Lower Respiratory Infections

Description

This is an inflammation of the lungs usually caused by Streptococcus pneumoniae, Mycoplasma pneumoniae and Staphylococcus aureus Haemophilus Influenzae type B and atypical organisms such as Jiroveci pneumonia.

Clinical features
These are usually of sudden onset.

Signs and Symptoms

• Fever
• Dry or productive cough
• Chest pain
• Chills
• Breathlessness
• Children may be unable to drink or breastfeed
• Bronchial breathing
• Drowsiness
• Increased respiration rate
• Cyanosis may be present
• Flaring of nostrils
• Chest indrawing
• Increased pulse rate
• Crepitations
• Breath sounds may be reduced
• Sputum may be “rusty”.

Complications

• Septicaemia
• Lung abscess
• Emphysema
• Heart failure
• Meningitis

Investigations

This is based on clinical findings but may be supported by radiological examinations which show lobar and bronchial pneumonia.

Treatment

Some patients will need admission particularly if there is cyanosis or complications.
• Benzylpenicillin 1-2MU intravenously 6 hourly for 5 days adults, children 25,000-50,000 units/kg
intravenously/intramuscularly in 4 divided doses for 7 days (as soon as the symptoms and respiratory rates
are controlled change to oral medication i.e. Amoxycillin 250mg for adults and 125 mg/5ml in children) or
• Ceftriaxone 1g - 2g daily adults, children 20 50mg/kg daily intravenously/intramuscularly for 7 days. if
allergic to penicillin or
• Erythromycin 500mg adults, orally 6 hourly for 7 days, children 2030mg/kg in 4 divided doses for 7 days
• Oxygen is indicated if respiratory distress or cyanosis is present
• Non-opiate analgesics; Paracetamol 500mg - 1g orally 3 - 4 times daily adults, children 10-20mg/kg orally3 - 4 times daily.
Refer early to a specialist if the patient is not rapidly improving with antibiotic treatment

Description

This is a chronic inflammatory disease of the airways whose main characteristics are airflow limitation, airway hyper-responsiveness and inflammation of the bronchi.
Asthma may start in childhood, worsening or improving in adolescence. Airflow limitation is usually reversible either spontaneously or with treatment.

Signs and Symptoms

• Difficulty in breathing
• Coughing
• Restlessness
• Wheezing
• Prolonged expiration
• Cyanosis if severe
• Rapid pulse

Treatment

Supportive
• Modification in lifestyle
• Stop smoking
• Avoid known precipitants
• Reduction in weight (to normal BMI)

Pharmacological
For long-term management of Asthma, the step-wise approach is recommended.
STEP 1
• Intermittent asthma (symptoms < twice a month)
• Use Low dose inhaled corticosteroids (ICS) & Short acting β-blockers (SAβA) as needed.
STEP 2
• Mild persistent (symptoms ≥ twice a month but < daily)
• Daily low dose ICS + as needed SaβA
STEP 3
• Moderate persistent (symptoms most days, or waking with asthma once a week or more, or low lung
function)
• Low dose ICS-LAβA maintenance + Reliever therapy
OR
• Low-dose ICS-LAβA maintenance
• Plus as needed SAβA
• Consider adding leucotriene receptor antagonist
STEP 4
• Severe persistent symptoms most days or waking with asthma once a week or more, Or low lung function
• Medium-dose ICS-LAβA as maintenance + reliever therapy
• Alternative options include
• High-dose ICS, add-on ipratropium or /add on LTRA
STEP 5
• High dose ICS plus LABA
• Refer to phenotypic assessment ± add-on therapy anti-IGE and anti-IL4R (Interleukin 4 Receptor)
Management of Acute Exacerbation
Mild to Moderate attack
• Inhaled SAβA 4-10 puffs by metered dose inhaler plus spacer till symptoms improve.
OR
• Nebulized salbutamol 5mg every 15 – 20 minutes until symptoms improve.
• Oral prednisolone 30-60 mg once daily for 3-5 days
Severe Attack
• Prop-up patient
• Give O2 @ 60% (6-15L/min) high flow mask
• Nebulization with Salbutamol 5mg. Repeat after 30 minutes.
• Then add Ipratropium Bromide 0.5mg 4 hourly and Hydrocortisone 200mg IV stat then 100mg tds IV

Description

COPD is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually
progressive (over time) COPD cover a wide variety of clinical syndromes associated with airflow obstruction and destruction of the lung parenchyma, spanning the spectrum with chronic bronchitis on one end and emphysema on the other extreme.
Risk factors:
• Cigarette smoke
• Biofuel smoke
• Genetic-α1-antitrypsin deficiency

Signs and Symptoms

• Cough
• Sputum
• Exertional breathlessness
• Wheezes

Investigations

• Sputum- for Gram staining
• Blood culture (where necessary)
• CxR
• Chest CT Scan
• FBC – Hb and PCV are elevated due to persistent hypoxemia
• Urea & Creatinine
• SpO2
• Arterial Blood Gases
• Peak Flows
• ECG- maybe normal or reveal P-pulmonale or RVH
• 1-antitrypsin levels where possible

