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4 Chest medicine
Dierential diagnosis Pulmonary oedema (‘cardiac asthma’);
https://t.me/med1917
large airway obstruction (eg foreign body, tumour— consider if focal, monophonic
SVC
wheeze);
chiectasis; obliterative bronchiolitis (suspect in elderly); post- viral tussive syndrome;
Churg– Strauss syndrome (asthma may precede the vasculitic phase by
hyperventilation and panic attack.
obstruction (wheeze/ dyspnoea not episodic); pneumothorax; PE; bron-
COPD
(may coexist);
8– 10
years);
Coexistent conditions Allergic rhinitis (in most; postnasal drip— 'integrated
airway hypothesis'), sinus disease (as per allergic rhinitis, inflammation in the upper
airways can drive inflammation in the lower airways, exacerbating asthma), obesity
(may worsen perception of symptom severity), gastro- oesophageal reflux disease
GORD
). All can worsen asthma symptoms.
(
Be aware Dicult asthma may be associated with psychological morbidity.
Treatment Chronic asthma (p
Natural history Most childhood asthmatics (see
164
). Emergency treatment (p
OHCS
794
p
212
).
) either grow out of
1
asthma in adolescence or suer much less as adults. 'New- onset' asthma in adulthood sometimes has its origin in undiagnosed childhood asthma. The risk of progressive clinical deterioration in adults is small, and asthma in the absence of other
comorbidities does not appear to decrease life expectancy. Patients with severe
asthma and one or more adverse psychosocial factors are at risk of death.
Mortality
Table 4.
Source: data from
impr ovem ent/ gui deli nes/ ast hma/
1320
asthma deaths in the UK in
3
Initial structured clinical assessment of the probability of asthma
High probability
Intermediate
probability
Low probability
Features Testing strategy
• Episodic symptoms
('attacks')
• Wheeze
• Variable airflow
obstruction
• History of atopy
• No features suggestive of
alternative diagnosis
• Some but not all typical
features of asthma
• Does not respond well to
a monitored initiation of
treatment
• No typical features (eg no
lung function abnormalities, onset >
• Symptoms suggest alter-
native diagnosis
BTS/ SIGN
Guide line for the manageme nt of asthm a
50
2017, 20
years)
% increase in last 5 years.
1
Commence monitored treatment
6
weeks of inhaled corticosteroids)
(
2
Assess status with symptom ques-
tionnaire and/ or lung function tests
3
Confirm diagnosis with response to
treatment
4
If response is poor, check inhaler
technique and arrange further tests
1
Spirometry with reversibility tests
and/ or a monitored initiation of
treatment
2
Assess the response by repeating
lung function tests.
3
If normal spirometry results, do
challenge tests and/ or measurement
of FeNO to identify eosinophilic
inflammation
1
Investigate for alternative diagnosis
2
Undertake/ refer for further asthma
tests
2019
: https:// www.brit- thora cic.org.uk/ qual ity-
161
1
During the
1930
s to
1950
was considered to be psychological, with treatment often based on psychoanalysis and other talking cures.
As these psychoanalysts interpreted the asthmatic wheeze as the suppressed cry of the child for its mother,
they considered the treatment of depression to be especially important for individuals with asthma.
s, asthma was known as one of the 'holy seven' psychosomatic illnesses. Its cause
162
4 Chest medicine
https://t.me/med1917
Fig 4.
8
BTS/ SIGN
Guideline for the diagnosis of asthma (
Reproduced from
Table 4.
4
Diagnostic indications for specialist referral and 'red flag' features (
BTS/ SIGN
Guideline for the management of asthma.
Diagnostic indications for referral for specialist advice/ investigations
Referral for tests not available in primary care
• Diagnosis unclear
• Suspected occupational asthma (symptoms that improve when patient is not at
work, adult- onset asthma, and workers in high- risk occupations)
• Poor response to asthma treatment
• Severe/ life- threatening asthma attack
'Red flags' and indicators of other diagnoses
• Prominent systemic features (myalgia, fever, weight loss)
• Unexpected clinical findings (eg crackles, clubbing, cyanosis, cardiac disease,
monophonic wheeze or stridor)
• Persistent invariable breathlessness
• Chronic sputum production
• Unexplained restrictive spirometry
•
CXR
shadowing
• Marked blood eosinophilia
Source: data from
impr ovem ent/ gui deli nes/ ast hma/
BTS/ SIGN
Guide line for the manageme nt of asthm a
2019
).
