Chest Medicine
The ageing lung
Most of the functional impairment of the lungs that is seen in older people is due to disease, often smoking-related. Intrinsic ageing leads only to mild functional deterioration. The respiratory system has a capacity well in excess of that required for normal activity, so intrinsic ageing:
Does not lead to symptoms in the non-smoker without respiratory disease
In those with respiratory disease (eg emphysema) will cause progressively worsening symptoms with age even if the disease itself remains stable
In acute disease, eg pneumonia, may cause earlier decompensation or a more severe presentation
Specific respiratory changes
Seen in healthy older people are similar to those seen in mild chronic obstructive pulmonary disease, and include:
Decreased elastic recoil causing small airways to collapse at low lung volumes and increased residual volume
Increased chest wall stiffness, due to:
Degenerative change in intercostal, intervertebral and costovertebral joints
Osteoporosis and kyphoscoliosis
Weaker respiratory muscles that may have lower endurance
Reduced gas exchange and increased ventilation-perfusion (V/Q) mismatch, due to collapse of peripheral airways while perfusion remains intact
Impaired chemoreceptor function, leading to lessened ventilatory response to decreased P a O 2 or increased P a CO 2
Impaired microbial defence mechanisms. Less effective mucociliary clearance and less sensitive cough reflex
Observed consequences of these changes
These include:
Increased susceptibility to infection (underventilation of and inability to clear sputum from dependent lung zones)
Lower maximum minute ventilation (weaker musculature acting against a stiffer chest)
An approximately linear fall in PaO2 with age (70.3% /year). Since alveolar oxygen tension remains stable, the alveolar-arterial (A-a) oxygen gradient rises
Reduced exercise capacity. However, oxygen consumption and cardiac output decline in proportion to lung function, so the lungs are rarely the limiting factor in exercise performance
Breathlessness in older people is often multifactorial
Chronic breathlessness in an individual may be the result of, eg, decreased fitness, obesity, an inefficient gait (osteoarthritis or stroke), kyphosis, previous lung damage (eg apical fibrosis due to tuberculosis (TB)) and intrinsic ageing. In this example, note that only one of the factors is specific to the lung
In the acutely breathless patient, pathologies commonly coexist, eg infection, fast AF, and heart failure. The classic treatment triad of digoxin, furosemide, and amoxicillin is not a sign of diagnostic indecision but is often entirely appropriate treatment
Respiratory infections
Cough with or without sputum, shortness of breath, fever or chest pain is a very common presentation in older patients. It is very important to try to distinguish which part of the airway is primarily affected because this implies completely different pathogens, prognoses, and treatment strategies. Try to avoid aggregating all such patients together using the imprecise term ‘chest infection’.
Upper respiratory tract infections
These are caused by viruses, eg rhinovirus, respiratory syncytial virus, influenza, and parainfluenza. Symptoms include nasal discharge and congestion, fever, and sore throat. These may extend to the lower tract and then include cough, wheeze, sputum production, or worsening of existing cardiopulmonary disease.
With increasing age:
Upper respiratory tract infection becomes less frequent, but more severe
The risk of complications increases. These include:
Lower tract infection such as bronchitis or pneumonia, which may be bacterial or viral
Bronchospasm
Extrapulmonary manifestations such as falls, immobility, and delirium
Postinfection weakness, fatigue, and anorexia is more severe and prolonged, maybe lasting several weeks
Frequency of hospital admission and death increases substantially
Acute bronchitis
Occurs with inflammation of the bronchial tree with little or no involvement of lung parenchyma (which is pneumonia). Is commoner in those with chronic airways disease (see 
‘Asthma and COPD: assessment’, p.342).
‘Asthma and COPD: assessment’, p.342).Compared with pneumonia, bronchitis:
Has fewer systemic features and a better prognosis
Has no chest symptoms and signs, eg pleuritic pain or crepitations, but may have prominent cough and wheeze
CXR not routinely indicated
Can be managed less aggressively, with more reliance on supportive treatment and bronchodilators than antibiotics. Often viral in origin, if an antibacterial is thought appropriate, give amoxicillin to cover Streptococcus pneumoniae (erythromycin or clarithromycin if penicillin sensitive)
Influenza
This is the most serious viral respiratory tract infection, and is often a severe, systemic illness with pulmonary bacterial superinfection (Staphylococcus aureus, Haemophilus influenzae, Strep. pneumoniae). It occurs most commonly in December-February. Antigenic shifts result in periodic pandemics (large-scale epidemics).
