Case presentation on bronchiectasis with community acquired pneumonia

Bronchiectasis is defined as abnormal and irreversible dilatation of the bronchi and bronchioles (greater than 2 mm in diameter) developing inflammatory weakening of the bronchial walls.

1. Case presentation on Infective exacerbation of bronchiectasis with community Acquired pneumonia Presented by, M.Tejashree Pharm D 3 rd year

2. Bronchiectasis Definition : Bronckos   – airways   Ectasis  – widening Bronchiectasis is defined as abnormal and irreversible dilatation of the bronchi and bronchioles (greater than 2 mm in diameter) developing inflammatory weakening of the bronchial walls. It is a  chronic condition where the airways are damage and have become widened with scarred and thickened walls. In this case include a chronic cough with  mucus production.

3. Types Bronchiectasis can be classified into the following forms morphologically Cylindrical bronchiectasis : bronchi are enlarged and cylindrical. Varicose bronchiectasis : bronchi are irregular with areas of dilatation and constriction. Saccular or cystic : dilated bronchi form clusters of cysts. This is the most severe form of bronchiectasis and is often found in patients with cystic fibrosis

4. Signs and symptoms: Pain areas:  in the chest Cough: chronic persistent cough with expectoration,Hemoptysis , Recurring chest infections (exacerbations) productive cough of frequent green/yellow  mucus (sputum) , Respiratory:  shortness of breath, sinusitis, or wheezing Whole body:  fatigue, Lethargy and exercise limitation Also common:  phlegm, recurrent infection, deformity of nails, or weight loss, Chest pain, Gastro- oesophageal reflux.

5. Causes Bronchiectasis has both  congenital and acquired causes. Congenital bronchiectasis caused by developmental defect of the bronchial system like Cystic fibrosis - genetic disorder that affects mostly the lungs, but also the pancreas, liver, kidneys, and intestine It is Long-term issues include difficulty breathing and coughing up mucus as a result of frequent lung infections. A cquired causes Infective causes associated with bronchiectasis include infections caused by the   Staphylococcus ,  Klebsiella , or  Bordetella pertussis , the causative agent. History of Tuberculosis, pneumonia, ,  allergic bronchopulmonary aspergillosis  and  bronchial tumours and also Crohns disease   ( nflammatory bowel disease ). Nontuberculous mycobacterial: Mycobacterium avium comple , Mycobacteriumm abscessu Aspiration n of  ammonia  and other toxic gases,  pulmonary aspiration ,  alcoholism ,  heroin (drug use), various  allergies  all appear to be linked to the development of bronchiectasis .

6. Pathophysiology mcro organisms or allergents entry into airways triggers a mucociliary response Micro-organisms trigger the release of toxins and an inflammatory response within the airways.  release of neutrophils , lymphocytes and macrophages within the bronchial lumen Neutrophils alter the function of the cilial epithelium, leading mucous gland hypersecretion ( mucociliary clearance) loss of mucociliary transport renders the airways microbial colonization. release of inflammatory mediators, which facilitate neutrophil migration to the bronchial lumen and mucosa.  destroy the bronchial elastin , leading to permanent dilatation of the bronchi  Airway walls become thickened and substituted by oedema , ulceration or fibrosis. pooling of mucus =>promotes progressive airway damage and recurrent infections bronchiectasis

7. Community-acquired pneumonia ( CAP ) its symptoms occur as a result of oxygen-absorbing areas of the lung (alveoli) filling with fluid. This inhibits lung function, causing dyspnea , fever, chest pains and cough. Common symptoms Coughing which produces greenish or yellow sputum A high fever , accompanied by sweating, chills and shivering Sharp, stabbing chest pains Rapid, shallow, often-painful breathing Causes Over 100 microorganisms can cause CAP, with most cases caused by Streptococcus pneumoniae .

8. Subjective data Patient name :XXX Age : 80/F Department : Respiratory medical Ward – 2 Date of admission : 10-11-18 Op : 1811121560 Chief complaints : cause of SOB 4 th grade mMRC (modified Medical Research Council dyspnea scale), cough with expectoration, fever with chills since 10days. History of present illness : cause of SOB grade 4 th mMRC since 10 days, c/o wheeze, More lying down position feeling sweating, palpitation. Cause of cough – whitish, mucoid,non foul smelling non blood stained since 10 days. History of past illness : cause of fever with chills and rigors 10days Intermittently with high grade In evening times, H/o altered bowel habits since 10 days. C/O chest pain With Diffused, pricking type, radiating to back, occurs since 10 days, H/O wt loss, H/O repeated infection since 20yrs – common cold, fever since 3times / 1yr, Appetite decreased, yellowish discoloration of urine.