2019
: https:// www.brit- thora cic.org.uk/ qual ity-
SIGN
158
BTS/ SIGN
revised
2019
2019
.
)
4 Chest medicine
660
640
PEF L/min
660
640
620
600
580
560
540
520
500
480
460
440
420
400
380
Age in years
BMJ
Peak expiratory flow (L/min)
Arrows point to early morning ‘dips’
6
Time of day (h)
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620
600
580
560
540
520
500
480
460
440
420
400
380
19075
72
183
69
175
66
167
63
160
Ht.
Ht.
(ins)
(cm)
Standard deviation men 48 litres/min
Standard deviation women
175
69
42
litres/min
16766
16063
15260
14557
Ht.
Ht.
(cm)
(ins)
163
MEN
WOMEN
15 20 25 30 35
Fig 4.
9
Normal peak expiratory flow (
Data from Nunn AJ, Gregg I. New regression equations for predicting peak expiratory
1800 18001000 1800
1400
0600 0600 0600 0600 06001400 1400 1400 1400
250
200
150
100
50
Day 1Day
Recovery from severe attack of asthma
Fig 4.
Predicted PEF was
10
Example of serial peak flow chart.
40 45
PEF
).
50 55 60 65 70
flow in adults.
1989;298:1068– 70
.
1800 18001000 10001000
2
Day
3
Day
4
Day
5
Day
320
L/min
4 Chest medicine
Management of chronic asthma
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164
Lifestyle Help to quit smoking (p85). Avoid precipitants. Weight loss if overweight.
Check inhaler technique. Teach use of a peak flow meter to monitor
day. Oer self- management education which should include a written personalized
asthma action plan with specific advice about what to do in an emergency and
how to alter their medication in the light of symptoms or
programmes have been shown to improve quality of life (
Global Initiative for Asthma guidelines (
GINA
PEF
. Breathing exercise
QOL
) & reduce symptoms.
5
) Start at the step most appropriate to severity; moving up if needed, or down if control is good for >
Before initiating a new therapy, check adherence with existing therapies, check
inhaler technique, and eliminate trigger factors. Treat modifiable risk factors and
comorbidities. For drug examples see
Treatment with short- acting 2- agonists (
ICS
steroids (
adults with asthma should now receive
(in mild asthma,
serious exacerbations and to control symptoms.
• Step 1: intermittent asthma (symptoms < twice/ month) Use a combination in-
haler of low- dose
) is no longer recommended as this appears to exacerbations. All
GINA
steps 1 to 2) or daily (
ICS
and long- acting 2- agonist (
as needed for symptoms relief. Alternatively, use low- dose
needed.
• Step 2: mild persistent (symptoms ≥ twice a month but < than daily) Daily low-
ICS
+ as- needed
dose
antagonists (
• Step 3: moderate persistent (symptoms most days, or waking with asthma
once a week or more)
SABA
LTRA
) are an alternative if avoiding
Low- dose
ferred) or daily low- dose
addition of long- acting muscarinic antagonist (
contraindicated/ not tolerated. Less eective alternatives include medium dose of
ICS +
inhaled
• Step 4: severe persistent (symptoms most days, or waking with asthma once a
week or more, or low lung function)
reliever therapy
add- on
• Step 5 High- dose
as- needed
LTRA.
tiotropium, anti-
SABA
.
Alternative options include high- dose
ICS- LABA.
IgE
, anti-
IL- 5/ 5R
dose oral corticosteroids but long- term systemic
table
4.5
.
SABA
) alone without inhaled cortico-
ICS
. This can be either symptom- driven
GINA
steps 2 to 5), to reduce the risk of
LABA
) (eg budesonide- formoterol)
ICS
whenever a
or as- needed low- dose
ICS- LABA
ICS- LABA
maintenance plus as- needed
or low- dose
Medium- dose
ICS- LABA.
ICS,
Leukotriene receptor
but less ecacious.
maintenance and reliever therapy (pre-
LAMA
) (eg tiotropium) if
ICS
with
LTRA.
ICS- LABA
as maintenance and
ICS
, add- on tiotropium, or
Refer for phenotypic assessment ± add- on therapy, eg
, anti-
IL- 4R
. Some patients may benefit from low-
SE
are common and serious.
