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PATOLOGIA DO APARELHO RESPIRATÓRIO

PATOLOGIA DO APARELHO RESPIRATÓRIO. Pneumonias. Carlos Robalo Cordeiro. O termo pneumonia, do ponto de vista etimológico, deriva da noção de infecção pulmonar por pneumococo- Streptococcus pneumoniae . Pneumonia

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PATOLOGIA DO APARELHO RESPIRATÓRIO

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  1. PATOLOGIA DO APARELHO RESPIRATÓRIO Pneumonias Carlos Robalo Cordeiro

  2. O termo pneumonia, do ponto de vista etimológico, deriva da noção de infecção pulmonar por pneumococo- Streptococcus pneumoniae. • Pneumonia • todo o processo infeccioso dos espaços alveolares ou do parênquima pulmonar, com substituição do seu conteudo aéreo por células inflamatórias e secreções • Ambulatório sintomas de Infecção.R.aguda sinais focais no exame objectivo queixas sistémicas ausência de outra explicação

  3. Pneumonia • Hospitalar sintomas e sinais de Infecção.R.aguda + alterações radiológicas In THORAX 2001, 56, (suppl4)- BTS GUIDELINES 2001

  4. Classificação • radiológica segmentares lobares intersticiais broncopneumonia • histológica alveolares intersticiais • etiológica bacteriana virusal fúngica • tipo de evolução agudas subagudas crónicas • Classificação • epidemiológica PAC PN/PH P. Imunodeprimido

  5. Epidemiologia Maioria tratada em ambulatório 0- 42 % requerem hospitalização

  6. Epidemiologia Incidência 5- 11/ 1000/ ano UK 4 Milhões de casos/ano 60.000 mortes/ ano PAC é uma importante causa de mortalidade 4-12 % D. internados In THORAX 2001, 56, (suppl4)- BTS GUIDELINES 2001

  7. Etiologia • 30- 60 % impossível identificar • agente etiológico varia consoante: • - área geográfica • - idade • - patologias associadas • DPOC • Patologia CV • DM • Lar • Alcoolismo • CT

  8. Etiologia • Streptococcus pneumoniae 20- 60 % • Haemophilus influenza 3- 10 • Chlamydea pneumoniae 5- 17 • Vírus 2- 15 • anaeróbios 6- 10 • gram - 3- 10 • S. Aureus 3- 5 • L. Pneumophila 2- 8 • M. Catarrhalis 1- 3 In CHEST/115/3/ MARCH, 1999

  9. Penicillin-resistant and drug-resistant pneumococci   Age > 65 yr   B-Lactam therapy within the past 3 mo   Alcoholism   Immune-suppressive illness   Multiple medical comorbidities   Exposure to a child in a day care center Enteric gram-negatives   Residence in a nursing home   Underlying cardiopulmonary disease   Multiple medical comorbidities   Recent antibiotic therapy Pseudomonas aeruginosa   Structural lung disease (bronchiectasis)   Corticosteroid therapy (> 10 mg of prednisone per day)   Broad-spectrum antibiotic therapy for > 7 d in the past month   Malnutrition Factores que aumentam o risco de infecção por agentes específicos In AJCCRM- ATS Guidelines

  10. Clínica • febre • tosse • expectoração purulenta • dor torácica pleurítica • dispneia • alteração estado geral • odinofagia • mialgias • náuseas/ vómitos • exame objectivo • auscultação • palpação • percussão • ECD • H • BQ • GSA • Radiologia

  11. Diagnóstico • clínica • exame objectivo • radiologia • confirmação DX • localização • extensão • complicações • radiologia • p. alveolar • p. broncopneumónico • p. intersticial

  12. Diagnóstico- radiologia • padrão alveolar • Imagem de condensação homogénea de limites mal definidos • Broncograma aéreo • Distribuição segmentar ou lobar • padrão intersticial • Opacidades lineares, reticulo-micronodular • padrão broncopneumónico • Distribuição segmentar • Aspecto algodonoso e multifocal, podendo coalescer

  13. Consolidação do lobo inferior direito

  14. Diagnóstico • Exmes laboratoriais • Exame directo • Cultura • Hemograma • Bioquímica • GSA • Hemoculturas • Serologia VIH • Serologias específicas

  15. Pneumonia Típica // Atípica ??? • Apresentação clínico-radiológica diferente ? • sobreposição de achados ? • -AB b- lactâmicos ineficazes • meios de diagnóstico específicos • terapêutica diferente

