Lower respiratory tract infection

Short description: Medical term

Lower respiratory tract infection

Depiction of a person with LRTI
Frequency| 291 million (2015)[1]
Deaths| 2.74 million (2015)[2]

Lower respiratory tract infection (LRTI) is a term often used as a synonym for pneumonia but can also be applied to other types of infection including lung abscess and acute bronchitis. Symptoms include shortness of breath, weakness, fever, coughing and fatigue.[3] A routine chest X-ray is not always necessary for people who have symptoms of a lower respiratory tract infection.[4]

Antibiotics are the first line treatment for pneumonia; however, they are neither effective nor indicated for parasitic or viral infections. Acute bronchitis typically resolves on its own with time.[citation needed]

In 2015 there were about 291 million cases.[1] These resulted in 2.74 million deaths down from 3.4 million deaths in 1990.[5][2] This was 4.8% of all deaths in 2013.[5]

The World Health Organization has reported that, in 2021, "Lower respiratory infections remained the world's most deadly communicable disease other than COVID-19, ranked as the fifth leading cause of death." However, the number of deaths caused has decreased by around 13% from 2000 to 2021.[6]

## Contents

* 1 Bronchitis
* 2 Pneumonia
* 3 Causes
* 4 Prevention
* 5 Treatment
* 6 Epidemiology
* 7 Society and culture
* 8 References
* 9 External links

## Bronchitis

Main article: Medicine:Bronchitis

Bronchitis describes the swelling or inflammation of the[7] bronchial tubes. Additionally, bronchitis is described as either acute or chronic depending on its presentation and is also further described by the causative agent. Acute bronchitis can be defined as acute bacterial or viral infection of the larger airways in healthy patients with no history of recurrent disease.[8] It affects over 40 adults per 1000 each year and consists of transient inflammation of the major bronchi and trachea.[9] Most often it is caused by viral infection and hence antibiotic therapy is not indicated in immunocompetent individuals.[10][7] Viral bronchitis can sometimes be treated using antiviral medications depending on the virus causing the infection, and medications such as anti-inflammatory drugs and expectorants can help mitigate the symptoms.[11][7] Treatment of acute bronchitis with antibiotics is common but controversial as their use has only moderate benefit weighted against potential side effects (nausea and vomiting), increased resistance, and cost of treatment in a self-limiting condition.[9][12] Beta2 agonists are sometimes used to relieve the cough associated with acute bronchitis. In a recent systematic review it was found there was no evidence to support their use.[7]

Acute exacerbations of chronic bronchitis (AECB) are frequently due to non-infective causes along with viral ones. 50% of patients are colonised with Haemophilus influenzae, Streptococcus pneumoniae, or Moraxella catarrhalis.[8] Antibiotics have only been shown to be effective if all three of the following symptoms are present: increased dyspnea, increased sputum volume, and purulence. In these cases, 500 mg of amoxicillin orally, every 8 hours for 5 days or 100 mg doxycycline orally for 5 days should be used.[8]

## Pneumonia

Main article: Medicine:Pneumonia

Pneumonia occurs in a variety of situations and treatment must vary according to the situation.[11] It is classified as either community or hospital acquired depending on where the patient contracted the infection. It is life-threatening in the elderly or those who are immunocompromised.[13][14] The most common treatment is antibiotics and these vary in their adverse effects and their effectiveness.[13][15] Pneumonia is also the leading cause of death in children less than five years of age in low income countries.[15] The most common cause of pneumonia is pneumococcal bacteria, Streptococcus pneumoniae accounts for 2/3 of bacteremic pneumonias.[16] For optimal management of a pneumonia patient, the following must be assessed: pneumonia severity (including treatment location, e.g., home, hospital or intensive care), identification of causative organism, analgesia of chest pain, the need for supplemental oxygen, physiotherapy, hydration, bronchodilators and possible complications of emphysema or lung abscess.[17]

