TAKE MY BREATH AWAY…...

TAKE MY BREATH AWAY…... Ali Hasan May Harker Anna Harrison-Murray Amer Ullah

MB • A 62 year old Caucasian woman breathing quickly, who arrived in England from Australia three weeks ago • Complained of feeling “lousy”

SYMPTOMS • One episode of haemoptysis • A tight chest affecting breathing - RR 20 on admission • 3/7 before attending A+E – first presentation of illness was aching knee and ankle joints. • Left shoulder pain later emerged

ALSO … • Anorexia, nausea, and vomiting • Dizziness, with one marked episode of confusion and loss of balance • Hot and cold flushes • Feeling very tired • Hot and cold flushes • Profound lethargy • Nausea and vomiting

PAST MEDICAL HISTORY • Previous episode of pneumonia, age 31. • Hot and cold flushes – previously well • controlled by HRT. • Hallux rigidus • High cholesterol – 7.5 (normal 4 - <6).

AND … • Occasional headaches when overworked. • Neurodermatitis which has not recurred for years.

SURGICAL HISTORY • Removal of fibroadenoma in the right breast • Tubal ligation

CURRENT MEDICATION • Remifem, an OTC HRT “replacement” • ALLERGIES • An adverse reaction to voltarol which caused paraesthesia in her foot.

FAMILY HISTORY • No illnesses mentioned in daughters • Mother had a cholesterol problem, for which she had an endarterectomy – and subsequently suffered a stroke which left her senile. • Maternal grandmother died of rheumatic heart disease.

SOCIAL HISTORY • An English woman who lives in Australia • Migrated to Australia, age 17 • Lives with her husband, a cattle farmer, two daughters • Smoked for 12 pack years, age 18-35

SYSTEMS REVIEW • CVS: • No palpitations, swelling, or previous history of SOB

SYSTEMS REVIEW CONT. • Respiratory system: • No cough • No wheezing • Occasional “nasal drip”

SYSTEMS REVIEW CONT • GU System: • Increased thirst • Went to the toilet 5x/24h • No urinary urgency, and usually one episode of nocturia per night • Two past urinary infections

SYSTEMS REVIEW CONT • GI System: • Patient has not eaten, and there were no bowel motions since presentation 3/7 ago. • Patient suffered from “plenty of wind”. • No tenderness or pain.

VITAL SIGNS BP 135/69 Temp. 38.6 Pulse 100 reg RR 20 O2 Sat 91% (air) GCS 15 CLINICAL EXAMINATION CVS ° abnormalities detected Resp GI ° abnormalities detected XX XX

INVESTIGATIONS • ECG • Blood Analysis • Chest Radiography • CT Scan • Microbiology

BLOOD ANALYSIS

ECG • Tachycardic sinus rhythm CHEST RADIOGRAPHY • Patchy consolidation left lung • Slight left pleural effusion CT SCAN

MICROBIOLOGY • Blood Cultures • Blood and Sputum Gram Stains • Antibiotic Sensitivity Tests • Legionella Titre

FOLLOW UP • 3/7 later • Patient appeared visibly better • IV antibiotics and fluid had been stopped – antibiotics were now oral • Nausea stopped 2/7 after admission

FOLLOW UP CONT • Chest no longer “tight”. Breaths deeper but still some pain on left side when taking very deep breaths • An intermittent dry unproductive cough appeared 2/7 after admission. No further sputum production or haemoptysis - referred to physio

MORE FOLLOW UP • Patient now eating small meals and resumed bowel movements • No further dizziness, but still the occasional flush

AND FINALLY… • Some lethargy. • Vital signs good. Pulse around 76, temp 36.6, resp rate around 15. • Discharge planned 3/7 after.

PATHOLOGY • DEFINITION • Inflammation of the lung parenchyma - exudative solidification (consolidation) • CAUSES • Bacterial (most common) Other

EPIDEMIOLOGY • Incidence of CAP - 12 per 1000 adults • CAP accounts for 5-12 % of all LRTI’s • Approximately 10% require hospitalisation

EPIDEMIOLOGY CONT • Mortality reduced by effective use of antibiotics but remains dangerous condition and a major cause of death in over 70’s • - Mx community < 1% - Mx in hospital Approximately 10%

CLASSIFICATION (1) • COMMUNITY AQCUIRED (CAP) • - Primary or secondary • - Mainly Gram +ve bacteria • HOSPITAL ACQUIRED • - Acquired > 48hrs after admission • - Mostly caused by Gram -ve bacteria • - Problem with antibiotic resistance

CLASSIFICATION (2) BY SITE • DIFFUSE (LOBULAR) • - patchy consolidation • - extension of pre-existing disease • - extremely common esp. infancy and old age • LOCALISED (LOBAR) • - involvement of large portion / entire lobe • - infrequent due to antibiotic effectiveness

CLASSIFICATION (3) • BY AETIOLOGY • COMMON ORGANISMS • - Streptococcus Pneumoniae (60-75%) • - Mycoplasma Pneumoniae (5-18%) • - Influenza A (usually with bacterial) • - Haemophilus influenzae • - Staphylococcus aureus • - Legionella species • - Chlamydia psittaci

CLINICAL FEATURES • Vary according to immune system and infecting agent • Symptoms • - Malaise • - high temp (up to 39.5) • - pleuritic pain • - dyspnoea • - cough • - purulent / rusty sputum • Signs • - fever • - cyanosis • - confusion • - tachypnoea • - tachycardia • - consolidation signs • - pleural rub

COMPLICATIONS • Respiratory failure • Hypotension • Atrial fibrilation • Pleural effusion • Empyema • Lung abscess • Organisation of exudate • Bacteremic dissemintion

Mild community acquired MANAGEMENT 1 Nonsmoking adults < 60 yrs Smoking adults & > 60 yrs Erythromycin 500 mg X 3 or Clarithromycin 250 mg x 2 Cefaclor 500 mg x3

MANAGEMENT 2 • Patients with severe pneumonia best managed on an intensive care unit Severe community acquired i.v. 6 h Cefuroxime 1.5 g & Clarithromycin 500 mg 12 h

MANAGEMENT OF MB • Severe community acquired pneumonia • No causative organism identified but L. pneumophilia Ag test (urine) negative

DRUGS 1 • Regular • CEFOTAXIME (broad spectrum antibiotic) 1g i.v. tds • ERYTHROMYCIN 500 mg oral qds • PARACETAMOL 1g oral qds • METOCLOPRAMIDE 10mg i.v. tds (for nausea - side-effect of antibiotics)

DRUGS 2 • As Required • DIHYDROCODEINE 30 mg oral (for pleuritic chest pain) • CYCLIZINE (for nausea/vomiting)50 mg oral • Saline

OTHER • O2 therapy for hypoxaemia • Fluids encouraged to avoid dehydration • Seen by chest physiotherapist due to inability to expectorate • Antibiotics shifted to oral route after 3 days of i.v.

TAKE MY BREATH AWAY…...