9. Objective Data Personal History : alcoholic Occasionally, bowels– Regular but yellowish discolouration of urine since 10days Physical examination : Pallor pt, Temperature: 98F, Pulse rate: 104bpm SpO2: 84 % BP : 120/70 mmHg On examination : JVP raised P I C K L E : P (+) => pallor

10. Respiratory system exam : Inspection: B/l chest appears to be symmetrical, trachea appears to be centeral , apical impulse appears not visible, Rt supraclavicular fosses Hollowness (+), Intercostal retraction (+) Spino -Scapular distance is equal on both sides Respiratory movements appears to be diminished on Rt side, No visible scars/sinuses, JVP- rised . Palpation: all inspectory Finding as confirmed ,That trachea slightly deviated to Rt apex beat in Lt 5 th Increase at mid clavicular line. Respiratory movements slightly Diminished Rt hemithorax . Auscultation : B/L normal berath sounds with late inspiration, easly Expiration coarse crackles in hemithorax With Lt infra axillary , infra scapulary area, Aortic valve replacement AVR – equal

11. Assessment Ultra sonography : Gall bladder: partially distended Pancreases: poor window Rt Kidney: 10 ×4cm size Lt kidney: 8 × 3.3 cm size ( Increased echogenicity ) Examination in kidney: 1.7 × 1.6cm cyst noted in upper portion of Lt kidney. Urinary bladder: minimal distended Prostate: 10cc (normal) Other findings : no fluid accumulation Impression: Lt renal clavical cyst B/L renal parenchymal changes grade 1 (L>R) Rt pleural effusion (very minimal) Smear study : RBC: microcytic hypochromic WBC: leucocytosis Platelets: elevated

12. Lab reports Parameters Recording values Normal values Serum bilirubin total 0.5mg/dl 0.1 – 1.0mg/dl Serum bilirubin direct 0.2mg/dl <0.25mg/dl Total proteins 7.0gm/dl 6.0 – 8.0gm/dl Albumin 3.0gm/dl 3.5 – 5.0gm/dl Globulins 4.0gm/dl 2 – 3.5gm/dl A/G ratio 0.7 1.2 – 2:1 SGOT (AST) 36 IU/U <49 IU/U SGPT (ALT) 20 IU/U <49 IU/U Alkaline phosphate 55 IU/U <147 IU/U PCV 18.4vol% 38.8-50% MCV 69.4fl 80-96fl/red cells MCH 27.0pg 27-33pg/cell MCHC 39.0% 33-36%

13. Parameters 12/11 13/11 14/11 15/11 16/11 Normal values Total WBC 13,000 10,100 7,200 8,700 6,500 4000 – 13,000/cmm Neutrophils 80% 75% 79% 78% 74% 40-80% Lymphocytes 15% 20% 19% 17% 18% 20-40% Monocytes 2% 2% 1% 1% 3% 2-10% eosinophils 3% 3% 1% 4% 5% 1-6% Hemoglobin 7.2gm% 8.1gm% 7.3% 7.2% 7.1gm% 13.5-17.5gm% RBC 2.66mil/ cmm 2.9mil/ cmm 2.68mil/ cmm 2.72 2.68 4.2 - 5.9 million  cells/ cmm .  Platelets 4.8Lks/ cumm 5.64Lks/ cmm 6.16 6.58 8.26 1.5-4.5Lks/ cmm ESR 40mm/hr 40mm/hr 45mm/hr 45mm/hr 40mm/hr 0-22mm/hr

14. Provisional Diagnosis ? community Acquired pneumonia ? Infective exacerbation of bronchiectasis

15. DAY TO DAY PROGRESS 13/11/18 : COMPLINTS :- C/O SOB grad 4 mmRC , chest pain diffused O/E ; PT afebril PR: 104 bpm SpO2 : 98% Bl normal breath sounds with late inspiration and early coarse respiratory crackles in RT Hemithorax , with LT infra axiliary and scapular area. 2D ECHO : DILATED RA, RV, LVSD Moderate TR, PAH RVSP: 53mmHg MEDICATIONS : INJ CEFTRIMAX, O2 supplement, T.AZEE,T.MUCINAAC 14/11/18 COMPLAINTS : C/O SOB grade 3 mmRC , same as 13/11/18 AFEBRIL PA : 86bpm SpO2 : 94% Urine output : 1900ml Bp : 120/70mmHg Medications : same and add on MFER-XT and Ned DUOLIN.