Presentation is similar in young and old, ie rapid onset of fever (rigors, chills), myalgia, headache, and fatigue with variable degrees of prostration. Compared with less threatening viruses such as rhinovirus:
Nausea, vomiting, diarrhoea, high fever, rigors and ocular symptoms (eg photophobia) are more common
Rhinorrhoea is less common
Less common serious complications include myocarditis and meningoencephalitis. Mild meningism is common, and if combined with other sinister features (eg altered conscious level) is an indication for CSF sampling.
Diagnosis is usually based on combining clinical assessment with epidemiological data, particularly current influenza incidence. Some other viruses can cause an identical clinical syndrome, and serological test results are not immediately available. Thus an initial assessment cannot produce an absolutely confident microbiological diagnosis. The syndrome may therefore most precisely be labelled ‘influenza-like illness’.
Positive virological diagnosis in the context of increased community incidence or a care home outbreak is helpful by prompting vigorous attempts to reduce transmission of infection.
Reducing viral transmission
Mass outbreaks of respiratory viral infection are common in care homes and hospitals. They can occur at any time of year but are commonest from autumn to spring, Viruses are spread by aerosol or hand-to-hand contact (sometimes indirect, via fomites such as cutlery or drinking vessels).
During an outbreak
Reduce transfers of healthy patients into, or symptomatic patients out of, the affected area
Reduce staff movement across work areas (especially applicable to short-term staff who may work in many clinical areas in a short time)
Care for symptomatic patients in single rooms, or in ward bays with similarly infected patients
Exclude visitors with respiratory or viral symptoms from the ward
Ensure that care staff have been immunized against influenza
Ensure that scrupulous hand-washing procedures are followed
Consider using face masks for staff caring for symptomatic patients
HOW TO … Treat influenza-like illness in older people
The following guidance is generic, and should be tailored to the patient, their illness, and their care environment. If the highest quality care cannot be provided, then a prompt step-up of care should be arranged. This may include hospital admission.
Do not underestimate the disease. Mortality and morbidity increases exponentially with age and frailty
Give excellent supportive and symptomatic care. Its effectiveness should not be underestimated
Fluids. Reduced intake and increased losses (fever) lead to volume depletion and end organ dysfunction. Encourage frequent oral fluid and suspend any diuretic treatment. Consider early initiation of s/c or iv fluids if a vicious spiral of dehydration and poor intake seems likely to ensue
Nutrition. Encourage high-calorie, high-protein drinks or solids. If the illness is especially severe, prolonged, or complicated, or if the patient is especially frail or malnourished, consider a period of NG feeding. Involve a dietician early
Paracetamol. If fever, discomfort, or pain occur
Maintain mobility. Bed rest may sentence the patient to death or dependency. Carers may need clear, firm advice about this
Identify and treat complications promptly
Carers may need information about important warning signs and the need to seek prompt medical advice
Perform regular observations of BP, pulse, and temperature where possible
Common serious complications include delirium, secondary bacterial infection, bronchospasm, pressure sores, and circulatory collapse
Antiviral agents (the neuraminidase inhibitors zanamivir and oseltamivir) can reduce both the severity and duration of influenza
They are indicated in patients > 65 years who have an influenzalike illness during a period of high community incidence, provided they present early (<48hr)
They are well tolerated, reduce symptom severity and duration and they may reduce mortality
Zanamivir is inhaled, oseltamivir is taken orally
Further reading
NICE. Amantadine, oseltamivir and zanamivir for the treatment of influenza (2009). Online: 
www.nice.org.uk/ta168.
