In this presentation I have tried to explain the types, etiology, pathophysiology of respiratory tract infections such as bronchitis, pnemonia, otitis media, sinusitis, pharyngitis, and their treatment

1. Respiratory tractRespiratory tract
infections and theirinfections and their
treatment (Atreatment (A
PharmacotherapeuticPharmacotherapeutic
Approach)Approach)
By: Dr. Ankit Gaur
Pharm.D, M.Sc, RPh

2.  Upper respiratory tractUpper respiratory tract
nose, nasal cavity, sinuses,nose, nasal cavity, sinuses,
mouth, throatmouth, throat
 Lower respiratory tractLower respiratory tract
Trachea, bronchi,Trachea, bronchi,
bronchioles, andbronchioles, and
alveoli in the lungsalveoli in the lungs

3. Lower respiratory tract infectionLower respiratory tract infection
 BronchitisBronchitis
--Inflammatory conditions of bronchial tubesInflammatory conditions of bronchial tubes
Classified asClassified as
AcuteAcute -- occurs in all age,occurs in all age,manifested by cough and, occasionally, sputummanifested by cough and, occasionally, sputum
production that last for no more than 3 weeks.production that last for no more than 3 weeks.
ChronicChronic -- occurs mostly in infants,occurs mostly in infants,cough with sputum expectoration for atcough with sputum expectoration for at
least 3 months a year during a period of 2 consecutive yearsleast 3 months a year during a period of 2 consecutive years

4. EtiologyEtiology
Cold.Cold.
Damp climate.Damp climate.
Presence of high concentration of irritating substance.Presence of high concentration of irritating substance.
Influenza virusInfluenza virus
Common cold virusCommon cold virus
Mycoplasma pneumoniaesMycoplasma pneumoniaes

5. PathogensisPathogensis
infection of trachea & bronchiinfection of trachea & bronchi
edematous mucous membrane with increaseedematous mucous membrane with increase
in bronchial secretionin bronchial secretion
destruction of respiratory epitheliumdestruction of respiratory epithelium
impairs bronchial mucociliary function.impairs bronchial mucociliary function.
the air passages become clogged by debristhe air passages become clogged by debris
narrowing of airways and obstruction in breathingnarrowing of airways and obstruction in breathing

6. Clinical presentationClinical presentation
Acute bronchitisAcute bronchitis
 Signs and symptomsSigns and symptoms
Cough persisting more than 5days ,purulent sputum ,malaise ,headacheCough persisting more than 5days ,purulent sputum ,malaise ,headache
 Physical examinationPhysical examination
Rhonchi or coarses, moist, bilateral ralesRhonchi or coarses, moist, bilateral rales
 Chest radiograph : normalChest radiograph : normal
 Siprometry :large reduction of fev1Siprometry :large reduction of fev1
 Bacterial culture.Bacterial culture.
Chronic bronchitisChronic bronchitis
 Signs and symptomsSigns and symptoms
Smokers cough, dyspnea ,wheezing ,coughing productive of purulent sputumSmokers cough, dyspnea ,wheezing ,coughing productive of purulent sputum

7.  Physical examinationPhysical examination
Clubbing of digits, mild wheezing normal vesicular breathing sounds areClubbing of digits, mild wheezing normal vesicular breathing sounds are
diminisheddiminished
 Chest radiographChest radiograph
Observed as barrel chest ,depressed diaphragmObserved as barrel chest ,depressed diaphragm

SiprometrySiprometry:: decreased vital capacitydecreased vital capacity
prolonged expiratory flow.prolonged expiratory flow.

