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Clinical features

  • Tachypnoea, expiratory grunt

  • Possible focal chest signs

  • Diagnosis often only made by chest X-ray


  • Viruses are the most common cause in infants.

  • Mycoplasma is common in children over 5 years.

  • S. pneumoniae is a cause in all age groups.

  • Pathogens are difficult to isolate—may need blood culture.


Depends on age and tropical vs non-tropical. Almost all those under 48 months should be admitted to hospital. Indicators for hospital admission are shown in the box.

  • Minimal handling

  • Careful observations including pulse oximetry

  • Attend to hydration

  • Antibiotics indicated in all cases. Refer to guidelines for 5 years and older12

    Mild (general guidelines only):16

    • amoxycillin (o) or roxithromycin (o)


    • benzylpenicillin IV + roxithromycin (o) or doxycycline (o)


    • ceftriaxone IV or cefotaxamine IV ± azithromycin (o)

Note: Refer to eTG for various age groups and tropical regions.

Pneumonia in children: guidelines for hospitalisation14

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  • RR>70

  • Intermittent apnoea

  • Not feeding

Older children:

  • RR>50

  • Grunting

  • Signs of dehydration

Both groups:
  • SaO2 ≤ 92%

  • Cyanosis

  • Difficulty breathing

  • Family/social issues


A cough associated with a viral respiratory infection should last no more than 2 weeks. If it does, it is termed persistent. A cough lasting 2 months or more is defined as a chronic cough. A cough that lasts longer than 3–4 weeks requires scrutiny. TABLE 42.3 includes some causes of chronic cough.

A chronic cough can be divided into productive and non-productive. If productive, the presence of pus is significant, as purulent sputum usually means bacterial infection in the bronchi and/or sinuses.4 The main organisms are Haemophilus influenzae (the most common), S. pneumoniae and Moraxella. Such infections are most susceptible to amoxycillin or amoxycillin/clavulanate or parenteral cephalosporins.

Non-productive cough

Some of the many causes of a non-productive cough are included in TABLE 42.1 and more than one may be operative in a patient simultaneously; for example, an allergic snorer with oesophageal reflux taking an ACE inhibitor for hypertension may have a viral respiratory infection.4 It has been shown that a non-productive or irritating cough is usually caused by persistent stimulation of irritant receptors in the trachea and major bronchi, and may result in the production of small amounts of mucoid sputum.

Investigations to be considered in intractable chronic cough include a chest X-ray, spirometry, CT scan of the thorax (searching in particular for a tumour) and ambulatory oesophageal pH monitoring.

If bronchial hyper-responsiveness is proven, a trial of inhaled or oral corticosteroids can be used in these patients.5

Gastro-oesophageal reflux

This common condition is the most likely cause of a persistent, non-productive cough in an apparently well patient with a history of reflux. Recent studies utilising 24-hour ambulatory oesophageal pH monitoring have demonstrated that in patients with persistent unexplained cough the predominant cause is asymptomatic gastro-oesophageal reflux.4,5 In the absence of evidence of aspiration, the cough is considered to be due to stimulation of a distal oesophageal-tracheobronchial reflex. Other studies have established a relationship between bronchial asthma and reflux or swallowing disorders whereby microaspiration can initiate an inflammatory response in the airways.

Indications for 24-hour ambulatory oesophageal pH monitoring in chronic cough include:

  • unexplained chronic cough after clinical assessment

  • symptomatic gastro-oesophageal reflux

  • chronic cough with known aetiology unresponsive to therapy

If reflux is proven or suspected, treat with routine conservative anti-reflux measures and at least a 4-week trial of histamine H2-receptor antagonists. If cough persists, refer for further evaluation.5

If all investigations and treatment trials (including anti-reflux and corticosteroids) prove unrewarding, a trial of ipratropium bromide both nebulised (500 mcg, qid) and to a lesser degree metered dose inhaler (4 × 20 μg puffs qid) has been found to be effective.5,17

However, for patients with idiopathic chronic cough it is important to provide ongoing interest and support, and not eventually to dismiss them as ‘just a cough’.

Bronchial carcinoma

Lung cancer accounts for 25% of cancer deaths in men and 24% of cancer deaths in women (rapidly rising), with cigarette smoking being the most common cause of lung cancer in both sexes.11 It is also the most common lethal cancer in both sexes in Australia. Bronchial carcinoma accounts for over 95% of primary lung malignancies. The prognosis is poor—the 5-year overall survival is 12–14%.18 The mesothelioma incidence continues to rise.

