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Important causes of cough to consider in the elderly include chronic bronchitis, lung cancer, pulmonary infarct (check calves), bronchiectasis and left ventricular failure, in addition to the acute upper and lower respiratory infections to which they are prone. It is important to be surveillant for bronchial carcinoma in an older person presenting with cough, bearing in mind that the incidence rises with age. One study found the causes of chronic cough in the elderly to be postnasal drip syndrome 48%, gastro-oesophageal reflux 20% and asthma 17%.10
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COMMON RESPIRATORY INFECTIONS
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Respiratory infections, especially those of the upper respiratory tract, are usually regarded as trivial, but they account for an estimated one-fifth of all time lost from work and three-fifths of time lost from school, and are thus of great importance to the community.11 The majority of respiratory infections are viral in origin and antibiotics are therefore not indicated.
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URTIs are those involving the nasal airways to the larynx, while lower respiratory tract infections (LRTIs) affect the trachea downwards.
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Combined URTIs and LRTIs include influenza, measles, whooping cough and laryngotracheobronchitis.
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The common cold (acute coryza)
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This highly infectious URTI, which is often mistakenly referred to as ‘the flu’, produces a mild systemic upset and prominent nasal symptoms (see FIG. 42.1).
++
++
24–48 hours of weakness
Malaise and tiredness
Sore, runny nose
Sneezing
Sore throat
Slight fever
++
++
headache
hoarseness
cough
++
The watery nasal discharge becomes thick and purulent in about 24 hours and persists for up to a week. Secondary bacterial infection is uncommon.
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Advice to the patient includes:
++
rest—adequate sleep and rest
drink copious fluids
stop smoking (if applicable)
analgesics—paracetamol (acetaminophen) or aspirin (max. 8 tablets a day in adults)
steam inhalations for a blocked nose
cough mixture for a dry cough
gargling aspirin in water or lemon juice for a sore throat (avoid aspirin in children <16 years)
vitamin C powder or tablets (e.g. 2 g daily) may aid recovery; however, clinical trials are inconclusive
clinical trials of vitamin C, zinc lozenges and echinacea give contradictory results to date11
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Influenza causes a relatively debilitating illness and should not be confused with the common cold. The differences are presented in TABLE 42.6. The incubation period is usually 1–3 days and the illness commences abruptly with a fever, headache, shivering and generalised muscle aching (see FIG. 42.2).
++
++
++
During an influenza epidemic:
++
++
Tracheitis, bronchitis, bronchiolitis
Secondary bacterial infection
Pneumonia due to Staphylococcus aureus (mortality up to 20%)1
Toxic cardiomyopathy with sudden death (rare)
Encephalomyelitis (rare)
Depression (a common sequela)
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Advice to the patient includes:
++
rest in bed until the fever subsides and patient feels better
analgesics: paracetamol and aspirin or ibuprofen are effective, especially for fever
fluids: maintain high fluid intake (water and fruit juice)
freshly squeezed lemon juice and honey preparation
++
++
Note: These antiviral agents have questionable benefit in a low-risk population, but treatment for vulnerable patients is appropriate.
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Influenza vaccination offers some protection for up to 70% of the population for about 12 months.1 (See CHAPTER 9.)
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(The swine variety of H1N1 influenza A.)
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This strain presents with typical influenza symptoms commonly accompanied by gastrointestinal symptoms (especially diarrhoea). Like avian flu, it tends to occur in a pandemic and affects the young in particular.
++
The treatment is the same as for influenza in general, with neuraminidase inhibitors. A vaccine is now available.
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Avian (bird) flu due to H5N1 strain: refer to CHAPTER 28.
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Middle East respiratory syndrome (MERS–CoV)
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This is a viral respiratory disease of varying severity caused by a novel coronavirus. Symptoms include cough, fever and dyspnoea. Endemic to the Middle East, especially Saudi Arabia. No specific treatment but supportive. Significant mortality rate.
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This is acute inflammation of the tracheobronchial tree that usually follows an upper respiratory infection. Although generally mild and self-limiting, it may be serious in debilitated patients.
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Features of acute infectious bronchitis are:
++
cough and sputum (main symptoms)
wheeze and dyspnoea
usually viral infection
can complicate chronic bronchitis—often due to Haemophilus influenzae and Streptococcus pneumoniae
scattered wheeze on auscultation
fever or haemoptysis (uncommon)
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Symptomatic treatment
Inhaled bronchodilators for airflow limitation
Antibiotics usually not needed in previously healthy adult or child
Use antibiotics only if evidence of acute bacterial infection with fever, increased sputum volume and sputum purulence:
amoxycillin 500 mg (o) 8-hourly for 5 days
or
especially if mycoplasma suspected, doxycycline 200 mg (o) statim, 100 mg, daily for 5 days.
