, and radiographic changes.

DIFFERENTIAL

COPD, interstitial fibrosis, pneumonia, asthma

DIAGNOSIS

■ Suspect based on history and patient risk factors

■ Evaluation primarily consists of PFTS and chest CT.

TREATMENT

■ Inhaled bronchodilators: Helpful when used routinely as many patients

have hyperresponsiveness that likely results from airway inflammation

■ Inhaled corticosteroids: Can reduce inflammation and improve dyspnea,

cough, and pulmonary function in severe cases

■ Antibiotics:The standard of care for acute exacerbations, a reasonable

first-line choice would include a fluoroquinolone.

■ Other treatment aimed toward specific underlying cause (eg, percussive

vests to aid in clearance of secretions in patients with CF)

■ Surgical resection remains an option for patients with localized focal

bronchiectasis.

■ Double-lung transplantation has been performed in patients with severe

bronchiectasis.

COMMUNITY-ACQUIRED PNEUMONIA

An infection of the lower respiratory tract in an individual who has not been

recently hospitalized

CAUSES

The single leading cause of community-acquired pneumonia is Streptococcus

pneumoniae.Common organisms are listed in Table 10.8. Less common

pathogens will be discussed further.

PATHOPHYSIOLOGY

■ Decreased mucociliary clearance of airway (eg, cystic fibrosis, smoking,

COPD, elderly) →↓host defenses.

■ Relative/absolute immunosuppression (eg, chronic disease, HIV) →↓sus-

ceptibility to bacterial infection.

■ Hematogenous spread of organism to lung (eg, IDU, Pneumococcus)

Patients at risk for the above pathophysiologic process are most likely to get

pneumonia.

THORACIC AND RESPIRATORY

DISORDERS

S. pneumoniaeandS. aureus

are common causes of

postinfluenza pneumonia.

Pneumonia in alcoholics is

most likely due to S.

pneumoniae,anaerobes, or

coliforms.