TAKE MY BREATH AWAY

1
TAKE MY BREATH AWAY...

• Ali Hasan
• May Harker
• Anna Harrison-Murray
• Amer Ullah

2
MB

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

3
SYMPTOMS

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

4
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

5
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 - lt6).

6
AND

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

7

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

8

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

9

• 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.

10

• 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

11

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

12
SYSTEMS REVIEW CONT.

• Respiratory system
• No cough
• No wheezing
• Occasional nasal drip

13
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

14
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.

15
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
16
INVESTIGATIONS

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

17
BLOOD ANALYSIS
18

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

19
(No Transcript)
20
(No Transcript)
21
MICROBIOLOGY

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

22

• 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

23
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

24

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

25

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

26
PATHOLOGY

• DEFINITION
• Inflammation of the lung parenchyma -
  exudative solidification (consolidation)

• CAUSES
• Bacterial (most common)
  Other

27
EPIDEMIOLOGY

• Incidence of CAP - 12 per 1000 adults
• CAP accounts for 5-12 of all LRTIs
• Approximately 10 require hospitalisation

28
EPIDEMIOLOGY CONT

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

29
CLASSIFICATION (1)

• COMMUNITY AQCUIRED (CAP)
• - Primary or secondary
• - Mainly Gram ve bacteria

• HOSPITAL ACQUIRED
• - Acquired gt 48hrs after admission
• - Mostly caused by Gram -ve bacteria
• - Problem with antibiotic resistance

30
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

31
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

32
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

33
COMPLICATIONS

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

34

• MANAGEMENT 1

Mild community acquired
Nonsmoking adults lt 60 yrs
Smoking adults gt 60 yrs
Erythromycin 500 mg X 3 or Clarithromycin 250 mg
x 2
Cefaclor 500 mg x3
35
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
36
MANAGEMENT OF MB

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

37
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)

38
DRUGS 2

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

39
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.