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This is a chronic productive cough for at least 3 successive months in 2 successive years:
++
++
Refer to COPD (in CHAPTER 83).
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This is inflammation of lung tissue. It usually presents as an acute illness with cough, fever and purulent sputum plus physical signs and X-ray changes of consolidation.
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However, the initial presentation of pneumonia can be misleading, especially when the patient presents with constitutional symptoms (fever, malaise and headache) rather than respiratory symptoms. A cough, although usually present, can be relatively insignificant in the total clinical picture. This diagnostic problem applies particularly to atypical pneumonia but can occur with bacterial pneumonia, especially lobar pneumonia.
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Community-acquired pneumonia12,14
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CAP occurs in people who are not or have not been in hospital recently, and who are not institutionalised or immunocompromised. The choice of antibiotic is initially empirical. CAP is usually caused by a single organism, especially Streptococcus pneumoniae, which is now becoming resistant to antibiotics.15 Treatment is usually for 5–10 days for most bacterial causes, 2 weeks for Mycoplasma or Chlamydia infection and 2–3 weeks for Legionella.
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The commonest community-acquired infection is with Streptococcus pneumoniae (majority), now becoming resistant to antibiotics, Haemophilus influenzae15 (mainly in COPD), M. pneumoniae (young adults), Klebsiella pneumoniae.
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Often history of viral respiratory infection
Rapidly ill with high temperature, dry cough, pleuritic pain, rigors or night sweats
1–2 days later may be rusty-coloured sputum
Rapid and shallow breathing follows
Examination: focal chest signs, consolidation
Investigations: CXR, sputum M&C, oxygen saturation, specific tests/serology, PCR
Complications: pleural effusion, empyema, lung abscess, respiratory failure
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The atypical pneumonias
++
++
Fever, malaise
Headache
Minimal respiratory symptoms, non-productive cough
Signs of consolidation absent
Chest X-ray (diffuse infiltration) incompatible with chest signs
++
++
Diagnostic criteria include:
++
prodromal influenza-like illness
a dry cough, confusion or diarrhoea
very high fever (may be relative bradycardia)
lymphopaenia with moderate leucocytosis
hyponatraemia
++
Patients can become prostrate with complications. Treat with:
++
++
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Antibiotic treatment according to severity11,12
++
This is usually empirical.
++
This does not require hospitalisation.
++
amoxycillin/clavulanate 875/125 mg (o) 12-hourly
for 5–7 days or amoxycillin 1 g 8-hourly
especially if S. pneumoniae isolated or suspected
plus (especially if atypical pneumonia suspected)
roxithromycin 300 mg (o) daily for 5 days or doxycycline 100 mg bd for 5 days
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Moderately severe pneumonia
++
This requires hospitalisation (see Guidelines box for severe pneumonia and hospital admission). Monitor with CXR; oximeter (keep PaO2 ≥ 94%).
++
Neonates
Age over 65 years
Coexisting illness
High temperature: >38°C
Clinical features of severe pneumonia
Involvement of more than one lobe
Inability to tolerate oral therapy
benzylpenicillin 1.2 g IV 4–6 hourly for 7 days
or
procaine penicillin 1.5 g IM daily (drugs of choice for S. pneumoniae) plus doxycycline
or
ceftriaxone 1 g IV daily for 7 days (in penicillin-allergic patient)
If not so severe and oral medication tolerated, can use amoxycillin/clavulanate or cefaclor or doxycycline
In tropical regions use a different regimen (refer to eTG)
If atypical pneumonia, use doxycycline, erythromycin or roxithromycin
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The criteria for severity (with increased risk of death) are presented in the box on Guidelines for severe pneumonia and hospital admission.14,15,16 The CURB-65 score indicates severity (Confusion, Urea > 7 mmol/L, Respiratory rate ≥30/min, BP <90/60 mmHg, Age ≥65).17
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azithromycin 500 mg IV daily (covers Mycoplasma, Chlamydia and Legionella)
plus
cefotaxime 1 g IV 8-hourly
or
ceftriaxone 1 g IV daily
add
flucloxacillin for Staphylococcus aureus
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Guidelines for severe pneumonia and hospital admission: the red flags
Altered mental state/acute onset confusion
Rapidly deteriorating course
Respiratory rate >30 per minute
Pulse rate >100 per minute
BP <90/60 mmHg
CURB-65 ≥2
Hypoxia PaO2 <60 mm Hg or O2 saturation <92%
Leucocytes <4 × 108L or >20 × 109/L
Multilobular involvement on CXR