Acute Respiratory Infections

Question 1

How do you assess a patient in an emergency setting?

Answer 1

ABCDE

Question 2

‘A’ in ABCDE

Answer 2

o Ensure the patient is able to speak to you.
o Listen for added inspiratory sounds (i.e. stridor) from the end of the bed.
oAdminister oxygen – 15L/min via a non-rebreathe mask

Question 3

‘B’ in ABCDE

Answer 3

o Check respiratory rate and oxygen saturations.
o Check for tracheal deviation and lung expansion.
o Percuss the chest and then auscultate.

Question 4

‘C’ in ABCDE

Answer 4

o Check blood pressure, heart rate and capillary refill time.
o Obtain IV access – preferably two large cannulae.
o Administer a bolus of intravenous fluid – crystalloid is the preferred fluid.

Question 5

‘D’ in ABCDE

Answer 5

o Measure his conscious level on the AVPU scale (Alert / Responds to voice / Responds to pain / Unresponsive)
o If responsive, are they confused?
o Check a blood glucose
o Examine for photophobia and neck stiffness

Question 6

‘E’ in ABCDE

Answer 6

o Check Temperature
o Expose the rest of the body and examine thoroughly for rashes
o Palpate abdomen

Question 7

What is the influenza virus?

Answer 7

The influenza virus was first identified in 1933. There are three different types of Influenza, A, B and C.
• A and B are the two more common and serious types. Type C usually only causes a mild respiratory illness. Influenza is highly contagious

Question 8

How is the influenza virus transmitted?

Answer 8

• It is transmitted in large droplets when an infected patient coughs, sneezes or talks.
• The influenza virus can remain infectious on surfaces that are not cleaned for up to 24 hours but this is not a documented source of transmission as yet.

Question 9

What is the average incubation period for influenza?

Answer 9

• The average incubation period, i.e. the time between the patient acquiring the infection to them having symptoms is 2 days (ranging from 1 to 4 days).

Individuals are most infectious 24 to 48 hours prior to developing symptoms but some never develop symptoms at all.

Question 10

How does person to person spread occurs?

Answer 10

• Person-to-person spread occurs through:
o Direct contact with infectious individuals
o Contact with contaminated surfaces (fomites)
o Inhalation of infectious aerosol

Question 11

Which influenza sub-type causes pandemics?

Answer 11

• Influenza pandemics are caused by Flu A. These can occur at any time of the year and spread worldwide.
• Examples are the Spanish Influenza pandemic after the first world war that killed 40-50 million people worldwide or, more recently, the H1N1 swine flu pandemic originated in Mexico and caused a mild respiratory illness.

Question 12

When do influenza outbreaks tend to occur?

Answer 12

• Epidemics or outbreaks are common, and these tend to be seasonal, peaking in winter months in temperate regions but can occur all year round in the tropics. Outbreaks can be caused by Flu A or B.

Question 13

How many ways can the influenza virus mutate?

Answer 13

2. Antigenic drift
   Antigenic shift

Question 14

What is antigenic drift?

Answer 14

o Antigenic drift – gradual accumulation of mutations that change the surface antigens and make the virus less susceptible to the antibodies produced during previous infections.

Question 15

What is antigenic shift?

Answer 15

o Antigenic shift – two or more strains combine to form a new subtype with surface antigens that humans have not encountered previously

Question 16

What is the clinical presentation of the flu?

Answer 16

• The clinical presentation is variable, usually with a fever, cough, sore throat, myalgias, frontal or retro-orbital headache, fatigue and conjunctivitis.
• However, it is variable and can present as a predominant respiratory illness (dry or productive cough, sore throat or nasal discharge) to a systemic illness with little respiratory involvement (muscle aches, severe fatigue, headache).

Question 17

How long does it take for uncomplicated influenza to improve?

Answer 17

• Uncomplicated influenza usually improves after 2 to 5 days although some patients only start getting better after over one week. Influenza A usually causes a more severe illness than Flu B.

Question 18

What are the types of influenza?

Answer 18

Uncomplicated

Complicated

Question 19

What is uncomplicated influenza?

Answer 19

• Uncomplicated influenza: Influenza presenting with fever, coryza, generalised symptoms (headache, malaise, myalgia, arthralgia) and sometimes gastrointestinal symptoms, but without any features of complicated influenza.

Question 20

What is complicated influenza?

Answer 20

• Complicated influenza: Influenza requiring hospital admission and/or with symptoms and signs of lower respiratory tract infection (hypoxaemia, dyspnoea, lung infiltrates), central nervous system involvement and/or a significant exacerbation of an underlying medical condition.

Question 21

What are the risk factors for complicated influenza?

Answer 21

Neurological, hepatic, renal, pulmonary and chronic cardiac disease

Diabetes mellitus

Immunosuppression

Age over 65 years

Pregnancy (including up to two weeks post-partum)

Morbid obesity (BMI >=40)

Question 22

What are the complications of influenza?

