1. Dr A.J.France © 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 40  Cyanosis PaO2 < 8 kPa  WBC 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