8. TreatmentTreatment
Acute bronchitisAcute bronchitis
 aspirin : dose(650mg in adults or 10-15 mg/kg per dose in childrenaspirin : dose(650mg in adults or 10-15 mg/kg per dose in children
 Ibuprofen : dose(200-800mg in adults 10mg/kg per dose in children)Ibuprofen : dose(200-800mg in adults 10mg/kg per dose in children)
 To treat s. pneumonia – azithromycin.To treat s. pneumonia – azithromycin.
 To treat from influneza virus – amantidine, rimantadine, neuraminidaseTo treat from influneza virus – amantidine, rimantadine, neuraminidase
inhibitor (zanamivir, oseltamivir effective against both A&B)inhibitor (zanamivir, oseltamivir effective against both A&B)
Chronic bronchitisChronic bronchitis
 Short acting bronchodilators (albuterol aresol)Short acting bronchodilators (albuterol aresol)
 Long term inhalation( ipratropium, tiotropium)Long term inhalation( ipratropium, tiotropium)
 Antibiotic (ampicillin0.25-0.5,amoxicillin 0.5-0.8,ciprofloxacin,doxycycline)Antibiotic (ampicillin0.25-0.5,amoxicillin 0.5-0.8,ciprofloxacin,doxycycline)
 Supplemental drugs (azithromycin, erythromycin)Supplemental drugs (azithromycin, erythromycin)

9. PneumoniaPneumonia
““pneumonia is defined as an Infection or inflammation of the lungpneumonia is defined as an Infection or inflammation of the lung
parenchyma caused most often by microbial pathogensparenchyma caused most often by microbial pathogens.”.”
EtiologyEtiology

BacteriaBacteria ::Streptococcus pneumoniaeStreptococcus pneumoniae ,, Klebsiella pneumoniae and HemophilusKlebsiella pneumoniae and Hemophilus
influenzaeinfluenzae..
 Virus: Adenoviruses, rhinovirus, influenza virus (flu), respiratory syncytialVirus: Adenoviruses, rhinovirus, influenza virus (flu), respiratory syncytial
virus (RSV), and parainfluenza virusvirus (RSV), and parainfluenza virus

10. PathophysiologyPathophysiology
Aspiration of potential pathogens from oropharynxAspiration of potential pathogens from oropharynx
alveolar macrophages releases inflammatory mediators(IL1,TNF)alveolar macrophages releases inflammatory mediators(IL1,TNF)
Chemokines (IL8) stimulate release of neutrophils producing increasedChemokines (IL8) stimulate release of neutrophils producing increased
purulent secretionpurulent secretion
Inflammatory mediators lead to capillary leak leading to fluid filledInflammatory mediators lead to capillary leak leading to fluid filled
alveolialveoli
Decreases gas exchange within lung leading to hypoxiaDecreases gas exchange within lung leading to hypoxia
alveoli become solid because debris and fluid collectionalveoli become solid because debris and fluid collection
(conslidation)(conslidation)

11. Signs and symptomsSigns and symptoms
 Abrupt onset of feverAbrupt onset of fever
 ChillsChills
 DyspneaDyspnea
 Productive coughProductive cough
 chest painchest pain
 Rust colored sputum or hemoptysisRust colored sputum or hemoptysis
 Physical examPhysical exam
 Tachypnea and tachycardiaTachypnea and tachycardia
 Diminshed breath sounds over affected areaDiminshed breath sounds over affected area
 Inspiratory crackles during lung expansionInspiratory crackles during lung expansion
DiagnosisDiagnosis
Chest x_ray: dense lobar or segmental infilterateChest x_ray: dense lobar or segmental infilterate
SiprometrySiprometry
BronchoscopyBronchoscopy
Sputum testSputum test
Blood testBlood test

