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Chest infections - adult - Management
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How do I know my patient has acute bronchitis or community-acquired pneumonia?
Symptoms and signs of acute bronchitis and community-acquired pneumonia (CAP):
- Cough is the predominant symptom present in both acute bronchitis and CAP.
- A combination of symptoms and signs have been shown to have a high sensitivity for diagnosing CAP.
- The British Thoracic Society recommend using differentiating clinical features as an aid to diagnosing CAP and distinguishing it from acute bronchitis. Clinical judgement must always be used in combination with these recommendations because:
- No combination of symptoms or signs are clearly diagnostic for CAP.
- Elderly people with CAP present more frequently with non-specific symptoms, and are less likely to have a fever compared with younger people.
Features of acute bronchitis and community-acquired pneumonia
- The differentiating clinical features of acute bronchitis and community-acquired pneumonia are shown in Table 1.
Table 1. Symptoms and signs of acute bronchitis and community-acquired pneumonia.
Factor | Acute bronchitis | Community acquired pneumonia |
|---|
History | Cough | Cough |
May or may not have sputum, wheeze, or dyspnoea | At least one other symptom of sputum, wheeze, dyspnoea, or pleuritic pain |
Examination | Wheeze often present, but no other focal chest signs | Focal chest signs present Includes dullness to percussion, course crepitations, vocal fremitus |
May have systemic features with or without a raised temperature Features include sweats, fevers, myalgia | At least one systemic feature present with or without a temperature above 38°C Features include sweats, fevers, myalgia |
Investigations (not usually considered necessary in general practice) | Chest X–ray clear | Chest X–ray diagnostic |
|
Basis for recommendation
Recommendations on the diagnosis of bronchitis or community-acquired pneumonia are based on expert opinion from the British Thoracic Society in the guideline Recommendations for the management of cough in adults [Morice et al, 2006] and expert opinion from a review article [Metlay et al, 1997].
When should I investigate a chest infection?
- A chest X-ray is diagnostic of pneumonia, but is not considered necessary for most people with suspected community-acquired pneumonia (CAP) who are managed in the community.
- Microbiological investigations are not usually considered necessary to diagnose community-acquired pneumonia or acute bronchitis in most people with suspected acute bronchitis or CAP managed in the community. Sputum samples for culture and/or sensitivity may be useful in people with recurrent episodes of acute bronchitis who may have become colonized with bacteria resistant to first-line antibiotics.
Basis for recommendation
Recommendations on investigations are based on expert opinion from the British Thoracic Society in the guideline Recommendations for the management of cough in adults [Morice et al, 2006].
What else might it be?
- For people diagnosed with acute bronchitis in whom symptoms persist for longer than 3 weeks, other conditions to be ruled out include:
- Asthma/chronic obstructive pulmonary disease.
- Post-infectious cough.
- Whooping cough.
- Post-nasal drip.
- Gastro-oesophageal reflux.
- Tuberculosis.
- An underlying malignancy in people who smoke.
- For people with chest signs, other conditions to be ruled out include:
- Pneumonia with underlying malignancy.
- Heart failure.
- Pulmonary embolism.
- Asthma.
Basis for recommendation
Information on the differential diagnosis of chest infection is based on expert opinion from American clinical guidelines [Braman, 2006].
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