Answer 22

Primary viral pneumonia
Secondary bacterial pneumonia
Myositis and rhabdomyolysis
CNS complications

Question 23

What is primary viral pneumonia?

Answer 23

• Primary viral pneumonia: A pneumonic process caused directly by the Influenza virus itself. This is most common in patients with chronic lung problems but is overall uncommon. The patient gradually worsens from the initial presentation and their breathlessness, fever and cough all progress.

Question 24

What is secondary bacterial infection?

Answer 24

• Secondary bacterial pneumonia: A superimposed bacterial infection of the lungs usually occurs when the patient’s symptoms from Influenza are improving. After improving for 24 to 48 hours the patient becomes more breathless, their fever recurs, and they may be hypoxic.

Streptococcus pneumoniae, staphylococcus aureus and haemophilus influenzae are the three most common bacteria that cause superimposed infections. This needs treatment with antibiotics.

Question 25

What is myositis and rhabdomyolysis?

Answer 25

• Myositis and Rhabdomyolysis: These complications are most common in children but are overall rare. A rise in creatinine kinase (CK) with myoglobuminuria and tender and occasionally swollen muscles occurs.

Question 26

Which CNS complications can occur with influenza?

Answer 26

• Central Nervous System Complications: Encephalitis, transverse myelitis, Guillain-Barre syndrome and aseptic meningitis have all been reported secondary to Influenza but how these come about is poorly understood.

Question 27

What are coronaviruses?

Answer 27

• Coronaviruses are a large group of viruses that cause diseases in animals and humans. Human Coronaviruses were first identified in the 1960s.
• Severity of disease can vary significantly, with some coronaviruses causing the common cold and others causing severe respiratory infection with significant fatality rate.

Question 28

Which animal is the major reservoir host for MERS-CoV?

Answer 28

• MERS was identified in Saudi Arabia in 2012. Evidence suggests that camels are a major reservoir host for MERS-CoV and an animal source of MERS infection in humans.

Question 29

What is SARS-CoV?

Answer 29

o Originated in Wuhan, China in 2019
o Spread from mucosal contact with infected secretions e.g. eyes, nose and mouth.
o Each new infection leads to 2-3 new infections if no protective measures taken.
o Aerosol generating procedures (such as suctioning) appear to be particularly liable to transmit infections.

Question 30

Clinical presentations of SARS-CoV2

Answer 30

Mild symptoms or no symptoms

Mean incubation period is 5 days (2-14 days range)

Persistent cough, loss of smell and taste and fever.

Symptoms may develop over illness.

Patients may have none of these symptoms at presentation.

Headache, diarrhoea and meningism are all potential PCs.

Question 31

Which drugs are used for the treatment of influenza?

Answer 31

Oseltamivir and Zanamivir.

The role of Neuraminidase inhibitors (Oseltamivir and Zanamivir) in the management of influenza is much debated at the moment. The evidence does not show any benefit in using them for everyone who has influenza virus infection. The general consensus seems to be that it is worth using them in patients in critical care and immunocompromised patients.

Question 32

How can you prevent the transmission of respiratory viruses?

Answer 32

Vaccination
Hand hygiene
Cough etiquette

Question 33

Who gets vaccinated for protection against the flu in the UK?

Answer 33

All health care professionals directly involved in patient care

People living in long stay care homes ie. Residential or nursing homes.

People with chronic health conditions: chronic liver, kidney, lung, heart or neurological diseases, diabetes or patients that are immunosuppressed

Pregnant women

All those > 65 years of age

Children aged 2 years of age and up to year 3 (although this is being rolled out nationally to cover all children up to 17 years of age)

Question 34

When should you wash your hands in the hospital?

Answer 34

o Use soap and water and/or alcohol:
Before touching a patient
Before clean/aseptic techniques
After body fluid exposure
After touching patients
After touching patient surroundings

Question 35

What is the droplet spread?

Answer 35

Many respiratory viruses and bacteria are spread by droplets: respiratory secretions that are generated when patients cough, sneeze or talk.

They are propelled through the air and land on the recipient’s conjunctiva, mouth or nasal mucosa and cause infection.

The recipient needs to be a maximum of 3 metres from the infective person to become infected themselves.

Question 36

What is airborne spread?

Answer 36

Airborne transmission occurs with viruses like varicella or bacteria like tuberculosis that can remain suspended in air for long periods and are inhaled by others and then transmit infection.

The pathogen is suspended in evaporated droplets. When dealing with patients with highly virulent respiratory infections with airborne transmission they have to be nursed in a room with special air handling and ventilation systems to ensure members of staff seeing to them are not infected.

Question 37

What are forties?

Answer 37

Fomites are inanimate objects or materials that may be contaminated with infectious agents and therefore acting as a route for infection transmission.

The source of infection can be direct contact with an infected or colonized person or exposure to droplets and aerosols. This is why in case of high consequence infectious diseases, particular care must be given to any transport of objects in and out of an infected patient’s room.