  16. Pneumonia Atípica • etiologia: • Mycoplasma pneumoniae • Chlamydia pneumoniae • Chlamydia psitacci • Legionella pneumophila • Coxiella burnetti

  17. Pneumonia Atípica • início mais gradual • tosse irritativa • contexto epidémico/ epidemiológico • manifestações extrapulmonares • mialgias • conjuntivite • exantema • diarreia • dor abdominal • vómitos • padrão radiológico intersticial • dissociação clínico- radiológica

  18. Tratamento Estratificação de doentes Grupo 1 ambulatório sem factores modificadores Grupo 2 ambulatório com doença cardio-pulmonar outros factores modificadores Grupo 3 D. Internados Grupo 4 D. Internados UCI In AJCCRM 2001, 163- ATS Guidelines

  19. Organisms Therapy Streptococcus pneumoniae Advanced generation macrolide:    azithromycin or clarithromycinor Doxycycline or amoxicillin/clavulanate Mycoplasma pneumoniae Chlamydia pneumoniae Hemophilus influenzae Respiratory viruses Miscellaneous Legionella spp. Mycobacterium tuberculosis Endemic fungi Grupo 1 Nova FQ In AJCCRM 2001, 163- ATS Guidelines

  20. Organisms Therapy Streptococcus pneumoniae Mycoplasma pneumoniaeChlamydia pneumoniaeMixed infection (bacteria plus   atypical pathogen or virus)Hemophilus influenzaeEnteric gram-negativesRespiratory virusesMiscellaneousMoraxella catarrhalis, Legionella spp.,   aspiration (anaerobes), Mycobacterium   tuberculosis, endemic fungi • B-Lactam • (oral cefpodoxime,   cefuroxime,   HD amoxicillin,   amoxicillin/clavulanate;or   parenteral ceftriaxone   followed by oral   cefpodoxime) • plusMacrolide or doxycycline Or • Antipneumococcal fluoroquinolone  (used alone) Grupo 2 Ambulatório Cardio pulmonar/ F. modificadores In AJCCRM 2001, 163- ATS Guidelines

  21. Organisms Therapy a. Cardiopulmonary Disease and/or Modifying Factors Streptococcus pneumoniae Hemophilus influenzaeMycoplasma pneumoniaeChlamdia pneumoniaeMixed infection (bacteria   plus atypical pathogen)Enteric gram-negativesAspiration (anaerobes)VirusesLegionella spp.Miscellaneous  Mycobacterium tuberculosis, endemic     fungi, Pneumocystis carinii • Intravenous B-lactam (cefotaxime, cefuroxime,ceftriaxone,   ampicillin/sulbactam,   high-dose ampicillin) • plusIntravenous or oral macrolide   or doxycycline • or • Iv antipneumococcal   fluoroquinolone alone Grupo 3 D. internados In AJCCRM 2001, 163- ATS Guidelines

  22. b. No cardiopulmonary Disease, No Modifying Factors S. Pneumoniae H. influenzaeM. pneumoniaeC. pneumoniaeMixed infection (bacteria  plus atypical pathogen)VirusesLegionella spp.MiscellaneousM. tuberculosis, endemic fungi, P. carinii • Intravenous azithromycin alone.  • If macrolide allergic   or intolerant: • Doxycycline  and a B-lactamorMonotherapy with an    • antipneumococcal   fluoroquinolone Grupo 3 D. internados In AJCCRM 2001, 163- ATS Guidelines

  23. Duração do tratamento • variável 7-14 D • aparecimento de fármacos com maior semivida tecidular • considerar: • doenças associadas • gravidade da doença • evolução da doença • agente etiológico • M. Pneumoniae 10-14 D • C. Pneumoniae • Legionella 14 D In AJCCRM 2001, 163- ATS Guidelines

  24. Reports of respiratory infection, WHO global surveillance networks, 2002–2003 • 27 November • Guangdong Province, China: Non-official report of outbreak of respiratory illness with government recommending isolation of anyone with symptoms (GPHIN) • 11 February • Guangdong Province, China: Non-official report of health worker outbreak of atypical pneumonia with high mortality (e-mail) • 14 February • Guangdong Province, China: Official confirmation of outbreak of atypical pneumonia with 305 cases and 5 deaths (China) • 19 February • Hong Kong, SAR China: Official report of 33-year male and 9 year old son in Hong Kong with Avian influenza (H5N1), source linked to Fujian Province, China (FluNet) Fonte: OMS D. Heymann

