Dr A.J.France

© A.J.France 2010

Objectives

Define the range of conditions Recognise the common clinical

presentations Understand the significance of pre-

existing respiratory disease Look at the different features seen in

immuno-compromised patients

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Range of conditions – Upper tract Common cold - coryza Sore throat - Pharyngitis Sinusitis Epiglottitis

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Range of conditions – Lower

Acute bronchitis Acute exacerbation of chronic

bronchitis Pneumonia Influenza

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Vocal cords – the dividing line

Upper Resp Tract Air conditioning Filtration Commensal

organisms Shared with Gastro

– Intestinal tract

Lower Resp Tract Gas exchange Usually sterile Temperature

regulation

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Common cold - coryza

Acute viral infection of the nasal passages

Often accompanied by sore throat Sometimes a mild fever Spread by droplets and fomites Complications can include

Sinusitis Acute bronchitis – see later

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Treatment for coryza

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Acute sinusitis

Preceded by a common cold Purulent nasal discharge Treatment….

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Special conditions

Acute tonsillitis and quinsy – go to ENT lecture

Diphtheria Life threatening due to toxin production Characteristic pseudo-membrane Not seen in UK due to vaccination

Acute epiglottitis in children Life threatening due to obstruction

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Acute bronchitis

The cold which goes to the chest Preceded by common cold Clinical features

Productive cough Fever – minority of cases Normal chest examination Normal chest X-ray May have a transient wheeze

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Acute bronchitis - Treatment

Antibiotics are NOT indicated Unless they have underlying chronic

lung disease.

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Acute exacerbation of chronic bronchitis Remember – pre-existing lung

disease with excess sputum and broncho-constriction.

Clinical features Usually preceded by upper resp tract

infection Worsening of sputum production which is

now purulent More wheezy Breathless

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Acute exacerbation of chronic bronchitis On examination

Breathless Wheeze Coarse crackles May be cyanosed In advanced disease – ankle oedema

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Acute exacerbation of chronic bronchitis Management in primary care

Antibiotic. e.g. doxycycline or amoxicillin Bronchodilator inhalers Short course of steroids in some cases

Refer to hospital if Evidence of respiratory failure Not coping at home

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Acute exacerbation of chronic bronchitis

Management in hospital – same as before AND Measure arterial blood gases CXR to look for other diseases Give oxygen if has respiratory failure

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Right upper lobe

Lobar pneumonia

Pneumonia: Introduction

Significant risk of fatal outcome 5-10% mortality from pneumococcal

pneumonia 30% if bacteraemic

2600 deaths from pneumococcal pneumonia in UK every year

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Middle lobe. Lobar pneumonia

Lobar pneumonia

Normal

Red hepatisation

Lobar pneumonia

Lung biopsy - autopsy

Symptoms of pneumonia

Malaise Anorexia Sweats Rigors Myalgia Arthralgia Headache Confusion

Cough Pleurisy Haemoptysis Dyspnoea Preceding URTI Abdominal pain Diarrhoea

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Right lower lobe pneumonia - abdominal pain ?

Pneumonia

Signs Fever Rigors Herpes labialis Tachypnoea Crackles Rub Cyanosis Hypotension

Investigations Blood culture Serology

Arterial gases Full blood count Urea Liver function Chest X-ray

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Herpes simplex stomatitis

Cyanosis

CURB 65 severity score for pneumonia C New onset of confusion U Urea >7 R Respiratory rate >30/min B Blood pressure

Systolic <90 OR Diastolic <61 65 age 65 years or older

Score 1 point for each of above

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Pneumonia. Other severity markers Temperature < 35 or > 40 Cyanosis PaO2 < 8 kPa WBC < 4 or > 30 Multi-lobar involvement

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Pathogens in pneumonia

Strep pneumoniae (pneumococcus) H. influenzae Mycoplasma pneumoniae Influenza Chicken pox – in adult smokers Legionella Coxiella burnetti Chlamydia psittaci

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Community acquired pneumonia:Management Antibiotics

Amoxicillin + Doxycycline (see “antibiotic man” for details)

Oxygen Maintain SaO2 94-98 %

Fluids Bed rest No smoking

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Complications of pneumonia

Respiratory failure Pleural effusion Empyema Death

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Empyema

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Empyema

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Special cases of pneumonia

Hospital acquired Need extended gram negative cover

Aspiration pneumonia Need anaerobic cover

Legionella Chest symptoms may be absent GI disturbance is common

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History taking in pneumonia

Cough Breathless Chest pain Fever Pre-existing chest

disease Smoking history

Foreign travel Pets, including

birds Contact history Other medical

conditions Lifestyle Prescribed drugs

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Prevention of pneumonia

Influenza and pneumococcal vaccines Over 65 Chronic chest or cardiac disease Diabetes Immunocompromised

e.g. splenectomy

Influenza vaccine Health care workers

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Coffee break

© A.J.France 2010