12. TreatmentTreatment
 Bacterial pneumonia( s. pneumonia ):penicillin, ampicillin-clavulanateBacterial pneumonia( s. pneumonia ):penicillin, ampicillin-clavulanate
(Augmentin) and erythromycin.(Augmentin) and erythromycin.
 Bacterial pneumonia (caused by the hemophilus influenza bacteria) :Bacterial pneumonia (caused by the hemophilus influenza bacteria) :
cefuroxime (Ceftin), ampicillin-clavulanate (Augmentin), ofloxacincefuroxime (Ceftin), ampicillin-clavulanate (Augmentin), ofloxacin
(Floxin), and trimethoprim-sulfamethoxazole (Bactrim and Septra).(Floxin), and trimethoprim-sulfamethoxazole (Bactrim and Septra).
 Bacterial pneumonia (caused by legionella pneumophilia andBacterial pneumonia (caused by legionella pneumophilia and
staphylococcus aureus bacteria) are treated with antibiotics, such asstaphylococcus aureus bacteria) are treated with antibiotics, such as
erythromycin.erythromycin.
 Mycoplasma pneumonia:Mycoplasma pneumonia: erythromycin, clarithromycin (Biaxin),erythromycin, clarithromycin (Biaxin),
tetracycline or azithromycin (Zithromax).tetracycline or azithromycin (Zithromax).

13. Upper respiratory tract infectionUpper respiratory tract infection
Otitis mediaOtitis media ::
““acute or chronic inflammation of the middle earacute or chronic inflammation of the middle ear espesp an acutean acute
inflammation esp. in infants or young children that is caused by a virus orinflammation esp. in infants or young children that is caused by a virus or
bacteriumbacterium
There are two typesThere are two types
Acute otitis mediaAcute otitis media ::usually of rapid onset and short duration. Acute otitisusually of rapid onset and short duration. Acute otitis
media is typically associated with fluid accumulation in the middle earmedia is typically associated with fluid accumulation in the middle ear
together with signs or symptoms of ear infection; a bulging eardrumtogether with signs or symptoms of ear infection; a bulging eardrum
usually accompanied by pain, or a perforated eardrum, often with drainageusually accompanied by pain, or a perforated eardrum, often with drainage
of purulent material (pus). fever can be present.of purulent material (pus). fever can be present.
Chronic otitis mediaChronic otitis media :: is a persistent inflammation of the middle ear,is a persistent inflammation of the middle ear,
typically for a minimum of a month. This is in distinction to an acute eartypically for a minimum of a month. This is in distinction to an acute ear
infection (acute otitis media) that usually lasts only several weeks.infection (acute otitis media) that usually lasts only several weeks.

14. EtiologyEtiology
 Immune system: The immature immune systems of infants orImmune system: The immature immune systems of infants or
the impaired immune systems of patients with congenitalthe impaired immune systems of patients with congenital
immune deficiencies, HIV infection, or diabetes may beimmune deficiencies, HIV infection, or diabetes may be
involved in the development of OMinvolved in the development of OM
 Genetic predispostionGenetic predispostion
 Anatomic abnormailityAnatomic abnormaility
 Bacterial pathogens like s.pneumonia,e.coliBacterial pathogens like s.pneumonia,e.coli
 Virus:Virus: respiratory syncytial virusrespiratory syncytial virus (RSV), influenza viruses,(RSV), influenza viruses,
parainfluenza viruses, rhinovirus, and adenovirus.parainfluenza viruses, rhinovirus, and adenovirus.
 enivronmental factors: smokersenivronmental factors: smokers

15. PathophysiolgyPathophysiolgy
In ET dysfunction (ETD), the mucosa at the pharyngeal end of the ET isIn ET dysfunction (ETD), the mucosa at the pharyngeal end of the ET is
part of the mucociliary system of the middle ear.part of the mucociliary system of the middle ear.
Interference with this mucosa by edema, tumor, or negative intratympanicInterference with this mucosa by edema, tumor, or negative intratympanic
pressure facilitates direct extension of infectious processes from thepressure facilitates direct extension of infectious processes from the
nasopharynx to the middle ear, causing OM.nasopharynx to the middle ear, causing OM.
Esophageal contents regurgitated into the nasopharynx and middle ear throughEsophageal contents regurgitated into the nasopharynx and middle ear through
the ET can create a direct mechanical disturbance of the middle ear mucosathe ET can create a direct mechanical disturbance of the middle ear mucosa
and cause middle ear inflammationand cause middle ear inflammation..

