Chest Infection

Let’s start by defining what a chest infection is.

Infection of the lower airways. The two types of it are bronchitis and pneumonia.

Bronchitis is the inflammation of the tubes while pneumonia is the inflammation of the very small tubes and the air sacs of the lung called alveoli.

In lay language both of these could be called “chest infection” however the two conditions are very different in terms of how worried we need to be about them.

(Pleurisy is another commonly used term referring to sharp localised chest pain that is worse on deep breathing. This is sometimes related to chest infection, but could have other causes that are beyond the scope of this summary.)

• Good morning, this is Dr. Komlosi calling from Kingsnorth Medical Practice regarding Mrs. Hughes.
• Speaking.
• Mrs. Hughes, could you please confirm your full name and date of birth to make sure I have the correct notes open in front of me?
• Sure, Amanda Hughes, 23. May. 1972.
• Thank you. How may I help today? 
• Doctor, I had a cold and it has now spread to my chest. I bring up green, thick mucus and my chest hurts in the middle as I cough. I tried 2 different cough medicines the past week and they did not work. I have a chest infection, I need antibiotics.
• I see, Mrs. Hughes, I am sorry to hear that you are unwell. Do you also have a temperature?
• No, I had it about a week and a half ago, when the cold started, but I don't think I have a temperature now.
• This is good news. You mentioned that you have chest pain in the middle. Any other chest pains?
• No, just behind the breast bone in the middle and it feels heavy and tight. It is really bad when I am coughing.
• Do you feel short of breath with this tightness?
• Yes! I can't seem to catch my breath when coughing, I feel I am choking. It is really the worst at night! I haven't slept for 3 days now, I am knackered.
• You must be very tired. This doesn't help. You say that you have green, thick sputum with the cough. Do you also bring up blood? 
• Yes, doctor. I noticed once a few streaks of blood with the green frothy mucus after coughing violently.
• This must be frightening Mrs. Hughes, but let me reassure you that a few streaks of blood only once or a few times after heavy coughing is most likely coming from the broken lining of the airways rather than being a sign of a more serious infection, especially that you are generally well, aren't you?
• Yes, I can manage at work, but I am very tired, and only eat here and there. And of course I cannot sleep from the cough.
• I see. This cough is very bothersome. You say you tried to treat it with the medicine from the Pharmacist.
• They did nothing. I really need antibiotics.
• It is understandable that you want to get better as soon as possible. Before we talk about the treatment I just want to make sure that you don't have any risk factors for a serious lung infection. I see in your notes that you never smoked tobacco.
• No, I never smoked.
• Good. I can't see any references in your notes that you would have asthma, COPD or any other lung conditions.
• No, nothing like that. I only take blood pressure medication and HRT.
• Great! I am glad to see that you don't have risk factors for a serious lung infection.
  So to summarise, you had a cold infection with temperature that started about 10 days ago and it has spread to the chest. Now you have a chesty cough with green sputum, had streaks of blood in the sputum once, you have heaviness and pain in the middle of the chest that is worse on coughing; you feel breathless when you are coughing, no temperatures now and you can manage with your daily activities, however you are tired from the constant cough that troubles you at night.
• Yes, correct.
• Mrs. Hughes, I agree with you, that you have a chest infection. In medical terms it is called bronchitis, which means inflammation of the lining of the airways. What happened is that the virus that caused the cold has spread to the deeper airways, called the bronchi and caused them to be inflamed, red, thickened and producing more mucus than normal. This is why you feel the chest pain and tightness as the airways behind your breastbone look just as red and upset as your throat was to start with. The mucus and the infection are irritating the lining causing the cough. The cough is very tiring and I understand why you want to stop it, but it is actually a protective mechanism clearing out the mucus and the infection and preventing it from spreading to the deeper airways causing a serious infection that would land you in hospital.
  You are asking for antibiotics, but unfortunately antibiotics don’t work for viruses, so it wouldn’t help you get better any sooner, if anything it might just give you side effects like nausea and diarrhoea on top of what you already have.
• But my mucus is thick green! I had a similar chest infection about five or six years ago and I was given antibiotics.
• Yes, you are right. Traditionally we believed that if the mucus is clear or pale yellow, then it is a viral infection and if the mucus is green and thick it is a sign of a bacterial infection. However, now we know from clinical studies that the sputum colour is not telling us if the infection is viral or bacterial. The colour of the sputum only counts in patients with underlying lung conditions, like COPD.
• Do you say that you are not giving me antibiotics?
• The vast majority of bronchitis are viral, antibiotics wouldn't really help you, I am afraid. 
• Can we at least try?
• I see you are desperate to get better, but I feel antibiotics would only make you feel worse with the side effects. And taking antibiotics unnecessarily increases the risk for resistance, so when you really need the antibiotics they might not work. The bronchitis and the cough last for about 3 weeks whatever treatment we use. This is not good news and not what you expected to hear from me, but you can try a few things to make you feel less poorly until your immune system fights the virus off. Taking rest and fluids, sleeping propped up, taking pain killers for the chest pain can help.
• This is very disappointing…
• I know. Doctors can do for example a double heart and lung transplant, but still cannot treat a cough virus… But the good news is that you have all the chances to get better within 3 weeks and it is unlikely that you need any prescriptions or hospital admission.
• OK, so I am about half way through it now.
• Exactly. I expect you to get better after 3 weeks, but if you are deteriorating with high temperature, breathlessness on walking at level or at rest when you are not coughing, if you bring up more blood, or you are still coughing beyond 3 weeks, please call me back.
• That’s fine, will do.
• I hope you will get better soon.
• Thank you. Bye.
• Bye for now.
  