## Causes

Deaths from lower respiratory infections per million persons in 2012:

24-120

121-151

152-200

201-241

242-345

346-436

437-673

674-864

865-1,209

1,210-2,085

Disability-adjusted life year for lower respiratory infections per 100,000 inhabitants in 2004:[18]

no data

less than 100

100–700

700–1,400

1,400–2,100

2,100–2,800

2,800–3,500

3,500–4,200

4,200–4,900

4,900–5,600

5,600–6,300

6,300–7,000

more than 7,000

Typical bacterial Infections:

* Haemophilus influenzae
* Staphylococcus aureus
* Klebsiella pneumoniae

Atypical bacterial Infections:

* Legionella pneumophila
* Mycoplasma pneumoniae
* Chlamydophila pneumoniae
* Chlamydia psittaci

Parasitic infections:

* Respiratory cryptosporidiosis

Viral infections:

* Adenovirus
* Influenza A virus
* Influenza B virus
* Human parainfluenza viruses
* Human respiratory syncytial virus
* Severe acute respiratory syndrome coronavirus (SARS-CoV)
* Middle East respiratory syndrome coronavirus (MERS-CoV)
* Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

Aspiration pneumonia

## Prevention

Vaccination helps prevent bronchopneumonia, mostly against influenza viruses, adenoviruses, measles, rubella, streptococcus pneumoniae, haemophilus influenzae, diphtheria, bacillus anthracis, chickenpox, and bordetella pertussis.[19] Specifically for the children with low serum retinol or who are suffering from malnutrition, vitamin A supplements are recommended as a preventive measure against acute LRTI.[20]

## Treatment

Antibiotics do not help the many lower respiratory infections which are caused by parasites or viruses. While acute bronchitis often does not require antibiotic therapy, antibiotics can be given to patients with acute exacerbations of chronic bronchitis.[21] The indications for treatment are increased dyspnoea, and an increase in the volume or purulence of the sputum.[22] The treatment of bacterial pneumonia is selected by considering the age of the patient, the severity of the illness and the presence of underlying disease. A systematic review of 32 randomised controlled trials with 6,078 participants with acute respiratory infections compared procalcitonin (a blood marker for bacterial infections) to guide the initiation and duration of antibiotic treatment, against no use of procalcitonin. Among 3,336 people receiving procalcitonin-guided antibiotic therapy, there were 236 deaths, compared to 336 deaths out 3,372 participants who did not. Procalcitonin-guided antibiotic therapy also reduced the antibiotic use duration by 2.4 days, and there were fewer antibiotic side effects. This means that procalcitonin is useful for guiding whether to use antibiotics for acute respiratory infections and the duration of the antibiotic.[23] Amoxicillin and doxycycline are suitable for many of the lower respiratory tract infections seen in general practice.[21] Another cochrane review suggests that new studies are needed to confirm that azithromycin may lead to less treatment failure and lower side effects than amoxycillin.[24] In the other hand, there is no sufficient evidence to consider the antibiotics as a prophylaxis for the high risk children under 12 years.[25]

Oxygen supplementation is often recommended for people with severe lower respiratory tract infections.[26] Oxygen can be provided in a non-invasive manner using nasal prongs, face masks, a head box or hood, a nasal catheter, or a nasopharyngeal catheter.[26] For children younger than 15 years old, nasopharyngel catheters or nasal prongs are recommended over a face mask or head box.[26] A Cochrane review in 2014 presented a summary to identify children complaining of severe LRTI, however; further research is required to determine the effectiveness of supplemental oxygen and the best delivery method.[26]

## Epidemiology

Lower respiratory infectious disease is the fifth-leading cause of death and the combined leading infectious cause of death, being responsible for 2.74 million deaths worldwide.[27] This is generally similar to estimates in the 2010 Global Burden of Disease study.[28] This total only accounts for Streptococcus pneumoniae and Haemophilus influenzae infections and does not account for atypical or nosocomial causes of lower respiratory disease, therefore underestimating total disease burden.[citation needed]

