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PATOLOGIA DO APARELHO RESPIRATÓRIO Carlos Robalo Cordeiro Pneumonias.

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Apresentação em tema: "PATOLOGIA DO APARELHO RESPIRATÓRIO Carlos Robalo Cordeiro Pneumonias."— Transcrição da apresentação:

1 PATOLOGIA DO APARELHO RESPIRATÓRIO Carlos Robalo Cordeiro Pneumonias

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 % requerem hospitalização

6 Epidemiologia Incidência 5- 11/ 1000/ anoUK 4 Milhões de casos/ano mortes/ ano PAC é uma importante causa de mortalidade4-12 % D. internados In THORAX 2001, 56, (suppl4)- BTS GUIDELINES 2001

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

8 Streptococcus pneumoniae % Haemophilus influenza3- 10 Chlamydea pneumoniae5- 17 Vírus anaeróbios6- 10 gram S. Aureus3- 5 L. Pneumophila2- 8 M. Catarrhalis1- 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 febre tosse expectoração purulenta dor torácica pleurítica dispneia alteração estado geral odinofagia mialgias náuseas/ vómitos Clínica exame objectivo auscultação palpação percussão ECD H BQ GSA Radiologia

11 clínica exame objectivo radiologia confirmação DX localização extensão complicações Diagnóstico 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 broncopneumónico Distribuição segmentar Aspecto algodonoso e multifocal, podendo coalescer padrão intersticial Opacidades lineares, reticulo-micronodular

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14 Consolidação do lobo inferior direito

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16 Exmes laboratoriais Exame directo Cultura Hemograma Bioquímica GSA Hemoculturas Serologia VIH Serologias específicas Diagnóstico

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

18 Pneumonia Atípica - etiologia: Mycoplasma pneumoniae Chlamydia pneumoniae Chlamydia psitacci Legionella pneumophila Coxiella burnetti

19 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

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22 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

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

24 Grupo 2 Ambulatório Cardio pulmonar/ F. modificadores OrganismsTherapy Streptococcus pneumoniae Mycoplasma pneumoniae Chlamydia pneumoniae Mixed infection (bacteria plus atypical pathogen or virus) Hemophilus influenzae Enteric gram- negatives Respiratory viruses Miscellaneous Moraxella 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) plus Macrolide or doxycycline Or Antipneumococcal fluoroquinolone (used alone) In AJCCRM 2001, 163- ATS Guidelines

25 Grupo 3 D. internados OrganismsTherapy a. Cardiopulmonary Disease and/or Modifying Factors Streptococcus pneumoniae Hemophilus influenzae Mycoplasma pneumoniae Chlamdia pneumoniae Mixed infection (bacteria plus atypical pathogen) Enteric gram-negatives Aspiration (anaerobes) Viruses Legionella spp. Miscellaneous Mycobacterium tuberculosis, endemic fungi, Pneumocystis carinii Intravenous B-lactam (cefotaxime, cefuroxime,ceftriaxone, ampicillin/sulbactam, high-dose ampicillin ) plus Intravenous or oral macrolide or doxycycline or Iv antipneumococcal fluoroquinolone alone In AJCCRM 2001, 163- ATS Guidelines

26 Grupo 3 D. internados b. No cardiopulmonary Disease, No Modifying Factors S. Pneumoniae H. influenzae M. pneumoniae C. pneumoniae Mixed infection (bacteria plus atypical pathogen) Viruses Legionella spp. Miscellaneous M. tuberculosis, endemic fungi, P. carinii Intravenous azithromycin alone. If macrolide allergic or intolerant: Doxycycline and a B-lactam or Monotherapy with an antipneumococcal fluoroquinolone In AJCCRM 2001, 163- ATS Guidelines

27 Duração do tratamento variável7-14 D aparecimento de fármacos com maior semivida tecidular considerar: doenças associadas gravidade da doença evolução da doença agente etiológico M. Pneumoniae10-14 D C. Pneumoniae Legionella14 D In AJCCRM 2001, 163- ATS Guidelines

