Remote Primary Health Care Manuals

Chest infections — over 5 years

Cough doesn’t always mean chest infection. Consider other causes — especially if shortness of breath is main problem

Red Flags — Urgent Medical Consult
  • Frail
  • Elderly
  • Chronic lung disease
  • Diabetes, kidney problems, liver disease
  • Heart failure
  • Cancer
  • Volatile substance misuse, alcohol misuse
  • Confused, altered mental state
  • Sepsis — signs and symptoms can include
    • High or low temperature
    • Fast breathing
    • Fast pulse
    • Low BP or dizziness
    • Confusion and/or agitation

Tropical Northern Australia

Consider melioidosis if moderate/severe pneumonia and risk factors of

  • Diabetes
  • Alcohol misuse
  • Kava use
  • Chronic kidney disease
  • Chronic lung disease
  • Medicines that suppress immune system
  • Cancer

Ask

  • Symptoms — cough, fever, wheeze, chest pain, shortness of breath, sputum
  • How long have they had symptoms 
  • History of previous chest infections — consider chronic lung disease
  • Other medical conditions — see red flags
  • Smoking — how many, how long, tried to stop, want to stop

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • ECG 
  • Head-to-toe exam — listen to chest

Do

  • Check for respiratory management plan
  • Pneumonia, bronchitis, exacerbations of bronchiectasis and COPD can look the same but treatment is different
  • If history of positive Pseudomonas and severe infection or septic shock — will need treatment with antipseudomonal antibiotics
  • Medical consult

Severe pneumonia

Fever, usually cough AND any of

  • Looks very unwell
  • Short of breath
  • Pulse more than 100 beats/min
  • Fast breathing — RR 26/min or more
  • O2 sats less than 94% on room air — when settled with good oximeter trace
    • If known chronic lung disease — check what O2 sats are when well
  • Temp less than 35°C OR more than 39°C
  • Low systolic BP for age or compared to previous measurement
  • Confused, altered mental state
  • Pain with breathing or percussion (tapping on chest)
  • Rib recession
  • Red flags

Do

  • Medical consult — consider sepsis
  • Give oxygen to target O2 sats 94–98% OR if moderate/severe COPD 88–92%
  • IV cannula
  • Blood cultures, urine for MC&S, sputum for MC&S
    • Ideally before giving antibiotics, but do not delay treatment — send in with person
  • Give ceftriaxone IV/IM — doses — single dose
    • AND azithromycin oral — doses — single dose
    • AND gentamicin IV/IM — doses— single dose
    • If allergy — medical consult
  • If low systolic BP for age — give normal saline bolus as directed by doctor

Mild or moderate pneumonia

  • Fever, usually cough AND
    • Looks unwell
    • Fast breathing — RR 21–25/min
    • O2 sats 94% or more on room air — when settled with good oximeter trace
    • If known chronic lung disease — check what O2 sats are when well
    • No other features of severe pneumonia

Do

Table 7.20  Antibiotics for mild and moderate pneumonia

Mild Moderate
  • Give amoxicillin oral — adult 1.5g, child 35mg/kg/dose up to 1.5g — doses — twice a day (bd) for 5 days
  • If allergy to penicillin — doxycycline oral — adult 100mg, child over 8 years and less than 26kg: 50mg, 26 to 35kg: 75mg, more than 35kg: 100mg — doses — twice a day for 5 days. Do not use if pregnant
  • Medical consult
    •  Ceftriaxone IV/IM — adult 2g, child 50mg/kg/dose up to 2g — doses — once a day for 3 days
    • If improving — amoxicillin oral — adult 1.5g, child 35mg/kg/dose up to 1.5g — doses — twice a day (bd) for 5 days
    • If allergy — medical consult
  • Give paracetamol — see Pain management
  • Tell person to get lots of fluids and rest
  • If getting worse at any time, not improving after 3 days, lots of sputum or blood in sputum — review daily and medical consult
    • May need to send to hospital for investigation and treatment

Cold (URTI) or influenza

  • Fever, aches and pains, sore throat, blocked or runny nose BUT no other features of pneumonia
  • Sputum clear or white and small amounts

Do

  • For fever, aches and pains — give paracetamol — adult 1g, child 15mg/kg/dose up to 1g, up to 4 times a day (qid)
  • Tell person to
    • Get lots of fluids and rest
    • Come back if not getting better or develops new symptoms
  • If known influenza activity in community AND fever, shakes, muscle aches  — medical consult about need for viral swabs and antivirals

Sinusitis

  • Fever, aches and pains, sore throat, blocked or runny nose BUT no other features of pneumonia
  • Nasal discharge coloured
  • Facial pain — tender over cheeks/eyebrows
  • Headaches

Do

  • For fever, aches and pains — give paracetamol — adult 1g, child 15mg/kg/dose up to 1g, up to 4 times a day (qid)
  • Give decongestant for 4–5 days only — nasal spray or oral
    • Do not give to children under 6 years
    • Medical consult before giving to children 6–11 years
  • Tell person
    • Sinusitis often takes 1 to 2 weeks to improve or get better
    • Antibiotics usually don't help 
    • Get lots of fluids and rest
    • Come back if not getting better or develops new symptoms — often need medical consult
  • If symptoms get worse, reoccur or become chronic — medical consult to refer for ENT specialist review

Bronchitis

  • Fever, aches and pains, sore throat, blocked or runny nose BUT no other features of pneumonia AND no history of chronic lung disease
  • Sputum may be coloured, thick with large amounts
  • Nasal discharge coloured or bloody

Do

Follow-up — all chest infections

Table 7.21 Looking for signs of a chronic problem

Feature Possible reason — what to do
Any or all of
  • Persistent cough for more than 4 weeks especially if producing sputum
  • Short of breath on activity
  • 3 or more chest infections in last 2 years
  • 2 or more episodes of pneumonia in last 5 years
  • Always has signs when listening with stethoscope — crackles, unequal air entry, bronchial breathing
 Chronic lung disease
  • Medical consult
  • Chest x-ray
  • Wheezing sickness 2 or more times in last year
 Asthma
  • Productive cough for more than 3 weeks
  • Weight loss, night sweats
  • Coughing up blood
  • Contact of known TB case in family or community
 TB or lung cancer