Clinical features

  • Most present between 50 and 70 years (mean 67 years)

  • Only 10–25% asymptomatic at time of diagnosis9

  • If symptomatic—usually advanced and not resectable

Local symptoms

  • Cough (42%)

  • Chest pain (22%)

  • Wheezing (15%)

  • Haemoptysis (7%)

  • Dyspnoea (5%)


  • Anorexia, malaise

  • Weight loss—unexplained


  • Unresolved chest infection

  • Hoarseness

  • Symptoms from metastases

The possible physical findings are summarised in FIGURE 42.3.


Possible physical findings of bronchial carcinoma


  • Chest X-ray

  • Sputum cytology

  • CT scanning

  • Fibre-optic bronchoscopy

  • PET scanning

  • Fluorescence bronchoscopy (helps early detection)

  • Tissue diagnosis where possible

Note: Based on a 2003 Cochrane review, no proven effect of any screening for asymptomatic patients.

Causes of a solitary pulmonary nodule on X-ray are presented in TABLE 42.7.

Table 42.7Causes of a solitary pulmonary nodule (on X-ray)19

Refer to a respiratory physician to determine the type of cancer. They are usually classified as small cell lung (oat cell) poorly differentiated cancer (15–20% incidence) (SCLC) and non-small cell lung cancer (NSCLC), which includes squamous cell carcinoma, adenocarcinoma and large cell carcinoma (approximately 20–30% of each). The main aim of management is a curative resection of NSCLC in those who can benefit from it. Surgery is not an option for SCLC since it metastasises so rapidly (80% have metastasised at the time of diagnosis).14 Chemotherapy is suitable for the deadly SCLC but currently only extends life expectancy from 3–20 months (at best). It also has an important place in treating NSCLC. The main role of radiotherapy is palliative.


Mesothelioma is a malignant tumour of mesothelial cells usually at the pleura. It is associated with prior asbestos exposure, possibly decades earlier (90% report exposure).

Clinical features include chest pain, dyspnoea, weight loss and recurrent pleural effusions. Diagnosis is based on imaging and on histology after pleural biopsy. Prognosis is poor and treatment is palliative support.


Bronchiectasis is dilatation of the bronchi when their walls become inflamed, thickened and irreversibly damaged, usually after obstruction followed by infection. Predisposing causes include whooping cough, measles, TB, inhaled foreign body (e.g. peanuts in children), bronchial carcinoma, cystic fibrosis and congenital ciliary dysfunction (Kartagener syndrome). The left lower lobe and lingula are the commonest sites for localised disease.

Clinical features

  • Chronic cough—worse on waking

  • Mild cases: yellow or green sputum only after infection

  • Advanced:

    • – profuse purulent offensive sputum

    • – persistent halitosis

    • – recurrent febrile episodes

    • – malaise, weight loss

  • Episodes of pneumonia

  • Sputum production related to posture

  • Haemoptysis (blood-stained sputum or massive) possible


  • Clubbing

  • Coarse crackles over infected areas (usually lung base)

  • Other respiratory signs are given in TABLE 49.6 (see CHAPTER 49).


  • Chest X-ray (normal or bronchial changes)

  • Sputum examination: for resistant pathogens and to exclude TB

  • Cytology: to rule out neoplasia

  • Main pathogens: Streptococcus pneumoniae, Pseudomonas aeruginosa, Haemophilus influenzae (commonest), Staphylococcus aureus

  • CT scan: can show bronchial wall thickening—high-resolution CT scan is the new gold standard for diagnosis

  • Spirometry

  • Bronchograms: very unpleasant and used only if diagnosis in doubt or possible localised disease amenable to surgery (rare)


  • Explanation and preventive advice.

  • Postural drainage (e.g. lie over side of bed with head and thorax down for 10–20 minutes three times a day).

  • Antibiotics for acute exacerbations according to organism—it is important to eradicate infection to halt the progress of the disease. Amoxycillin 500 mg (o) tds for 14 days or doxycyclin 200 mg (o) daily (if child ≥8 years) is recommended for first presentation.20 Avoid long-term use.

  • Bronchodilators, if evidence of bronchospasm.21

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