At each step, every patient should also have a reliever inhaler, either low- dose
ICS
- formoterol (preferred) or
SABA
.
Drugs Corticosteroids Best inhaled to minimize systemic eects, eg beclometasone
PO
via spacer (or powder), but may be given
or IV. They act over days to bronchial
mucosal inflammation. Rinse mouth after inhaled steroids to prevent oral candidiasis. Oral steroids are used acutely (high- dose, short courses, eg prednisolone
40
mg/ 24h PO for 7d) and longer term in lower dose (eg 5– 10mg/ 24h) if control is not
optimal on inhalers. Warn about
2- adrenoceptor agonists Relax bronchial smooth muscle (
minutes. Salbutamol is best given by inhalation (aerosol, powder, nebulizer), but
may also be given
PO
or IV. SE: tachyarrhythmias, K+ , tremor, anxiety.
SE
: p
373
.
CAMP
Anticholinergics (Eg tiotropium (Spiriva®Respimat®), 2 pus (2.5 mcg) once daily.)
May muscle spasm synergistically with
5
by mist inhaler for patients with a history of exacerbations despite
: dry mouth,
SE
URTI.
- agonists. An add- on option at step 4 or
2
Leukotriene receptor antagonists (Eg oral montelukast, zafirlukast.) Block
the eects of cysteinyl leukotrienes in the airways by antagonizing the CystLT
receptor.
PEF
twice a
3
months.
SABA
SABA.
Consider
LABA
), acting within
ICS
±
LABA.
is
1
4 Chest medicine
Cromoglicate (Mast cell stabilizer.) Very limited role in long- term treatment of
SABA
LABA
COPD
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ICS
asthma. Weak anti- inflammatory eect, less eective than low- dose
meticulous inhaler maintenance.
SE:
cough upon inhalation, pharyngeal discomfort.
. Require
Anti- IgE monoclonal antibody Omalizumab 6 may be of use in highly selected pa-
IgE
tients with persistent allergic asthma who have a serum
and documented sensitivity to a perennial allergen. Given as a subcutaneous injection every
Anti-
or anti-
2– 4
wks depending on dose. Specialists prescribe only.
IL
- 5 therapy Anti-
IL- 5
receptor alpha antibody (eg benralizumab). Reduce exacerbations in
IL- 5
monoclonal antibodies (eg mepolizumab, reslizumab)
level of 30–
700IU/ mL
severe eosinophilic asthma.
Anti- IL- 4 receptor alpha- subunit antibody (eg dupilumab), similarly reduces ex-
acerbations in moderate- to- severe, eosinophilic asthma.
Table 4.
5
Adult doses of common inhaled drugs used in bronchoconstriction
Salbutamol (
Dose example:
Formoterol (
Single dose
Recommended regimen
Steroids
Budesonide
Doses available/ pu
Recommended regimen
Budesonide– formoterol combination
Recommended regimen
Fluticasone
Doses available/ pu
Recommended regimen
Tiotropium bromide (
Dose/ pu
Recommended regimen
Systemic absorption (via the throat) is less if inhalation is through a large- volume device, eg Volumatic®
or AeroChamber Plus® devices. The latter is more compact. Static charge on some devices reduces
dose delivery, so wash in water before dose; leave to dry (don’t rub). It’s pointless to squirt many pus
into a device: it is best to repeat single doses, and be sure to inhale as soon as the drug is in the spacer.
SE
: local (oral) candidiasis (p
Inhaled
aerosol
)
100– 200
)
373
mcg/ 6h
For maintenance therapy, initially
tenance and reliever therapy,
1
pu as required for relief of symptoms, increased
doses +
if necessary up to
50, 100, 250
500
mcg
100– 250
mcg/ 12h
)
2.5
mcg
25
mcg daily
); rate of cataract if lifetime dose ≥2g beclometasone.
, &
Inhaled
powder
200– 400
12
mcg
12
mcg/ 12h
100– 800
200– 400
100/ 6, 200/ 6
400/ 12
6
pus as required
As for aerosol
100– 250
max
9
mcg
18
mcg daily
Nebulized
(supervised)
mcg/ 6h
mcg/ 12h
mcg/ 24h0.25– 1mg/ 12h
mcg
2
pus daily in 1– 2 divided
mcg/ 12h
1
mg/ 12h
2.5– 5
250
,
1– 2
pus/ 12h. For main-
250
0.5– 2
—
—
7
mcg
mcg/ mL
mg/ 6h
mg/ 12h
Prescribe beclometasone by brand name, because, dose for dose, Qvar® is twice
CFC
as potent as the other available
Any dose ≥
ommendation is being widened, and lower doses (beclometasone) are now said to
merit a steroid card (manufacturer’s information).