16. Signs and symptomsSigns and symptoms
Otalgia:Otalgia:
 OtorrheaOtorrhea
 Hearing lossHearing loss
 FeverFever
 Lethargy and vomittingLethargy and vomitting
DiagnosisDiagnosis
 FeverFever
 OtorrheaOtorrhea
 Examination of tympanicExamination of tympanic
membrane by otoscopymembrane by otoscopy

17. TreatmentTreatment
First choiceFirst choice
AmoxicillineAmoxicilline 40 mg/kg/day, 3 doses40 mg/kg/day, 3 doses
Trimet./SulfamethoxazoleTrimet./Sulfamethoxazole 8mg TM/40mg SMX/kg8mg TM/40mg SMX/kg 2 dose2 dose
Second choiceSecond choice
Amoxicilline/clavulanateAmoxicilline/clavulanate 45 mg/kg/day, 2 doses45 mg/kg/day, 2 doses
ErythromycinErythromycin 40-50 mg/kg/day, 3 doses40-50 mg/kg/day, 3 doses
Reurrent AOM prophylaxisReurrent AOM prophylaxis
SulfisoxazoleSulfisoxazole 75 mg/kg/day, single dose 3-6 mo75 mg/kg/day, single dose 3-6 monthnth
AmoxicillineAmoxicilline 20 mg/kg/day, sin20 mg/kg/day, singgle dose 3-6 mole dose 3-6 monthnth

18. SinusitisSinusitis
 ““Sinusitis is inflammation of the sinuses, which are air-Sinusitis is inflammation of the sinuses, which are air-
filled cavities in the skullfilled cavities in the skull ““
 Sinusitis can be divided into the following categoriesSinusitis can be divided into the following categories::
– Acute sinusitis:Acute sinusitis: defined as symptoms of less than 4 weeks’ durationdefined as symptoms of less than 4 weeks’ duration
– Subacute sinusitis:Subacute sinusitis: defined as symptoms of 4 to 8 weeks’ duration;defined as symptoms of 4 to 8 weeks’ duration;
– Chronic sinusitis:Chronic sinusitis: defined as symptoms lasting longer than 8 weeksdefined as symptoms lasting longer than 8 weeks
– Recurrent acute sinusitis:Recurrent acute sinusitis: often defined as three or more episodes peroften defined as three or more episodes per
year, with each episode lasting less than 2 weeks.year, with each episode lasting less than 2 weeks.

19. EtiologyEtiology
Conditions that Predispose to SinusitisConditions that Predispose to Sinusitis
 Allergic rhinitisAllergic rhinitis
 Nonallergic rhinitisNonallergic rhinitis
 Anatomic factors:Anatomic factors:
– Septal deviationsSeptal deviations
– Adenoid hypertrophyAdenoid hypertrophy
 Hormonal conditions (e.g., progesterone-induced congestionHormonal conditions (e.g., progesterone-induced congestion
of pregnancy, rhinitis of hypothyroidism)of pregnancy, rhinitis of hypothyroidism)
 Gastroesophageal refluxGastroesophageal reflux
 Acquired immune deficiency:Acquired immune deficiency:
 Human immunodeficiency virusHuman immunodeficiency virus
 TransplantationTransplantation
 ChemotherapyChemotherapy
 Cystic fibrosisCystic fibrosis