www.nice.org.uk/ta168.Pneumonia
Pneumonia
This is a syndrome of acute respiratory infection with shadowing on CXR
May be primarily lobar, bronchial or mixed pattern
Symptoms may be mild and are often non-organ specific eg fever, malaise
Common presenting scenarios include cough (often unproductive), delirium, reduced conscious level, lethargy, anorexia, falls, immobility and dizziness. Rarely patients can present with shock, coma and adult respiratory distress syndrome (ARDS)
Chest pain, dyspnoea and high fever are less common than in younger people. Signs may be minimal:
The patient may be well or unwell. Assess severity using the CURB criteria (see
‘Characteristics of severe pneumonia: the CURB-65 score’, p.320)
Fever is often absent, but vasodilatation is common
Tachypnoea is a sensitive sign, as is at least moderate hypoxaemia (≤95% on air) on oximetry
Tests often guide management
Chest radiograph often reveals minimal infective infiltrate. Associated problems can include malignancy, effusion, or heart failure
Blood cultures should be sent, but sputum culture is rarely useful unless TB is suspected
White cell count may be raised, normal, or even depressed
CRP is often normal early in the illness. A very high CRP suggests pneumococcal disease or severe sepsis of any cause
U,C + E guide fluid management. Renal impairment is a sign of poor prognosis
Arterial blood gas (ABG) sampling is not usually necessary, unless oxygen saturations are <90% ; oximetry is much better tolerated and usually sufficient to guide oxygen therapy
Organisms (see Table 11.1)
Often no causative organism is identified
Pneumococcus is a common pathogen in all settings, including hospital
Viral pneumonia, especially influenza, is under-recognized, and is the second most common cause of community-acquired pneumonia
Legionella and Mycoplasma pneumonias are uncommon. Mycoplasma is much more frequent during epidemics, occurring every 3 years or so
Unusual organisms are more common in frail patients, in higher dependency environments and in those who have recently received courses of antibiotics. These organisms include Gram negatives (which colonize the oropharynx) and anaerobes (a result of aspiration of gut contents). MRSA pneumonia and septicaemia is an increasing problem and may be contracted in the community, ie not just a hospital problem
Table 11.1 Pneumonia pathogens in various care settings; in approximate order of frequency | ||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
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Pneumonia: treatment
Treatment is much more than antimicrobials alone:
Assess and optimize fluid volume status; give oral, s/c, or iv fluid as appropriate. Concurrent heart failure is common, but volume depletion more so
If there is subjective dyspnoea or moderate/severe hypoxaemia, then supplement oxygen, titrating the inspired oxygen concentration upwards to achieve arterial oxygen saturations > 90% (see
‘Oxygen therapy’, p.348). For lesser degrees of hypoxaemia, it is not necessary to subject patients to claustrophobic, uncomfortable oxygen masks: simply monitoring saturations may be sufficient
Avoid the use of nasal specs acutely: if ventilatory drive is poor, inspired oxygen concentrations are very uncontrolled
Encourage mobility. If immobile, sit upright in bed, and sit out in a chair
Request physiotherapy if there is a poor cough, or lobar/lung collapse
Use saline nebulizers to loosen secretions which are difficult to expectorate and bronchodilator nebulizers when wheeze suggests associated bronchoconstriction
Minimize risk of thromboembolism unless contraindicated through prophylactic heparin, early mobilization, and compression stockings
Assess pressure sore risk and act accordingly (see
‘Pressure sores’, p.502)
If dyspnoea, anxiety or pain is very distressing, consider opiates. Side effects include respiratory depression, sedation and delirium, so begin with small doses and assess effect
Anticipate possible deterioration, and judge in advance the appropriate levels of intervention. Would renal dialysis, ventilation and/or cardiopulmonary resuscitation be effective and appropriate? (See
‘Diagnosing dying and estimating when treatment is without hope’, p.666)
Keep the family informed. Where possible, enlist their help, eg in encouraging eating and drinking
Characteristics of severe pneumonia: the CURB-65 score
Five key criteria (acronym ‘CURB-65’) determine prognosis:
C onfusion (AMTS ≤8)
U rea (serum urea > 7mmol/L)
R espiratory rate (≥30/min)
B lood pressure (<90 systolic and/or ≤60mmHg diastolic)
65 years of age or more
The score has a six point scale (0-5 adverse prognostic features):
0 or 1: Low risk of death (0-3%). Possibility of home treatment (but consider other factors, eg functional status, hypoxaemia
2: Intermediate risk of death (13%). Hospital treatment is indicated
3, 4, or 5: Severe pneumonia, with high risk of death (score 3: mortality 17%, 4: 41%, 5: 57%). Consider intensive care admission.
