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LOWER RESPIRATORY TRACT INFECTION BRONCHITIS SUBMITTED TO MR. SATHISH KUMAR BP Asst. Professor Submitted by Prasanna Dahal Pharm D P.B Ist year Department of Clinical Pharmacy 5/6/2011 1 Pharmacotherapeutics II




Inflammation of the air passages within the lungs. Trachea (windpipe) and the large and small bronchi (airways) within the lungs become inflamed because of infection or other causes INTRODUCTION 5/6/2011 3 Pharmacotherapeutics II


ACUTE Viruses (Cold Causing) Pollutant (Cigarette Smoking) GERD CHRONIC Prolonged Smoking Heavy Exposure to Pollutant CLASSIFICATION 5/6/2011 4 Pharmacotherapeutics II

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Acute Bronchitis an inflammation of the large bronchi (medium-size airways) in the lungs that is usually caused by viruses or bacteria and may last several days or weeks. Chronic Bronchitis inflammation of large and small bronchi's by recurring injury or irritation to the respiratory epithelium of the bronchi, resulting in persistent cough and characterized by chronic inflammation, edema (swelling), and increased production of mucus that last at least 3 months for 2 consecutive years. 5/6/2011 5 Pharmacotherapeutics II


Acute bronchitis often occurs during the course of an acute viral illness such as the common cold or influenza. About 90% of cases of acute bronchitis are caused by viruses, including rhinoviruses, adenoviruses, and influenza. Bacteria, including Mycoplasma pneumoniae , Chlamydia pneumoniae , and Bordetella pertussis , account for about 10% of cases. Most cases chronic bronchitis are caused by smoking cigarettes or other forms of tobacco. Chronic inhalation of irritating fumes or dust from occupational exposure or air pollution may also be causative. About 5% of the population has chronic bronchitis, and it is two times more common in males than females. 10%-25% of population about 40years or above suffers from chronic bronchitis. EPIDEMOLOGY AND ETIOLOGY 5/6/2011 6 Pharmacotherapeutics II


ACUTE BRONCHITIS Infection of the trachea and bronchi causes hyperemic and edematous mucous membranes as well as destruction of respiratory epithelium and the increase in bronchial secretions (which can become thick and tenacious) further impairing mucociliary activity. CHRONIC BRONCHITIS Recurrent acute respiratory infections may be associated with increased airway hyperreactivity causing possibly the pathogenesis of chronic obstructive lung disease PATHOGENESIS 5/6/2011 7 Pharmacotherapeutics II

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Persistent Cough with yellowish-gray sputum Discolored mucous Soreness and a feeling of constriction or burning in your chest Sore throat Chest congestion Sinus fullness Breathlessness Wheezing Slight fever and chills Overall malaise CLINICAL MANIFESTATION 5/6/2011 9 Pharmacotherapeutics II


Physical examination decreased intensity of breath sounds, wheezing, rhonchi , and prolonged expiration. Pulmonary function test Decrease vital capacity Prolong expiratory flow chest X-ray reveals hyperinflation; collapse and consolidation of lung areas Sputum sample test neutrophil granulocytes (inflammatory white blood cells) and pathogenic microorganisms such as Streptococcus species, viruses. blood test indicate inflammation (as indicated by a raised white blood cell count and elevated C-reactive protein). DIAGNOSIS 5/6/2011 10 Pharmacotherapeutics II


ACUTE BRONCHITIS viral infection and are "self-limited" and resolve themselves in a few weeks. No antibacterial are indicated. epidemics involving the influenza A virus, amantadine or rimantadine may be effective in minimizing associated symptomatology if administered early in the course of the disease. Symptomatic treatment- Aspirin or acetaminophen (650 mg in adults or 10-15 mg/kg per dose in children with a maximum daily adult dose of 4 g and 60 mg/kg for children (not preferred drug) or ibuprofen (200 to 800 mg in adults or 10 mg/kg per dose in children with a maximum daily dose of 3.2 g for adults and 40 mg/kg for children) is administered every 4 to 6 hours. Persistent, mild cough, which may be bothersome, may be treated with dextromethorphan ; more severe coughs may require intermittent codeine or other similar agents. PHARMACO-THERAPY 5/6/2011 11 Pharmacotherapeutics II

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Bacterial infection need antibiotics. Commonly used antibiotics are Amoxicillin, erythromycin and macrolides , floroquinones etc. CHRONIC BRONCHITIS aerosolized bronchodilators (e.g., albuterol aerosol) Selective antibiotics should be used depending upon the pathogens for 10-14 days Ampicillin is often considered the drug of choice for the treatment of acute exacerbations of chronic bronchitis ( not indicated for penicillin resistant bacteria) Floroquinones can be used as effective alternatives if gram negative bacteria is involved. 5/6/2011 12 Pharmacotherapeutics II

Some common antibiotics:

Some common antibiotics 5/6/2011 13 Pharmacotherapeutics II

Classification system for patients with chronic bronchitis and initial treatment option:

Classification system for patients with chronic bronchitis and initial treatment option 5/6/2011 14 Pharmacotherapeutics II