Treatment

• Smoking cessation is a major factor in improving outcomes
• Treat hypoxia & respiratory failure - Oxygen 24-28% (Venturi mask)
• Bronchodilators adrenergic dilators - salbutamol inhaler 200mcg 6 hourly
• Anticholinergic agents-inhaled ipratropium bromide 20mcg/dose 6 hourly (not to exceed 12 puffs in 24
hours)
• Theophyllines - may not be helpful in COPD
• Phosphodiesterase type IV inhibitors-increase intracellular cyclic adenosine monophosphate (cAMP)
resulting in bronchodilatation
• Corticosteroid inhaler (investigation should be clearly done)
• Antibiotics - Erythromycin 500mg four times daily for 5 days (frequency to be uniform)

Exacerbation of COPD
Description
This is an acute deterioration of the respiratory symptoms of patients with underlying COPD results in
additional therapy.

Common causes include:
• Infections
o Bacteria-H. influenzae, S. pneumoniae, M. catarrhalis
o Viruses-Community Acquired Pneumonia
• Bullae-Pneumothorax

Treatment• Treat causes of exacerbations of the conditions
• Hydrocortisone 200mg intravenously 4 hourly for 24 hours and maintain on oral Prednisolone 30mg on
alternate days (duration required)
• Suction of the fluid from the airway
• Give an appropriate antibiotic: Erythromycin 500mg QID (frequency) daily for 10 days
• Smoking cessation
• Give oxygen.

Prevention• Reduce industrial exposure
• Wear gas masks

Description

This is an irreversible obstruction of the airways characterised with the destruction of the alveoli and bronchioles by fibrosis.

Signs and Symptoms

• Severe shortness of breath with slight exertion
• Recurrent coughs
• Slight wheezing
• Barrel chest Signs
• Barrel chest
• Clubbing of fingers
• Hyper inflated lungs on X-ray
• Air trapping on X-ray

Treatment

Treat causes of exacerbations of the conditions
• Hydrocortisone 200mg intravenously 4 hourly for 24 hours and maintain on oral Prednisolone 30mg on alternate days
• Suction of the fluid from the airway
• Give an appropriate antibiotic i.e. Erythromycin
• 500mg while awaiting sputum results Supportive
• Give up the habit that caused the emphysema e.g. stop smoking,
• Give oxygen. Prevention
• Stop smoking
• Reduce industrial exposure
• Wear gas masks

If a child has a cough or difficulty in breathing, then he/ she may have a respiratory tract infection.

Clinical featuresMay include:

• Fast breathing
• Chest in drawing
• Stridor in a calm child
• Wheezing

It is important to count the respiratory rate of the child.

Classification

• No pneumonia cough or cold: a child is classified as having no pneumonia cough or cold if there are no signs of pneumonia
• Pneumonia: a child is classified as having pneumonia if there is fast breathing accompanying wheeze or cough Severe pneumonia: a child is classified as having severe pneumonia if there is chest in-drawing or stridor in a calm child.

TreatmentNo pneumonia cough or cold:

• If coughing for more than 21 days, refer for assessment,
• If wheezing give oral Salbutamol
• Follow up in 5 days if not improving.

Description

A pulmonary infection resulting from inhalation of bacteria-rich fluids into the lower respiratory tract.
This is frequently found in:
• Older adults
• CVA & post-stroke pneumonia
• Alcohol Use Disorder (AUD)
• Seizures
• Drug overdose
• Use of sedatives
• CNS disorders
• Muscular disorders

Signs and Symptoms

Commonly present with features of CAP, including cough, fever and malaise

Investigations

A comprehensive history regarding current or previous dysphagia, previous stroke, instances of aspiration,
coughing during eating or drinking, and other medical conditions predisposing to overt or silent aspiration aids
in diagnosing aspiration pneumonia.
• CxR
• CT Scan
• Septic screen
• FBC
• Urea & Creatinine
• Videofluoroscopy swallowing study (VFSS) (a modified barium swallow

Treatment

Supportive
• Nurse in lateral decubitus or propped-up
• NG tube insertion where necessary
• Chest physiotherapy

Pharmacological
Local facility outpatient
• Amoxicillin 500mg eight hourly 5-7 days
• Doxycycline 100mg twelve hourly 5-7 days
• Azithromycin 500mg stat then 250 mg once daily for 4 days

Patients with co-morbidities who are not admitted may be given
• Amoxicillin/clavulanate 500mg/125mg 8 hourly
• A combination of a cephalosporin and a macrolide
• Also, a respiratory quinolones (levofloxacin or moxifloxacin)

Hospitalized patients with non-severe CAP, without risk factors for methicillin-resistant Staphylococcus aureus (MRSA) infection or Pseudomonas aeruginosa
• Ampicillin/sulbactam 1.5g to 3 g 6 hourly
• Cefotaxime 1g to 2g -8 hourly or ceftriaxone 1g to 2g daily
• Ceftaroline 600 mg 12hourly plus a macrolide
• Also, a respiratory quinolones

In patients with confirmed risk factors for MRSA or P-aeruginosa or a prior history of infections secondary to these organisms
• Piperacillin/tazobactam
• Cefepime imipenem, or meropenem in combination with vancomycin or linezolid is the CURB 65 score
necessary should it be included

Signs and symptoms of pneumonia plus extra- pulmonary signs such as arthritis, splenomegaly caused by Mycoplasma, Chlamydia, PCP.