## Society and culture

Lower respiratory tract infections place a considerable strain on the health budget and are generally more serious than upper respiratory tract infections.[citation needed]

Workplace burdens arise from the acquisition of a lower respiratory tract infection, with factors such as total per person expenditures and total medical service utilisation demonstrated as greater among individuals experiencing a lower respiratory tract infection.[29]

Pan-national data collection indicates that childhood nutrition plays a significant role in determining the acquisition of a lower respiratory tract infection, with the promotion of the implementation of nutrition program, and policy guidelines in affected countries.[27]

## References

1. ↑ 1.0 1.1 "Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet 388 (10053): 1545–1602. October 2016. doi:10.1016/S0140-6736(16)31678-6. PMID 27733282.
2. ↑ 2.0 2.1 "Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet 388 (10053): 1459–1544. October 2016. doi:10.1016/s0140-6736(16)31012-1. PMID 27733281.
3. ↑ Antibiotic Expert Group (2014). Therapeutic Guidelines: Antibiotic (15th ed.). Therapeutic Guidelines Limited. ISBN 978-0-9925272-1-1.
4. ↑ Cao, Amy Millicent Y.; Choy, Joleen P.; Mohanakrishnan, Lakshmi Narayana; Bain, Roger F.; van Driel, Mieke L. (2013-12-26). "Chest radiographs for acute lower respiratory tract infections". Cochrane Database of Systematic Reviews 2013 (12). doi:10.1002/14651858.CD009119.pub2. ISSN 1469-493X. PMID 24369343.
5. ↑ 5.0 5.1 "Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013". Lancet 385 (9963): 117–71. January 2015. doi:10.1016/S0140-6736(14)61682-2. PMID 25530442. PMC 4340604. http://discovery.ucl.ac.uk/1462383/1/Abubakar_Global_regional_and_national_age-sex_specific.pdf.
6. ↑ "The top 10 causes of death" (in en). https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death.
7. ↑ 7.0 7.1 7.2 7.3 "Beta2-agonists for acute cough or a clinical diagnosis of acute bronchitis". The Cochrane Database of Systematic Reviews 2015 (9). September 2015. doi:10.1002/14651858.CD001726.pub5. PMID 26333656.
8. ↑ 8.0 8.1 8.2 Antibiotic Expert Group. Therapeutic guidelines: Antibiotic. 13th ed. North Melbourne: Therapeutic Guidelines; 2006.
9. ↑ 9.0 9.1 "Bronchitis (acute)". BMJ Clinical Evidence 2015. July 2015. PMID 26186368.
10. ↑ Therapeutic guidelines : respiratory. 2nd ed: North Melbourne : Therapeutic Guidelines Limited, 2000.
11. ↑ 11.0 11.1 Integrated pharmacology / Clive Page ... [et al.]. 2nd ed: Edinburgh : Mosby, 2002.
12. ↑ Smith, SM; Fahey, T; Smucny, J; Becker, LA (19 June 2017). "Antibiotics for acute bronchitis.". The Cochrane Database of Systematic Reviews 2017 (6). doi:10.1002/14651858.CD000245.pub4. PMID 28626858.
13. ↑ 13.0 13.1 "Antibiotics for community-acquired pneumonia in adult outpatients". The Cochrane Database of Systematic Reviews 2014 (10). October 2014. doi:10.1002/14651858.CD002109.pub4. PMID 25300166.
14. ↑ Cite error: Invalid `<ref>` tag; no text was provided for refs named `pmid23440780`
15. ↑ 15.0 15.1 "Antibiotics for community-acquired pneumonia in children". The Cochrane Database of Systematic Reviews 2013 (6). June 2013. doi:10.1002/14651858.CD004874.pub4. PMID 23733365.
16. ↑ The Merck manual of diagnosis and therapy. 17th ed / Mark H. Beers and Robert Berkow ed: Whitehouse Station, N.J. : Merck Research Laboratories, 1999.