16. 15/11/18 COMPLAINTS : AFEBREIL PA: 96 bpm SpO2 : 88% BP: 110/70mmHg Infra scapular and axillary ; coarse respiratory crackles+ Rt bronchial breath sounds+ Medications : same 5 16/11/18 COMPLAINTS : AFEBREIL PA: 94 bpm SpO2 : 89% BP: 110/80mmHg SAME COMPLAINTS MEDICATIONS: SAME with plenty of oral fluids

17. 17/11/18 FEBREIL Repeated infections and slightly epileptic PA: 92 bpm SpO2 : 90% BP: 110/60mmHg Medications : same and add on INJ LEVIPIL, INJ PARACETAMOL 18/11/18 FEBREIL PA: 86 bpm SpO2 : 96% BP: 110/70mmHg Medications : same and add on INJ AMIKACIN

18. 19/11/18 AFEBREIL PA: 86 bpm SpO2 : 92% BP: 110/70mmHg MEDICATIONS: INJ PARACETAMOL, INJ LEVIPIL removed 20/11/18 AFEBREIL C/O Chest pain {diffused} pricking type, radiating from back, weight loss, appetite decreased PA: 82 bpm SpO2 : 94% BP: 110/70mmHg Mild coarse respiratory crackles MEDICATIONS: SAME

19. 21/11/18 Infra scapular diminished breath sounds AFEBREIL PR: 82 bpm SpO2 : 92% BP: 110/70mmHg MEDICATIONS: same 22/11/18 Infra scapular diminished breath sounds, AFEBREIL PR: 86 bpm RR: 18/MINS SpO2 : 85% BP: 110/70mmHg MEDICATIONS: same

20. Treatment history Brand names Generic names Indications Dosage frecency ROA SE INJ CEFTRIMAX Ceftriaxone+ sulbactam cefalosporins 1.5gms BD IV DIARRHOEA NEB DUOLIN INHALER Itratropium bromide+levo salbutamol bronchodilators 200MD 6 TH HR NASAL Paralytic ileus T.AZEE Azithromycin Antimicrobial 500mg OD PO Abd pain T.MUCINAAC Acetylcysteine Mycolytics 600mg/200ML OD PO Nausea INJ LEVIPIL Levetiracetem Antiepileptic 5ml OD IV Somnolence INJ PARACETAMOL Paracetamol Antipyretic 30ml 12 TH HR IV Stomach pain T.AMIKACIN Amikacin Antibiotic 500mg OD PO dizziness INJ LINEZOLID Linezolid Antimicrobial 600mg BD IV Diarrhoea MFER-XT Ferrous ascorbate Fe supplyment 100mg OD PO Stomach upset

21. Interventions Minor levetiracetam + acetaminophen levetiracetam decreases levels of acetaminophen by increasing metabolism. Minor/Significance Unknown. Enhanced metabolism incr levels of hepatotoxic metabolites.

22. Lifestyle modification minimizing exposure to environmental irritants like secondhand smoke, which can further impair lung function. Smoking irritates the lungs and exacerbates breathing problems. Exercise helps-The intensive breathing associated with exercise can help the airways clear mucus more efficiently. Stay Hydrated- Drinking 8 to 10 8-ounce glasses of water per day helps thin mucus, making it easier to expel. Get a flu shot every year in the fall. Get the pneumococcal vaccines as recommended by your health care provider. Check out  Eat Healthy, Live Healthy to get started. Show your doctor, pharmacist or asthma educator how you’re using your metered-dose inhaler.

23. Shake the puffer well before use (three or four shakes) Remove the cap Breathe out, away from your puffer Bring the puffer to your mouth. Place it in your mouth between your teeth and close your mouth around it Start to breathe in slowly . Press the top of your puffer once, and keep breathing in slowly until you’ve taken a full breath Remove the puffer from your mouth, and hold your breath for about 10 seconds, then breathe out

24. Thank you