  25. Intensified surveillance for pulmonary infections, WHO, 2003 • 26 February • Hanoi, Viet Nam: Official report of 48-year-old business man with high fever (> 38 ºC), atypical pneumonia and respiratory failure with history of previous travel to China and Hong Kong (Viet Nam) • 4 March • Hong Kong, SAR China: Official report of 77 medical staff from Kwong Wah Hospital reported with atypical pneumonia (Hong Kong, SAR) • 5 March • Hanoi, Viet Nam: Official report of 7 medical staff from French Hospital reported with atypical pneumonia (Viet Nam) • 8 March • WHO teams arrive Hong Kong and Hanoi, and with governments begin investigation and containment activities Fonte: OMS D. Heymann

  26. SARS Global Alert: 15 March 2003 • Atypical pneumonia with rapid progression to respiratory failure • Health workers appeared to be at greatest risk • Unidentified cause, presumed to be an infectious agent • Antibiotics and antivirals did not appear effective • Spreading internationally within Asia and to Europe and North America Fonte: OMS D. Heymann D. Heymann

  27. SARS Síndroma respiratória aguda • Casos iniciais: • China • Vietnam • Indonésia • Filipinas • Singapura • descohecimento do agente etiológico • mortalidade Alerta global

  28. SARS: chain of transmission among guests at Hotel Metropole, Hong Kong, 21 February Index case from Guangdong Hospital 2 Hong Kong 4 HCW + 2 Canada 12 HCW + 4 Ireland Hospital 3 Hong Kong 3 HCW F G A Hotel M. Hong Kong 156 close contacts of HCW and patients K USA H I Hospital 1 Hong Kong 99 HCW E D J C B Germany HCW + 2 Viet Nam 37 HCW + ? Hospital 4 Hong Kong Singapore 34 HCW + 37 New York Bangkok HCW 4 other Hong Kong hospitals 28 HCW Source: WHO/CDC D. Heymann

  29. 400 350 300 250 number of cases 200 150 100 50 0 1-Mar-03 8-Mar-03 15-Mar-03 22-Mar-03 29-Mar-03 5-Apr-03 12-Apr-03 19-Apr-03 26-Apr-03 3-May-03 Date of report SARS: number of probable cases by date of report worldwide*, 1 March–5 May 2003 (n = 5 393) * Includes all cases from Hong Kong SAR, Macao SAR and Taiwan, China, but only those cases elsewhere in China reported after 3 April 2003 (1,190 cases between 16 November 2002 and 3 April 2003 not shown). The United States of America began reporting probable cases of SARS to WHO on 20 April 2003. Fonte: OMS D. Heymann

  30. Severe Acute Respiratory Syndrome (SARS): Global Alert, Global Response World Health Organization K. Stohr

  31. SARS Epidemiology 1 • Routes of transmission • Mainly droplet; person-to-person • Virus excreted through respiratory secretions, stool, urine, tears • Fomites • Incubation period • Average: 2-7 d • Case fatality rate • Hong Kong: around 15%; Fonte:K. Stohr. WHO

  32. SARS Epidemiology 2 • Virus excretion • Begins with onset of clinical signs (perhaps earlier) • Respiratory tract • Appears to peak around day 5; continues throughout the disease • day 10: 95%; day 13: 90%, day 19: 75%; day 21: 47% • Stool • Begins as early as day 3; shedding up to 10log6; • Day 10: 100%; day 16:95%; day 19: 80%; day 21: 67%) Fonte:K. Stohr. WHO

  33. SARS Diagnosis Summary • Virus and Ab detection tests available • Test are reliable in scientific laboratories • Invaluable in understanding the epidemiology of the disease • Limited use for case management and infection control • Virus detection useful for case-management but negative results can not exclude presence of SARS virus • Ab detection comes too late in the course of the disease • Negative test can not yet rule out earlier presence of disease Fonte:K. Stohr. WHO

  34. SARS Síndroma respiratória aguda • Não é o primeiro caso de SARS, nem será o último • Legionelose 1976 • Hantanvírus 1993 EUA • Hendra vírus 1994 • H5 N1 influenza vírus 1997 Hong Kong • Nipah vírus 1997 • Metapneumovírus 2001 • H7 N7 influenza vírus 2003