17. ↑ Kumar Pius, Prince Sree; Alexis, Anitha; P, Suresh Kumar; Ganesan, Manivel (2017). "Diagnosis of Sputum Culture Positive Organisms and Their Antimicrobial Sensitivity Profile in a Tertiary Care Centre- Kanyakumari". Journal of Evidence Based Medicine and Healthcare 4 (4): 168–171. doi:10.18410/jebmh/2017/33.
18. ↑ "Mortality and Burden of Disease Estimates for WHO Member States in 2002" (xls). World Health Organization. 2002. https://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls.
19. ↑ "Guidelines for the management of adult lower respiratory tract infections--full version". Clinical Microbiology and Infection 17 (Suppl 6): E1–59. November 2011. doi:10.1111/j.1469-0691.2011.03672.x. PMID 21951385.
20. ↑ Chen, Hengxi; Zhuo, Qi; Yuan, Wei; Wang, Juan; Wu, Taixiang (23 January 2008). "Vitamin A for preventing acute lower respiratory tract infections in children up to seven years of age". Cochrane Database of Systematic Reviews (1). doi:10.1002/14651858.CD006090.pub2. PMID 18254093.
21. ↑ 21.0 21.1 "Antibiotic therapy of community respiratory tract infections: strategies for optimal outcomes and minimized resistance emergence". The Journal of Antimicrobial Chemotherapy 49 (1): 31–40. January 2002. doi:10.1093/jac/49.1.31. PMID 11751764.
22. ↑ "Guidelines for the management of adult lower respiratory tract infections". The European Respiratory Journal 26 (6): 1138–80. December 2005. doi:10.1183/09031936.05.00055705. PMID 16319346.
23. ↑ Schuetz, Philipp; Wirz, Yannick; Sager, Ramon; Christ-Crain, Mirjam; Stolz, Daiana; Tamm, Michael; Bouadma, Lila; Luyt, Charles E et al. (12 October 2017). "Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections". Cochrane Database of Systematic Reviews 10 (5). doi:10.1002/14651858.CD007498.pub3. PMID 29025194.
24. ↑ Laopaiboon, Malinee; Panpanich, Ratana; Swa Mya, Kyaw (8 March 2015). "Azithromycin for acute lower respiratory tract infections". Cochrane Database of Systematic Reviews 2015 (3). doi:10.1002/14651858.CD001954.pub4. PMID 25749735.
25. ↑ Onakpoya, Igho J; Hayward, Gail; Heneghan, Carl J (26 September 2015). "Antibiotics for preventing lower respiratory tract infections in high-risk children aged 12 years and under". Cochrane Database of Systematic Reviews 2015 (9). doi:10.1002/14651858.CD011530.pub2. PMID 26408070.
26. ↑ 26.0 26.1 26.2 26.3 Rojas-Reyes, Maria Ximena; Granados Rugeles, Claudia; Charry-Anzola, Laura Patricia (10 December 2014). "Oxygen therapy for lower respiratory tract infections in children between 3 months and 15 years of age". Cochrane Database of Systematic Reviews 2014 (12). doi:10.1002/14651858.CD005975.pub3. PMID 25493690.
27. ↑ 27.0 27.1 "Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory tract infections in 195 countries: a systematic analysis for the Global Burden of Disease Study 2015". The Lancet. Infectious Diseases 17 (11): 1133–1161. November 2017. doi:10.1016/S1473-3099(17)30396-1. PMID 28843578.
28. ↑ "Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010". Lancet 380 (9859): 2095–128. December 2012. doi:10.1016/S0140-6736(12)61728-0. PMID 23245604. PMC 10790329. https://zenodo.org/record/2557786.
29. ↑ "Predicting nosocomial lower respiratory tract infections by a risk index based system". Scientific Reports 7 (1): 15933. November 2017. doi:10.1038/s41598-017-15765-z. PMID 29162852. Bibcode: 2017NatSR...715933C.