250
mcg ≈ significant steroid absorption: carry a steroid card; this rec-
- free brand (Clenil Modulite®).
165
4 Chest medicine
Chronic obstructive pulmonary disease (
COPD
COPD
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166
Definitions
terized by persistent respiratory symptoms and airflow limitation (
dicted;
usually caused by significant exposure to noxious particles or gases.
include chronic bronchitis and emphysema though there is significant overlap.
Chronic bronchitis is defined clinically as cough, sputum production on most days
for
COPD
is a common, preventable, and treatable disease that is charac-
FEV
/
FVC
<0.7; see p
1
3
months of 2 successive years. Symptoms improve if they stop smoking. There is
no excess mortality if lung function is normal.
as enlarged air spaces distal to terminal bronchioles, with destruction of alveolar
walls but often visualized on
airflow limitation with several features usually associated with asthma and several
features usually associated with
Prevalence
251
million cases globally; 4th leading cause of death.
Risk factors Tobacco smoking (most commonly), indoor and outdoor air pollution,
occupational exposures (eg chemicals and fumes), genetic factors (
deficiency), ageing, female sex, low socioeconomic status, asthma, severe childhood
respiratory infections.
Assessment of
COPD
etry, risk of exacerbations, and comorbidities.
Symptoms Chronic cough; sputum; dyspnoea; wheeze. Recurrent
Tachypnoea; use of accessory muscles of respiration; hyperinflation; cricosternal
distance (<
breath sounds (eg over bullae); wheeze; cyanosis; cor pulmonale.
3
cm); expansion; resonant or hyperresonant percussion note; quiet
Complications Acute exacerbations ± infection; polycythaemia; respiratory failure;
cor pulmonale (oedema;
Concomitant chronic diseases
sion, anxiety.
Te st s
FBC PCV.
1- antitrypsin <20% highly suggestive of homozygous deficiency
Hyperinflation; flat hemidiaphragms; large central pulmonary arteries; peripheral
vascular markings; bullae.
ECG
Ri g ht at r ia l a n d v en tr i cu la r hy pe rt ro p hy (c o r p ul mo n al e) .
ment.
COPD.
in severe
ping (
DLCO
person: ensure maximal expiration of the full breath (it takes >
out).
PaO2 ± hypercapnia. Spirometry (p
FEV
<80% of predicted,
1
in emphysema— see p
6
- minute walk test Evaluate disability, rehab assessment. Assess complica-
tions/ comorbidities
disease, screen for lung cancer, osteoporosis, depression,
Treatment Multidisciplinary. Chronic stable: see
risk (including pneumonia) with
p85). Encourage exercise: consider physio or OT referral.
vice (
advice ± supplements
ductive cough (
for this (
p
392
. Assess inhaler technique and medication compliance regularly. Azithromycin
exacerbations. Consider in sputum- producing non- smokers, optimized on other
therapies, if ≥
quiring hospitalization. Check
NICE
). 10 Disabilities may cause serious, treatable depression; screen
p15). Oedema: diuretics. 'Flu and pneumococcal vaccinations: p
4
exacerbations/ year, prolonged exacerbation, or exacerbation re-
bronchodilator; less commonly used now due to risk of toxicity.
Long- term O2 therapy (
15
h a day, 3yr survival improved from 30% to 50%. UK
for
should be given for:
1
imal . These values should be stable on two occasions >
and pulmonary hypertension (eg
or nocturnal hypoxia.
)
FEV
<80% pre-
155
) that is due to airway and/ or alveolar abnormalities
1
COPD
subtypes
Emphysema is defined histologically
CT
. Asthma-
overlap is characterized by persistent
COPD.
8
- antitrypsin
1
Assess symptoms, degree of airflow limitation using spirom-
LRTIS.
Signs
JVP
); pneumothorax (ruptured bullae); lung carcinoma.