20. PathophysiologyPathophysiology
viral infection can lead to inflammationviral infection can lead to inflammation
inflammation lead to causing sinus ostial blockageinflammation lead to causing sinus ostial blockage
anterior ethmoid, frontal, and maxillary sinuses drain into the middleanterior ethmoid, frontal, and maxillary sinuses drain into the middle
meatus, creating an anatomic area known as themeatus, creating an anatomic area known as the ostiomeatal complexostiomeatal complex
nasal mucosa responds to the virus by producing mucus and recruitingnasal mucosa responds to the virus by producing mucus and recruiting
mediators of inflammation, such as white blood cells, to the lining of themediators of inflammation, such as white blood cells, to the lining of the
nose, which cause congestion and swelling of the nasal passages.nose, which cause congestion and swelling of the nasal passages.
The resultant sinus cavity hypoxia and mucus retention cause the cilia toThe resultant sinus cavity hypoxia and mucus retention cause the cilia to
function less efficiently, creating an environment for bacterial growth.function less efficiently, creating an environment for bacterial growth.

21. Signs and symptomsSigns and symptoms
– Facial pain or pressureFacial pain or pressure
– Facial congestion or fullnessFacial congestion or fullness
– Nasal obstruction or blockageNasal obstruction or blockage
– Nasal discharge, purulence, postnasal dripNasal discharge, purulence, postnasal drip
– HeadacheHeadache
– FeverFever
– FatigueFatigue
– Dental painDental pain
– CoughCough
– Ear pain, pressure, fullnessEar pain, pressure, fullness
DiagnosisDiagnosis
Radiographic EvaluationRadiographic Evaluation
UltrasonographyUltrasonography
Nasal smearNasal smear

22. TreatmentTreatment
– Amoxicillin or trimethoprim/sulfamethoxazole(320-1600mg) every 12Amoxicillin or trimethoprim/sulfamethoxazole(320-1600mg) every 12thth
hourhour
– Amoxicillin –clavulanate-500mg-1g every 8Amoxicillin –clavulanate-500mg-1g every 8thth
hourhour
– Clarithromycin-250-500mg every 12 hrClarithromycin-250-500mg every 12 hr
– Azithromycin -500mg every 4Azithromycin -500mg every 4thth
hourhour
– Nasal decongestants (pseudoephidrine)-30-120mg 4-6 hrsNasal decongestants (pseudoephidrine)-30-120mg 4-6 hrs
PharyngitisPharyngitis
““Inflammation of pharynx and surrounding lymphoid tissue “Inflammation of pharynx and surrounding lymphoid tissue “
EtiologyEtiology
virus-rhinovirus ,coronavirusvirus-rhinovirus ,coronavirus
Bacteria-streptococcus pyogensBacteria-streptococcus pyogens
smokingsmoking

23. PathophysiologyPathophysiology
 bacteria or viruses may directly invade the pharyngeal mucosa, causing abacteria or viruses may directly invade the pharyngeal mucosa, causing a
local inflammatory response.local inflammatory response.
 Other viruses, such as rhinovirus and coronavirus, can cause irritation ofOther viruses, such as rhinovirus and coronavirus, can cause irritation of
pharyngeal mucosa secondary to nasal secretions.pharyngeal mucosa secondary to nasal secretions.
 Streptococcal infections are characterized by local invasion and release ofStreptococcal infections are characterized by local invasion and release of
extracellular toxins and proteases.extracellular toxins and proteases.
Signs and symptomsSigns and symptoms
Sore throatSore throat
Pain on swallowingPain on swallowing
FeverFever
Enlarged lymph nodesEnlarged lymph nodes
Red swollen uvulaRed swollen uvula

24. DiagnosisDiagnosis
– Thorat swabThorat swab
– CultureCulture
– Rapid antigen detection testRapid antigen detection test
TreatmentTreatment
Pencillin V: 250mg BD given orally for 10 daysPencillin V: 250mg BD given orally for 10 days
Benzathine penicillin: 0.6 millon units for weight <27 kg (child)Benzathine penicillin: 0.6 millon units for weight <27 kg (child)
1.2 millon units intramuscularly (adult)1.2 millon units intramuscularly (adult)
as single doseas single dose
For pencillin allergic patient: erythromycin estolate 20-40mg/kg/dayFor pencillin allergic patient: erythromycin estolate 20-40mg/kg/day