28 Reports of respiratory infection, WHO global surveillance networks, 2002– 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 ( ) 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

29 Intensified surveillance for pulmonary infections, WHO, 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

30 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 D. Heymann Fonte: OMS D. Heymann

31 SARSSíndroma respiratória aguda Alerta global Casos iniciais: China Vietnam Indonésia Filipinas Singapura descohecimento do agente etiológico mortalidade

32 156 close contacts of HCW and patients Index case from Guangdong Index case from Guangdong Hospital 2 Hong Kong 4 HCW + 2 Hospital 2 Hong Kong 4 HCW + 2 Hospital 3 Hong Kong 3 HCW Hospital 3 Hong Kong 3 HCW Hospital 1 Hong Kong 99 HCW Hospital 1 Hong Kong 99 HCW Canada 12 HCW + 4 Canada 12 HCW + 4 Hotel M. Hong Kong Ireland USA New York Singapore 34 HCW + 37 Singapore 34 HCW + 37 Viet Nam 37 HCW + ? Viet Nam 37 HCW + ? Bangkok HCW Bangkok HCW 4 other Hong Kong hospitals 28 HCW 4 other Hong Kong hospitals 28 HCW Hospital 4 Hong Kong Hospital 4 Hong Kong B I K F G E D C J H A SARS: chain of transmission among guests at Hotel Metropole, Hong Kong, 21 February Germany HCW + 2 Germany HCW + 2 Source: WHO/CDC D. Heymann

33 SARS: number of probable cases by date of report worldwide*, 1 March–5 May 2003 Date of report Mar-038-Mar-0315-Mar-0322-Mar-0329-Mar-035-Apr-0312-Apr-0319-Apr-0326-Apr-033-May-03 number of cases (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 Fonte: OMS D. Heymann

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

38 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

39 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

40 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

41 SARSSíndroma respiratória aguda Não é o primeiro caso de SARS, nem será o último Legionelose1976 Hantanvírus1993 EUA Hendra vírus1994 H5 N1 influenza vírus1997 Hong Kong Nipah vírus1997 Metapneumovírus2001 H7 N7 influenza vírus2003

42 SARSSíndroma respiratória aguda novos casos/DIA Definição de caso suspeito caso provável 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 Critérios clínicos Critérios epidemiológicos Critérios laboratoriais - Acs SARS-CoV - RT- PCR - isolamento SARS- CoV

43 Fonte:CDC 16 MAIO 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 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 of fever (>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.

44 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

45 Preliminary Clinical Description of Severe Acute Respiratory Syndrome 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. Fonte:CDC 16 MAIO

46 Preliminary Clinical Description of Severe Acute Respiratory Syndrome 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. Fonte:CDC 16 MAIO

47 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

48 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 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

49 Worldwide6727 cases 478 deaths Europe 36 cases 0 deaths 0.5% of total Fonte: OMS SARS- 6 MAIO

50 Total countries29 Europe11 Fonte: OMS SARS- 6 MAIO

51 Fonte: OMS SARS- 6 MAIO Italy9 Germany7 UK6 France5 Sweden3 Bulgaria1 Poland1 Rep of Ireland1 Romania1 Spain1 Switzerland1

52 Worldwide6727 cases 478 deaths Europe 36 cases 0 deaths 0.5% of total Fonte: OMS SARS- 6 MAIO SARS- 16 MAIO Worldwide7739 cases 611 deaths

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54 SARSSíndroma respiratória aguda este caso é importante para lembrar constante ameaça das D. Infecciosas possibilidade de aparecimento novos agentes infecciosos

55 Apesar dos avanços terapêuticos Os esforços para controlar as infecções respiratórias não podem ser estáticos, dada a emergência de novos patogéneos e o aparecimento de resistências aos antibióticos comuns nos patogéneos antigos Michael Niederman Novos Fármacos


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