A five-point scale using only four criteria (CRB-65; urea excluded) can be applied outside hospital and also discriminates effectively between good and poor prognoses (eg mortality score 1: 5%, score 3: 33%).
Antimicrobials
Refer to local guidelines, reflecting pathogen sensitivities, and drug costs.
Community or care home settings
Amoxicillin orally is usually effective (vs. Strep. pneumoniae and H. influenzae). Erythromycin or clarithromycin if penicillin-allergic
Add clarithromycin (or erythromycin which has more gastric side effects) if there are features of atypical pneumonia, there is a Mycoplasma epidemic, or the patient may have had influenza
Co-amoxiclav orally has added activity against some Gram-negatives and Staph. aureus, and may be more effective in the frail patient or where aspiration is likely
Ciprofloxacin alone should be used rarely—it has Gram negative activity, but is less effective against Strep. pneumoniae, an important pathogen in most settings. If an antimicrobial is sought that will cover both chest and urinary sepsis, a better choice may be co-amoxiclav or trimethoprim
iv antibiotics are only necessary if the patient is very unwell (CURB-65 score of 3 or above) or unable to swallow. Co-administration of cefuroxime and erythromycin is a good choice in the unwell patient, treating all likely pathogens effectively. If you suspect MRSA pneumonia, add vancomycin. Convert to oral therapy and change broad to narrower spectrum drugs when the patient’s condition improves and/or culture results are known to minimize complications, eg CDAD (see
‘Clostridium difficile-associated diarrhoea’, p.614). Often, only 48hr or less of broad spectrum, iv therapy is needed
Hospital-acquired infection
This presents a difficult dilemma. Hospitalized patients, especially those who are more frail and have spent longer in hospital, are prone to Gramnegative and anaerobic pulmonary infections. However, they are also susceptible to the adverse effects (especially diarrhoea) of broad spectrum antimicrobials.
A hierarchical approach is sensible, considering likely pathogens and illness severity;
In the less frail patient who remains well, begin amoxicillin alone, co-amoxiclav or a combination of amoxicillin and ciprofloxacin (all po). Broaden the spectrum only if the patient deteriorates or culture results suggest that the likely pathogen is insensitive
If a patient is at high risk of Gram-negative infection (frail, dependency, prolonged stay, invasive procedures, aspiration risk), begin with iv cefuroxime (or equivalent). Narrow the antimicrobial spectrum when the patient’s condition improves and/or a pathogen is identified
If the patient has received multiple courses of treatment, seek microbiology advice
In all cases take blood cultures, and monitor the patient carefully
Further reading
British Thoracic Society guidelines online: 
www.brit.thoracic.org.uk.
www.brit.thoracic.org.uk.HOW TO … Manage the patient with pneumonia who fails to respond to treatment
Is the diagnosis correct?
Consider other chest pathology such as heart failure, pulmonary embolism, pleural effusion, empyema, cancer or cryptogenic organising pneumonia. Extrathoracic pathology mimicking pneumonia includes acidosis (tachypnoea), and biliary or pancreatic pathology
Review the history, examination and investigations
Consider admission to hospital and further tests
Is there a complication?
For example effusion, empyema, heart failure, silent myocardial infarction or pulmonary embolism
Is the antibiotic being taken regularly and in adequate dose?
Is concordance a problem? Could a friend or relative help prompt tablet-taking, or would a dosette box help?
Syrups may be swallowed more easily than tablets. An experienced nurse can help where there are swallowing difficulties
If swallowing remains ineffective, or drug absorption in doubt (eg vomiting) then consider iv therapy
Is the organism resistant?