Treatment

• Erythromycin 500mg orally QID for 14 days for Chlamydia
• Co-trimoxazole 960mg every 12 hours for 21 days in combination with a steroid i.e. Prednisolone for PCP starting with 40mg per day and reducing by
5mg every 3 days for adults
• For children above 4 weeks to adults 120mg/Kg body weight in 2 to 4 divided doses for 21 day

Description

Corona virus disease 2019 (COVID-19) is a respiratory disease caused by the Severe Acute Respiratory
Syndrome Corona-Virus 2 (SARS-CoV-2)

Signs and Symptoms

Non-severe
• Fever
• Cough
• Myalgia
• Fatigue
• Evidence of lower respiratory tract infections by clinical assessment or imaging
• Sp0₂ >93% on room air above sea level
• Lung infiltrates < 50%

NB: Some patients may test positive for COVID-19 but are asymptomatic

Severe and/or Critical
• Shortness of breath
• Increased respiratory rate >30 bpm
• Respiratory failure
• Low oxygen saturations (SpO₂ ≤ 93% on room air above sea level)
• Lung infiltrates > 50%
• PaO₂/ FiO₂ > 300mmHg
• Sepsis/ septic shock
• Multi-organ failure

Investigations

• SARS-CoV-2 Antigen RDT (rapid diagnostic test)
• SARS-CoV-2 rt-PCR (Nucleic Acid Amplification Test - NAAT) test
• Sp0₂
• D-dimer
• CRP
• RBS/ FBS
• BP
• Chest x-ray or other imaging
• LFTs
• RFTs
• Gene Xpert for TB
• HIV
• Malaria (RDT and MPS)

Treatment

Risk factors for hospitalization or progression to severe disease:
• Age > 50 years
• BMI <18 or >24
• Co-morbidities such as HTN, DM
• Immunosuppressive conditions such as HIV, cancer, long-standing steroid use
• Chronic cardiopulmonary disease (asthma, CHF,CAD)
• Chronic kidney disease
• Pregnancy

Non-severe
• Nirmatrelvir/ Ritonavir 300/ 100mg twice daily for 5 days (150mg/ 100mg for eGFR ≥30 ml/min and <60
ml/min) OR
• Remdesivir IV (Adults and Children ≥ 40kg): 200mg on day 1 and 100mg on subsequent days. Duration
3-5 days
• Dosage (Children ≥3kg to <40kg): 5mg/kg on day 1 and 2.5mg/kg on subsequent days. Duration 3-5 days
• Molnupiravir 800mg twice daily for 5 days

Indications for Antivirals:
• Positive COVID-19 test
• Symptoms within 5 days of onset (for oral antivirals)
• Symptoms within 7 days of onset (for IV antiviral)
• At least 1 risk factor for progression to severe disease
• ≥ 12 years and ≥ 40 kg body weight (Nirmatrelvir/Ritonavir)
• ≥ 28 days and ≥ 3kg body weight (Remdesivir)
• ≥ 18 years (Molnupiravir)

NB: Molnupiravir is contraindicated in Pregnancy

Multiple drug-drug interactions with Nirmatrelvir/Ritonavir. Check www.covid19-druginteractions.org/checker

Supportive treatment
Severe and Critical (hospitalized patients) need:
• Oxygen therapy
Escalate to achieve target SPO2 above 94%
• Immune modulating drugs
o Dexamethasone IV 6mg once daily for up to 14 days OR
o Hydrocortisone IV 50mg three times daily for up to 14 days
o Prednisolone 40mg once daily for up to 14 days
NB: Steroids are only indicated in patients on O2
• Baricitinib
o Adults and children >9 years: 4mg od for up to 14 days
o Children ≥2 to ≤9 years: 2mg od for up to 14 days
Given to:
Among hospitalized adults with severe COVID-19 having elevated inflammatory markers but not on invasive mechanical ventilation, or
Among hospitalized patients with severe COVID-19 who cannot receive a corticosteroid (which is standard of care) because of a contraindication (add Remdesivir)

Monitor ALC, ANC and renal function
• Tocilizumab Weight <30 kg: 12 mg/kg as a single IV infusion over 60 minutes. Weight ≥30 kg: 8 mg/kg as a single IV infusion over 60 minutes single dose administration. Second in 12-48 hrs depending on clinical response. Max 800mg per infusion should be given only in combination with dexamethasone (or another corticosteroid at an equivalent dose), age ≥ 2 years
Renal: adjustment currently not warranted
• Antithrombotic
o Enoxaparin 0.5mg/kg SC once daily for mild infection
o Enoxaparin 1mg/kg SC twice daily for severe infection
• Chest physiotherapy
• Psycho-social counselling