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 © A.J.France 2010
Range of conditions – Upper tract Common cold - coryza Sore throat - Pharyngitis Sinusitis Epiglottitis © A.J.France 2010
Range of conditions – Lower Acute bronchitis Acute exacerbation of chronic bronchitis Pneumonia Influenza © A.J.France 2010
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 © A.J.France 2010
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 © A.J.France 2010
Treatment for coryza © A.J.France 2010
Acute sinusitis Preceded by a common cold Purulent nasal discharge Treatment…. © A.J.France 2010
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 © A.J.France 2010
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 © A.J.France 2010
Acute bronchitis - Treatment Antibiotics are NOT indicated Unless they have underlying chronic lung disease. © A.J.France 2010
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 © A.J.France 2010
Acute exacerbation of chronic bronchitis On examination Breathless Wheeze Coarse crackles May be cyanosed In advanced disease – ankle oedema © A.J.France 2010
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 © A.J.France 2010
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 © A.J.France 2010
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 © A.J.France 2010
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 © A.J.France 2010
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 © A.J.France 2010
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 © A.J.France 2010
Pneumonia. Other severity markers Temperature 40 Cyanosis PaO2 < 8 kPa WBC 30 Multi-lobar involvement © A.J.France 2010
Pathogens in pneumonia Strep pneumoniae (pneumococcus) H. influenzae Mycoplasma pneumoniae Influenza Chicken pox – in adult smokers Legionella Coxiella burnetti Chlamydia psittaci © A.J.France 2010
Community acquired pneumonia: Management Antibiotics Amoxicillin + Doxycycline (see “antibiotic man” for details) Oxygen Maintain SaO % Fluids Bed rest No smoking © A.J.France 2010
Complications of pneumonia Respiratory failure Pleural effusion Empyema Death © A.J.France 2010
Empyema © A.J.France 2010
Empyema © A.J.France 2010
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 © A.J.France 2010
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 © A.J.France 2010
Prevention of pneumonia Influenza and pneumococcal vaccines Over 65 Chronic chest or cardiac disease Diabetes Immunocompromised e.g. splenectomy Influenza vaccine Health care workers © A.J.France 2010
Coffee break © A.J.France 2010