CVD
, metabolic syndrome, osteoporosis, depres-
CXR
CT
Bronchial wall thickening; scarring; air space enlarge-
154
BOX
, p
and fig
BNF 3.7
154
TTE
if signs of
9
may help (p
LTO T
) An
FEV
:
FVC
ratio <70% post- bronchodilator,
1
). Learn how to do spirometry from an experienced
RHF,
low threshold to evaluate for coronary artery
ICS
.2 Emergency : p
584
). Mucolytics (
QTC
before prescribing. Theophylline is an older, oral
MRC
trial showed that if PaO2 was maintained ≥8.0kPa
ABG
155
GORD,
794
Recommended
) Obstructive + air trap-
4
s; it’s not a quick pu
etc.
4.11
; be aware of SE
. Smoking cessation ad-
BMI
is often low; diet
) may help chronic pro-
NICE
guidelines suggest
TLC
169
, RV,
and
LTO T
Clinically stable non- smokers with PaO2 <7.3kPa— despite max-
3
RVH
; loud
S
), or polycythaemia, or peripheral oedema,
3
O2 can also be prescribed for terminally ill patients.
2
wks apart. 2 If PaO2 7.3– 8.0
4 Chest medicine
Severity assessment in
BODE
COPD
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Severity assessment has implications for therapy and prognosis. The Global Initiative
COPD (GOLD
for
FEV
% predicted. Later versions ('
1
exacerbation. But, neither predict outcome. The
) categorizes
flow Obstruction, Dyspnoea and Exercise capacity) does have some predictive value
for outcomes, and number and severity of exacerbations—
7–10
scoring
is only 20% and likely to have even poorer survival if oered mechanical ventilation. Similarly, being house-, bed-, or chair-bound carries a very poor
prognosis and it would be dicult to justify mechanical ventilation in this group.
NICE COPD
guidelines
Fig 4.
11
Chronic obstructive pulmonary disease in over 16s: non- pharmacological management and use of inhaled therapies. * Asthmatic features/ features suggesting steroid responsiveness: previous diagnosis of asthma/ atopy, blood eosinophil count, substantial variation in
FEV
(>
400
mL) or diurnal variation in
1
© National Institute for Health and Care Excellence
disease in over
NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to
regular review and may be updated or withdrawn.
More advanced
16
s: diagnosis and management. Available from https:// www.nice.org.uk/ guida nce/ ng115.
Pulmonary rehabilitation improves symptoms,
• Consider
• Surgery may be appropriate in selected patients, eg recurrent pneumothoraces;
•
•
• Consider palliative care input.
LTO T
if PaO2 <7.3kPa (see ‘Long- term O2 the rapy’, earli er in to pic).
isolated bullous disease. Lung volume reduction/ endobronchial valve/ transplant.
NIV
may b e appr opria te if hy percap nic on
NB:
may n eed an oxygen asses sment pre- flight as air travel is risky if very hypoxic.
Indications for specialist referral
• Uncertain diagnosis, or suspected severe
• Onset of cor pulmonale.
• Bullous lung disease (to assess for surgery).
• Assessment for oral corticosteroids, nebulizer therapy, or
• <10 pack- years smoking (= the number of packs/ day × years of smoking) or
in patient <
• Symptoms disproportionate to lung function tests.
• Fre que nt inf ect ion s ( to excl ude br onc hie ct asi s) o r h aem op tysi s.
2
Cochrane meta- analyses (
vs either alone.
halers alone are associated with mortality (by
40
yrs (eg is the cause α1- antitrypsin deficiency? p
2007
LABA
alone may exacerbation rates, but no excess hospitalizations or mortality; steroid in-
COPD
COPD
into four stages based on post- bronchodilator
ABCD
') also include symptom burden and risk of
index (Body mass index, air-
4
-year survival for those
PEF
(>20%).
2019
. NNG
115
Chronic obstructive pulmonary
QOL
, and reduces hospitalizations.
LTO T
.
COPD,
or a rapid d eclin e in
LTO T
.
286
) of trials (including
TORCH
) favour steroids +
33
%) compared with steroids +
LABA
LABA
FEV
.
1
COPD
).
(long- acting - agonist)
.