## External links

Classification|

* ICD-10: J10-J22, J40-J47

|

* v
* t
* e

Diseases of the respiratory system (J, 460–519)

Upper RT
(including URTIs,
common cold)|

| Head|

sinuses

Sinusitis

nose

Rhinitis

Vasomotor rhinitis
Atrophic rhinitis
Hay fever
Nasal polyp
Rhinorrhea
nasal septum

Nasal septum deviation
Nasal septum perforation
Nasal septal hematoma

tonsil

Tonsillitis
Adenoid hypertrophy
Peritonsillar abscess

|

Neck|

pharynx

Pharyngitis

Strep throat
Laryngopharyngeal reflux (LPR)
Retropharyngeal abscess

larynx

Croup
Laryngomalacia
Laryngeal cyst
Laryngitis
Laryngopharyngeal reflux (LPR)
Laryngospasm

vocal cords

Laryngopharyngeal reflux (LPR)
Vocal fold nodule
Vocal fold paresis
Vocal cord dysfunction

epiglottis

Epiglottitis

trachea

Tracheitis
Laryngotracheal stenosis

Lower RT/lung disease
(including LRTIs)|

| Bronchial/
obstructive|

acute

Acute bronchitis

chronic

COPD

Chronic bronchitis
Acute exacerbation of COPD)
Asthma (Status asthmaticus
Aspirin-induced
Exercise-induced
Bronchiectasis

unspecified

Bronchitis
Bronchiolitis

Bronchiolitis obliterans
Diffuse panbronchiolitis

|

Interstitial/
restrictive
(fibrosis)|

| External agents/
occupational
lung disease|

Pneumoconiosis

Aluminosis
Asbestosis
Baritosis
Bauxite fibrosis
Berylliosis
Caplan's syndrome
Chalicosis
Coalworker's pneumoconiosis
Siderosis
Silicosis
Talcosis
Byssinosis

Hypersensitivity pneumonitis

Bagassosis
Bird fancier's lung
Farmer's lung
Lycoperdonosis

|

Other|

* ARDS
* Combined pulmonary fibrosis and emphysema
* Pulmonary edema
* Löffler's syndrome/Eosinophilic pneumonia
* Respiratory hypersensitivity
* Allergic bronchopulmonary aspergillosis
* Hamman-Rich syndrome
* Idiopathic pulmonary fibrosis
* Sarcoidosis
* Vaping-associated pulmonary injury

Obstructive or
restrictive|

| Pneumonia/
pneumonitis|

| By pathogen|

* Viral
* Bacterial
* Pneumococcal
* Klebsiella
* Atypical bacterial
* Mycoplasma
* Legionnaires' disease
* Chlamydiae
* Fungal
* Pneumocystis
* Parasitic
* noninfectious
* Chemical/Mendelson's syndrome
* Aspiration/Lipid

|

By vector/route|

* Community-acquired
* Healthcare-associated
* Hospital-acquired

By distribution|

* Broncho-
* Lobar

IIP|

* UIP
* DIP
* BOOP-COP
* NSIP
* RB

Other|

* Atelectasis
* circulatory
* Pulmonary hypertension
* Pulmonary embolism
* Lung abscess

Pleural cavity/
mediastinum|

| Pleural disease|

* Pleuritis/pleurisy

* [[Medicine:PneumoPneumothorax]]/Hemopneumothorax

Pleural effusion

Hemothorax
Hydrothorax
Chylothorax
Empyema/pyothorax
Malignant

Fibrothorax

|

Mediastinal disease|

* Mediastinitis
* Mediastinal emphysema

Other/general|

* Respiratory failure
* Influenza
* SARS
* Coronavirus disease 2019
* Idiopathic pulmonary haemosiderosis
* Pulmonary alveolar proteinosis

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