  35. SARS Síndroma respiratória aguda • 50- 100 novos casos/DIA • Definição de caso suspeito • caso provável Critérios clínicos Critérios epidemiológicos Critérios laboratoriais - Acs SARS-CoV - RT- PCR - isolamento SARS- CoV T > 38 º C Tosse Polipneia Dispneia Hipoxémia Alt. Rx e Viagem ultimos 10 D início sintomas área SARS China, Hong Kong, Formosa, singapura, Toronto, Vietnam Contacto com pessoa sint resp. E viagem região SARS Com pessoa com SARS

  36. Preliminary Clinical Description of Severe Acute Respiratory Syndrome Severe Acute Respiratory Syndrome (SARS) is a disease of unknown etiology that has been described in patients in Asia, North America, and Europe. Most patients identified as of March 21, 2003 have been previously healthy adults aged 25-70 years. A few suspected cases of SARS have been reported among children (≤15 years). The incubation period of SARS is usually 2-7 days but may be as long as 10 days. The illness generally begins with a prodrome offever (>38°C), which is often high, sometimes associated with chills and rigors and sometimes accompanied by other symptoms including headache, malaise, and myalgias. At the onset of illness, some cases have mild respiratory symptoms. Typically, rash and neurologic or gastrointestinal findings are absent, although a few patients have reported diarrhoea during the febrile prodrome. Fonte:CDC 16 MAIO

  37. After 3-7 days, a lower respiratory phase begins with the onset of a dry, non-productive cough or dyspnea that may be accompanied by or progress to hypoxemia. In 10%-20% of cases, the respiratory illness is severe enough to require intubation and mechanical ventilation. The case fatality among persons with illness meeting the current WHO case definition for probable and suspected cases of SARS is around 3%. Chest radiographs may be normal during the febrile prodrome and throughout the course of illness. However, in a substantial proportion of patients, the respiratory phase is characterized by early focal infiltrates progressing to more generalized, patchy, interstitial infiltrates. Some chest radiographs from patients in the late stages of SARS have also shown areas of consolidation. Preliminary Clinical Description of Severe Acute Respiratory Syndrome Fonte:CDC 16 MAIO

  38. Early in the course of disease, the absolute lymphocyte count is often decreased. Overall white cell counts have generally been normal or decreased. At the peak of the respiratory illness, up to half of patients have leukopenia and thrombocytopenia or low-normal platelet counts (50,000 – 150,000 / μl). Early in the respiratory phase, elevated creatine phosphokinase levels (up to 3000 IU / L) and hepatic transaminases (2- to 6-times the upper limits of normal) have been noted. Renal function has remained normal in the majority of patients. Preliminary Clinical Description of Severe Acute Respiratory Syndrome Fonte:CDC 16 MAIO

  39. Treatment regimens have included a variety of antibiotics to presumptively treat known bacterial agents of atypical pneumonia. In several locations, therapy has also included antiviral agents such as oseltamivir or ribavirin. Steroids have also been given orally or intravenously to patients in combination with ribavirin and other antimicrobials. At present, the most efficacious treatment regime, if any is unknown. Preliminary Clinical Description of Severe Acute Respiratory Syndrome Fonte:CDC 16 MAIO

  40. First data on stability and resistance of SARS coronavirus compiled by members of WHO laboratory network • The below table provides the first compilation of data on resistance of the SARS Coronavirus against environmental factors and disinfectants. • WHO multi-center collaborative network on SARS diagnosis • The major conclusions from these studies are: • Virus survival in stool and urine • Virus is stable in faeces(and urine) at room temperature for at least 1-2 days. • Virus is more stable (up to 4 days) in stool from diarrhea patients (which has higher pH than normal stool). Fonte:CDC 16 MAIO

  41. Disinfectants • Virus loses infectivity after exposure to different commonly used disinfectants and fixatives. • Virus survival in cell-culture supernatant • Only minimal reduction in virus concentration after 21 days at 4°C and -80°C. • Reduction in virus concentration by one log only at stable room temperature for 2 days. This would indicate that the virus is more stable than the known human coronaviruses under these conditions. • Heat at 56°C kills the SARS coronavirus at around 10000 units per 15 min (quick reduction). • Fixatives (for use in laboratories only) • SARS virus fixation (killing) on glass slides for immunofluorescence assays in room temperature does not kill virus efficiently unless the acetone is cooled down to -20oC. Fonte:CDC 16 MAIO

  42. SARS- 6 MAIO Worldwide 6727 cases 478 deaths Europe 36 cases 0 deaths 0.5% of total Fonte: OMS

  43. SARS- 6 MAIO Total countries 29 Europe 11 Fonte: OMS

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