11
167
4 Chest medicine
Pneumonia
COVID
PCR
CURB
https://t.me/med1917
168
An acute lower respiratory tract infection associated with fever, symptoms and signs
in the chest, and abnormalities on the chest
if very young or old (
Classification and causes
Community- acquired pneumonia
derlying disease. Typical organisms: Streptococcus pneumoniae (commonest),
Haemophilus influenzae, Moraxella catarrhalis. Atypicals: Mycoplasma pneumoniae,
Staphylococcus aureus, Legion ella species, and Chlamydia. Gram- negative bacilli,
Coxiella burnetii and anaerobes are rarer (?aspiration). Viruses account for up to
'Flu may be complicated by community- acquired
Hospital- acquired Defined as >48h after hospital admission. If early onset (<5d) and
no other risk factors for multidrug- resistant (
Staph. aureus, H. influenzae, Gram- negative enterobacteria. If late onset (≥
factors for
MDR
organisms: Staph. aureus (often
(eg Pseudomonas, Klebsiella, E. coli, Serratia marcescens, Enterobacter).
Ventilator- associated Defined as >48h after endotracheal intubation.
Aspiration Those with stroke, myasthenia, bulbar palsies, consciousness (eg
postictal or intoxicated), oesophageal disease (achalasia, reflux), or poor dental
hygiene risk aspirating oropharyngeal anaerobes.
Immunocompromised patient Strep. pneumoniae, H. influenzae, Staph. aureus,
M. catarrhalis, M. pneumoniae, Gram −ve bacilli, and Pneumocystis jirovecii (formerly
named P. ca r in ii ,
p
397
Clinical features Symptoms Fever, rigors, malaise, anorexia, dyspnoea, cough,
purulent sputum, haemoptysis, and pleuritic pain.
(can be the only sign in the elderly— may also be hypothermic), tachypnoea, tachycardia, hypotension, signs of consolidation (reduced expansion, dull percussion,
tactile vocal fremitus/ vocal resonance, bronchial breathing), and a pleural rub.
Te st s Assess oxygenation: oxygen saturation, p
vere pneumonia) and
multilobar infiltrates, cavitation, or pleural eusion. Sputum for microscopy and
culture. Nasal
Urine: check for Legionella/ Pneumococcal urinary antigens. Atypical organism/ viral
serology (
influenza swabs ± respiratory BioFire®
MRSA
screen can help predict presence/ absence of
PCR
sp utu m/
culture. Consider bronchoscopy/
Severity ‘
- 65
each of:
• Confusion (abbreviated mental test ≤8).
• Urea >7mmol/ L.
• Respiratory rate ≥30/ min.
• BP <90mmHg systolic and/ or 60mmHg diastolic.
• Age ≥65.
0– 1
, PO antibiotic/ home treatment; 2, hospital therapy; ≥3, severe pneumonia
’ is a simple, validated severity scoring system.
indicates mortality
young— use clinical judgement. Other features increasing the risk of death are:
comorbidity; bilateral/ multilobar; P
Management p
When none exists, consult
1– 2
) give PO antibiotic; severe (
saturation ≥
Analgesia if pleurisy. Consider
adjunctive steroids in significant hypoxia (eg requiring
COVID-19
, or
796
94
%. IV fluids (anorexia, volume depletion, shock) and
COPD
. Follow- up: at 6 weeks (±
Complications (See p
failure, septicaemia, brain abscess, pericarditis, myocarditis, cholestatic jaundice.
X
30
- ray— fig 16.2, p
% are under 65yrs). Mortality: ~10% in hospital.
(
CAP
) May be primary or secondary to un-
MRSA
MDR
MRSA
). Other fungi, viruses (
CMV, HSV
707
. Incidence: 5– 11/
12
pneumonia.
13
) organisms: Strep. pneumoniae,
5
d) or risk
), Gram- negative enterobacteria
), and mycobacteria.
Signs Pyrexia, cyanosis, confusion
154
(
ABG
S if S
<92% or se-
BP
. Blood tests:
BAL
, complement fixation tests acutely, paired serology).
15– 40
%— consider
FBC, U&E, LFT, CRP. CXR
BAL
panel. Pleural fluid may be aspirated for
if p atient is immunocompromised or on
ITU
assessment. It may ‘underscore’ the
<8kPa.
aO2
(fig
16.2
aO2
MRSA
, p
707
): lobar or
pneumonia.
14,15
1 point for
ITU
. Antibiotics— refer to your local hospital antibiotic policy.
table
4.6
. If pneumonia not severe and not vomiting (
CURB- 65
>2) give IV. Oxygen: keep PaO2 >8.0 and/ or
ITU
if shock, hypercapnia, or remains hypoxic. Consider
175
.) Pleural eusion, empyema, lung abscess, respiratory
CXR
NIV
), refractory septic shock,
).