Take more blood cultures
Consider a change in antimicrobial, taking into account likely pathogens and their known sensitivities
Consider atypical infection; send urine for Legionella antigen test, especially if the patient is immunocompromised or if a patient appears disproportionately unwell. Remember MRSA pneumonia especially in those known to be previously colonized
Could other elements of care be more effective?
For example: fluid balance, oxygenation, nutrition, posture, and chest physiotherapy.
Is this an end-of-life situation?
Is treatment to extend life now inappropriate, the failure to respond a sign that the diagnosis is of ‘dying’ (see
‘Diagnosing dying and estimating when is treatment without hope’, p.666)? If the patient cannot tell you their wishes, determine their likely views by discussing with family and friends, a decision informed by your judgement of where in their life trajectory your patient sits
In determining prognosis consider comorbidity—is this an abrupt, potentially reversible illness in an otherwise fit person, or a further lurch downhill for a patient with multiorgan failure.Not for nothing is pneumonia referred to as ‘the old man’s friend’, sometimes bringing to a brisk and welcome end a period of irrevocable decline and suffering
Vaccinating against pneumonia and influenza
Vaccine delivery
Both vaccines should be offered simultaneously in October or early November to all aged > 65 years, especially:
The frail
Care home residents
The immunosuppressed
Those with comorbidity, eg heart failure, COPD
Reliable delivery of these vaccinations depends upon effective information management systems in general practice, and substantial efforts by patients, carers, district nurses, and GP nurses
A common reason to have missed immunization is to have been a long-term inpatient (eg undergoing rehabilitation) during the autumn immunization period. Hospitals should ensure that these inpatients are immunized
Vaccinating healthcare workers, especially those working in long-term care settings, reduces the spread of infection and therefore death due to influenza among patients
Pneumococcal vaccine
Pneumovax® II, a multivalent pneumococcal polysaccharide vaccine, is effective against 65% of serotypes
Immunity remains for at least five years, perhaps for life
Bacteraemia is reduced by at least 50%. The effect on incidence of pneumonia itself is less clear
Influenza vaccine
The trivalent vaccine is prepared from currently prevalent serotypes
Immunity develops in <2 weeks, and it is therefore useful during epidemics
Immunity remains for up to 8 months
The risk of pneumonia, hospitalization, or death due to influenza is reduced by over half
Postexposure antiviral prophylaxis
Pharmacological prophylaxis of influenza is currently recommended when an unimmunized, high-risk group adult (eg care home resident) has had close contact with a person with influenza-like illness during a period when flu is prevalent (NICE 2008)
Treatment with neuraminidase inhibitors must be initiated within 24hr (for oseltamivir) or 24hr (for zanamivir) (see
‘Upper respiratory tract infections’, p.314)
Consider why immunization was not performed. Is it too late to administer this year (this contact may not have ‘flu, but the next one might)? If not, then optimize the chances of immunization next year
Pulmonary fibrosis
This common problem is much underdiagnosed in older people due to a combination of under-investigation and overlap of clinical signs with common pathologies such as heart failure.
Consider when breathlessness coexists with profuse fine chest crepitations, with or without clubbing. On CXR, there may be bilateral pulmonary shadowing consistent with pulmonary oedema, but with little supporting evidence (eg normal heart size, absent Kerley B lines).
Causes
Idiopathic. The most common type in older people, known as usual interstitial pneumonia
Connective tissue disease, eg rheumatoid arthritis (most common), systemic lupus erythematosus, sarcoidosis. Lung involvement is sometimes the first manifestation of the multisystem disease
Drugs, eg amiodarone, nitrofurantoin rarely
Occupational exposure, eg asbestos, silica
If localized, consider TB, bronchiectasis, and radiotherapy
Tests
The diagnosis is usually confirmed by high-resolution CT scanning, which can also help distinguish subgroups likely to respond to immunosuppressive treatment
Respiratory function tests may be useful (a restrictive picture with decreased transfer factor is usual) but typically adds little in the frail older person
Refer to a respiratory physician to confirm diagnosis and guidance on management
Prognosis
This is very variable—about a third are clinically stable, a third improve and a third deteriorate at rates that vary greatly between individuals. Some can live with pulmonary fibrosis for years without significant functional impairment.
Treatment
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