Patients should be encouraged to drink fluids to prevent dehydration and possibly decrease the viscosity of respiratory secretions. Mist therapy and/or the use of a vaporizer may further promote the thinning and loosening of respiratory secretions. NON-PHARMACOLOGICAL TREATMENT 5/6/2011 15 Pharmacotherapeutics II


NSAIDS Aspirin and Ibrufen - acidic drug, major ADR- gastric mucosal damage, bleeding, limitation of renal blood flow-Na /water retension , delay of labour , asthma and anaphylactic reaction in susceptible individuals. Contraindication- In children, chronic liver disease, pregnancy and lactating mothers, elective surgery. Antibiotics Quinolones - acidic in nature , Inhibits DNA gyrase highly effective against grm – ve bacteria, mainly excreted through urine, highly protein bound. Major ADR- GI upset and rashes, hemolysis (G-6PD deficiency),Parkinsonism like sym on prolong use, neuroloical toxicity , luecopenia . Common drugs ciprofloxacin, levofloxacin . DRUG DETAILS 5/6/2011 16 Pharmacotherapeutics II

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Ciprofloxacin Broad spectrum antibiotics highly effective against aerobic gram – ve baccili . Usual adult dose- 500mg every 12 hrs,child 5-15mg/kg bid. Dose adjustment necessary in kidney disease-200-400mg every 18-24 hrly Precaution in pregnancy and lactation . ( C category) Contraindication-hypersensitivity to floroquinones ADR- mild, rarely hypersensitivity. Β Lactam Antibiotics Acid labile drug, inhibits cell wall synthesis, synthetic drugs are formulated acid resistant, effective against both grm + ve and grm – ve bacteria, usually safe antibiotics, rarely cause hypersensitivity and anaphylactic reaction. 5/6/2011 17 Pharmacotherapeutics II

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Amoxicillin/ Clavulate Synthetic penicillin acid stable .Broad spectrum antibiotics with β - lactamase inhibitor ( clavulate ) usual adult dose amox+clavulanic (500+125 mg) , children (250+125 mg) tid Common ADR- diarrheoa , rarely anaphylaxis, angioedema , laryngospasm , steven-johnson syndrome. Contraindication- hypersensitivity to penicillin or cephalosporin 5/6/2011 18 Pharmacotherapeutics II

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Tetracycline/ doxycycline Broad spectrum antibiotics, inhibit protein synthesis,high lipid solubility, absorption better in empty stomach, A/E- irritative effects, shows dose related toxicity in liver or kidney, teeth and bones (brown discoloration), phototoxicity . Should not be used in pregnancy,lactation and children, do not use with penicillins (inactivation occurs) Dose- adult- tetracycline -adult-250-500mg qid , max 4g daily Child – same max 2g daily Doxycycline - adult-200 stat followed by 100mg OD Child-4mg/kg stat followed by 2mg/kg OD 5/6/2011 19 Pharmacotherapeutics II

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Macrolide and azalide antibiotics Erythromycin - acid labile drugs, effective in both gram + ve and – Ve bacteria. A/E-mild to severe epigastric pain, high dose causes reversible hearing impairment, hypersensitivity reaction. Dose- adult-500mg OD, children 10mg/kg OD. Azithromycin - new azalides , acid stable, highly effective against H.influenza and other gram – ve bacteria. A/E mild GI upset, abd . Pain, headache ,dizziness etc. Dose- adult-250-500mg 24 hrly , Sulfonamides Basic in nature, folate synthesase inhibitor, bacteriostatic Major ADR- nephrotoxicity , hypersensitivity , hemopoietic disturbance. Contraindicated in new borns and pregnancy 5/6/2011 20 Pharmacotherapeutics II

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Cotrimoxazole ( Trimethoprim+sulfamethozole ) Trimethoprim – dihydrfolate reductase inhibitor, combine acts cidal effect on many organism A/E- nausea, vomiting, bone marrow toxicity, thrombocytopenia with diuretics Doses- adult- 160+800 mg BD, pedriatric—20+100 mg BD Cephalosporins most drug have poor oral absorption. Broad spectrum antibiotics. Main ADR- Allergy, disulfiram like effect and diarrheoa with some drugs. cefalexine - oral tab- 1 st generation. 1-2g daily at divided dose, max 6 gm (adult). Children 25-100 mg/kg divided dose daily, max 4 g . 5/6/2011 21 Pharmacotherapeutics II


1.Mark .L. Glover,Michael D Reed , Lower Respiratory Tract Infection.Joseph T Dipiro , Barbara G Wells , Terry L Schwinghammer , Cindy W Hamilton.Text Book Of Pharmacotherapy:A Pathologic Approach By,Mcgraw Hill Publishers.6 th edition Page no:943-49 2. J.Edwin Underwood Jr,bronchitis , Textbook of Therapeutics by Eric T.Herfindal Seventh Edition ,Page no:765-67 3. K.D.Tripathi . Essentials Of Medical Pharmacology.5 th Edition.Page no:627-86. 4. Addresion PO, Hand Book Of Clinical Drug Data, 10 th edition References 5/6/2011 22 Pharmacotherapeutics II

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Thank You 5/6/2011 23 Pharmacotherapeutics II