VTE
prophylaxis.
CURB- 65
1000
24
.
,
%.
/
4 Chest medicine
CI
Table 4.
https://t.me/med1917
6
Empirical treatment of pneumonia (check local policy)
Clinical
setting
Organisms
Community- acquired
Mild not
previously
CURB
Moderate
CURB
Streptococcus pneumoniae
Haemophilus influenzae
0–
1
Streptococcus pneumoniae
2
Haemophilus influenzae
Mycoplasma pneumoniae
Severe
CURB
As above
>
3
Panton– Valentine
Atypical
leucocidin- producing
Staph. aureus (
Legionella pneumophilia
PVL- SA
)
Chlamydophila species
Pneumocystis jirovecii
Hospital- acquired
Staph. aureus (often
MRSA
Gram- negative bacilli
Pseudomonas
Anaerobes
Aspiration
Streptococcus pneumoniae
Anaerobes
Gram- negative bacilli
Neutropenic patients
Gram- positive cocci
Gram- negative bacilli
Fungi (p
174
) Consider antifungals after 48h
Antibiotic (further dosage
details: pp
382– 3
)
16
Oral amoxicillin
clarithromycin
200
mg loading then
5
- day course)
Oral amoxicillin
clarithromycin
200
mg loading then
quired: amoxicillin
clarithromycin
Co- amoxiclav
sporin
clarithromycin
500
mg– 1g/ 8h or
500
mg/ 12h or doxycycline
100
mg/ day (initially
500
mg– 1g/ 8h +
500
mg/ 12h or doxycycline
100
mg/ 12h. If IV re-
500
mg/ 8h +
500
mg/ 12h (5– 7- day course)
1. 2
g/ 8h IV or cephalo-
IV
(eg ceftriaxone 2g/ 24h IV)
500
mg/ 12h IV (5– 7 days)
Add flucloxacillin ± rifampicin if Staph
suspected; vancomycin (or teicoplanin)
MRSA
suspected. Treat for 10d (14– 21d
if
if Staph, Legionella, or Gram −ve enteric
bacteria suspected)
Seek urgent help. Consider adding
linezolid, clindamycin, and rifampicin
Fluoroquinolone combined with clarithromycin, or rifampicin, if severe. See
Tetracycline
High- dose co- trimoxazole (
)
Co- amoxiclav
or signs and not at higher risk of resistance.
PO/ IV
If severe or higher risk of resistance,
antipseudomonal penicillin
piperacillin- tazobactam
generation cephalosporin
2
g/ 24h IV) or levofloxacin
p
383
). Add vancomycin if risk of
(
Co- amoxiclav
ceftriaxone
Aminoglycoside
cillin
IV OR
2
g/ 24h IV) + metronidazole
IV
or 3rd- generation cephalosporin
p
397
)
if non - severe symptoms
IV
(eg
4.5
g/ 8h) or 3rd-
IV
(eg ceftriaxone
750
mg
IV/ PO/
MRSA
cephalosporin IV (eg
IV
+ antipseudomo nal peni-
169
AND
IV
p
170
24h
IV
IV
Pneumococcal vaccine
At- risk groups
• All adults ≥65yrs old.
• Chronic heart, liver, kidney, or lung conditions.
• Diabetes mellitus not controlled by diet.
• Immunosuppression, eg spleen function,
20
mg/ d, cochlear implant, occupation risk (eg welders),
>
5
yrs.
every
Pre gn anc y, la ct ati on, T°, previous anaphylaxis to vaccine or one of its components.
AIDS
, or on chemotherapy or prednisolone
CSF
fluid leaks. Vaccinate
4 Chest medicine
Specific pneumonias
https://t.me/med1917
170
Pneumococcal pneumonia The commonest bacterial pneumonia. Aects all ages,
but is commoner in the elderly, alcoholics, post- splenectomy, immunosuppressed,
and patients with chronic heart failure or pre- existing lung disease.
Feve r, p leur isy, herp es l abia lis.
urinary antigen.
Tre at me nt Ceftriaxone (preferred), fluoroquinolone eg levofloxacin
or vancomycin. res istance to - lactams— check with Microbiology if in doubt.
Staphylococcal pneumonia May complicate influenza infection or occur in the
young, elderly, intravenous drug users, or patients with underlying disease, eg leukaemia, lymphoma, cystic fibrosis (
monia.
