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Respiratory tract infection

Dr A.J.France. Respiratory tract infection. 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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Respiratory tract infection

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  1. Dr A.J.France Respiratory tract infection © A.J.France 2010

  2. 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

  3. Range of conditions – Upper tract • Common cold - coryza • Sore throat - Pharyngitis • Sinusitis • Epiglottitis © A.J.France 2010

  4. Range of conditions – Lower • Acute bronchitis • Acute exacerbation of chronic bronchitis • Pneumonia • Influenza © A.J.France 2010

  5. 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

  6. 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

  7. Treatment for coryza © A.J.France 2010

  8. Acute sinusitis • Preceded by a common cold • Purulent nasal discharge • Treatment…. © A.J.France 2010

  9. 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

  10. 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

  11. Acute bronchitis - Treatment • Antibiotics are NOT indicated • Unless they have underlying chronic lung disease. © A.J.France 2010

  12. 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

  13. Acute exacerbation of chronic bronchitis • On examination • Breathless • Wheeze • Coarse crackles • May be cyanosed • In advanced disease – ankle oedema © A.J.France 2010

  14. 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

  15. 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

  16. Right upper lobe Lobar pneumonia

  17. 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

  18. Middle lobe. Lobar pneumonia

  19. Lobar pneumonia Normal Red hepatisation

  20. Lobar pneumonia Lung biopsy - autopsy

  21. Symptoms of pneumonia • Malaise • Anorexia • Sweats • Rigors • Myalgia • Arthralgia • Headache • Confusion • Cough • Pleurisy • Haemoptysis • Dyspnoea • Preceding URTI • Abdominal pain • Diarrhoea © A.J.France 2010

  22. Right lower lobe pneumonia - abdominal pain ?

  23. 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

  24. Herpes simplex stomatitis

  25. Cyanosis

  26. 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

  27. Pneumonia. Other severity markers • Temperature < 35 or > 40 • Cyanosis PaO2 < 8 kPa • WBC < 4 or > 30 • Multi-lobar involvement © A.J.France 2010

  28. 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

  29. Community acquired pneumonia:Management • Antibiotics • Amoxicillin + Doxycycline • (see “antibiotic man” for details) • Oxygen • Maintain SaO2 94-98 % • Fluids • Bed rest • No smoking © A.J.France 2010

  30. Complications of pneumonia • Respiratory failure • Pleural effusion • Empyema • Death © A.J.France 2010

  31. Empyema © A.J.France 2010

  32. Empyema © A.J.France 2010

  33. 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

  34. 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

  35. 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

  36. Coffee break © A.J.France 2010

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