Tre at me nt
MSSA
Klebsiella pneumonia Rare. Community- acquired in elderly, diabetics, and alco-
holics, otherwise often
lobes, often drug resistant.
Pseudomonas A common pathogen in bronchiectasis and
hospital- acquired infections, particularly on
pseudomonal penicillin eg piperacillin-tazobactam, ceftazidime, meropenem, or
ciprofloxacin + a min ogly coside. Cons ider dual t herapy u nti l sus cep tibi lity is know n.
Mycoplasma pneumoniae Occurs in epidemics about every 4yrs. It presents insidi-
ously with 'flu- like symptoms (headache, myalgia, arthralgia) followed by a dry cough.
CXR:
reticular- nodular shadowing or patchy consolidation often of one lower lobe,
and worse than signs suggest.
may cause an autoimmune haemolytic anaemia.
multiforme,
litis; Guillain– Barré syndrome,
line (
fig
200
mg loading then
12.23
, p
Legionella pneumophila Colonizes water tanks kept at <60°C (eg hotel air-
conditioning and hot water systems) causing outbreaks. Immunocompromise,
smoking and comorbidities are risk factors. 'Flu- like symptoms (fever, malaise,
myalgia) precede a dry cough and dyspnoea. Extrapulmonary features include an-
D&V
orexia,
Blood tests may show lymphopenia, hyponatraemia, and deranged
may show haematuria.
fluoroquinolone (eg levofloxacin) for 2– 3wks or azithromycin (p
, hepatitis,
Chlamydophila pneumoniae The commonest chlamydial infection. Person- to-
person spread, biphasic illness: pharyngitis, hoarseness, otitis, followed by pneu-
Diagnosis Chlamydophila complement fixation test,
monia.
Treatment Doxycycline or azithromycin.
Chlamydophila psittaci Causes psittacosis (also known as ornithosis), acquired
from infected birds (typically parrots). Symptoms include headache, fever, dry
cough, lethargy, arthralgia, anorexia, and
but rare, eg meningoencephalitis, infective endocarditis, hepatitis, nephritis, rash,
splenomegaly.
Treatment Doxycycline or azithromycin.
CXR
shows patchy consolidation. Diagnosis Chlamydophila serology.
Viral pneumonia Influenza commonest (p
considered seasonal and covered by the annual ‘flu vaccine. Others: measles,
varicella zoster.
Pneumocystis pneumonia Causes life- threatening pneumonia in the immunosup-
HIV,
pressed (eg
Pneumocystis carinii, and now P. jirovecii.
dyspnoea, P
perihilar interstitial shadowing.
high- dose steroids). The organism responsible was previously called
, fever, bilateral crepitations.
aO2
sputum, bronchoalveolar lavage, or in a lung biopsy specimen. Sputum
High- dose co- trimoxazole (
Steroids are beneficial if severe hypoxaemia. Prophylaxis is indicated if the
200
×
count is <
106/ L or after the 1st attack.
CXR
shows lo bar con solida tion. If mo d/ severe check for
CF
: flucloxacillin;
HAP.
). It causes a bilateral cavitating bronchopneu-
MRSA
: vancomycin or linezolid.
Causes a cavitating pneumonia, particularly of the upper
Treatment Ceftriaxone or meropenem (if resistant).
Clinical features
CF.
It also causes
Diagnosis
ITU
or after surgery. Tr eat me nt Anti-
PCR
sputum or serology. Cold agglutinins
Complications Skin rash (erythema
561
), Stevens– Johnson syndrome, meningoencephalitis, or mye-
GN
. Tr ea tm en t Clarithromycin (
100
mg OD) or a fluroquinolone (eg levofloxacin or moxifloxacin).
AKI
, confusion, and coma.
CXR
Diagnosis Urine antigen/ culture,
D&V
. Extrapulmonary features are legion
392
and
18
It presents with a dry cough, exertional
CXR
may be normal or show bilateral
500
mg/ 12h) or doxycyc-
shows bi- basal consolidation.
LFT
PCR
sputum/
PCR
BOX
), but ‘swine flu’ (
S. Urinalysis
BAL.
Treatment
383
). 10% mortality.
invasive samples. 17
H1N1
Diagnosis Visualization of the organism in induced
p
397
), or pentamidine by slow
IVI
for 2– 3 weeks (p
PCR
19
) is now
CMV,
. Drugs
397
CD4
).
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