We now see that antibiotics are not needed most times for the bronchitis type of chest infection, and being fed up with the cough is not an indication for antibiotic prescribing.

But what could we do to ease the symptoms?

For temperature and pain you might want to take paracetamol or ibuprofen.

What about the cough? Mrs. Hughes was bothered by the cough more than any other symptoms.

Experts agree that symptomatic treatments are the mainstay of treatment for acute bronchitis [Kinkade and Long, 2016; BMJ Best Practice, 2018; MQIC, 2018].

To treat the cough some people may wish to try the following self-care treatments:

• Honey.
• Pelargonium (a herbal medicine).
• Over-the-counter cough medicines containing guaifenesin (an expectorant). 
• Over-the-counter cough medicines containing cough suppressants (except codeine) if the person does not have a persistent cough or excessive secretions.

In the guideline Cough (acute): antimicrobial prescribing, the NICE committee acknowledged the limited evidence on self-care treatment, but noted that promoting self care may have a role in reducing antibiotic prescriptions and general practice consultations [NICE, 2019b].

So we advocate honey and lemon or cough medicine NOT because these things work, but because they cannot just say to the patient that THERE IS NOTHING THAT STOPS YOUR COUGH, YOU WILL JUST GET BETTER ON YOUR OWN IN 3 WEEKS AND UNTIL THAT YOU WILL KEEP COUGHING, SORRY. Despite this being the truth!  And GPs know this, and the guidelines are clear about this.

We GPs just play along and keep suggesting all the harmless and useless self help remedies to stop people calling for the doctor or if they do call to avoid antibiotics that would cause harm - as people cannot live with the truth that Medical Science cannot treat the viral cough they have.
If we want to think more broadly and philosophically we could see a parallel between cough medicine and the “posies”  used with the intention to protect the wearer from the black death in the Mediaeval times: it doesn't need to work, it only needs to give that illusion… There is a deep need to “do something about it” rather than accepting the total lack of control.

Well, in my opinion probably we should move on from the Mediaeval approach, use the evidence we have, and face the horrible truth that bronchitis cough cannot be stopped with medication.

As I explained to Mrs. Hughes,we need to start to worry  if the patient is generally very unwell, meaning that they spend most of their time in bed with high temperature, shivering, night sweats, or if they are genuinely breathless at rest or on a short walk out to the bathroom, or if they bring up blood with the sputum (pls see pictures below of what sputum you should be worried about), if the patient becomes confused or if they have underlying lung condition like asthma, COPD or bronchiectasis, or if their immune system is weak.

In these cases we are concerned that the patient might have a different type of chest infection, called pneumonia or an invasive bronchitis that needs intervention.

Bedside CRP( C-reactive protein)  is an interesting option that adds value to the assessment, with a very high 98.4% negative predictive value. It means that if the CRP is low, it is very unlikely that the patient has a serious infection. CRP testing is mainly used in hospitals and in urgent treatment centres.

https://www.researchgate.net/publication/313317233_Evaluation_of_the_bedside_Quikread_goR_CRP_test_in_the_management_of_febrile_infants_at_the_emergency_department

https://www.aidian.eu/news/crp-and-pulmonary-findings-correlate-in-covid-19

Another common scenario is when a worried mum calls asking that a doctor listens to her child’s chest and the child has a rattly cough. The parent hears the rattling or sometimes feels it as holding the child back and she starts to worry that it might be a sign of chest infection.
Again, I think there is an overestimation of how much a doctor can do with a stethoscope. I know that the stethoscope is the symbol of medicine as the wide hat was in the Middle Ages and doctors don’t rush to disperse the myths around it, however it is particularly useless when assessing for children’s pneumonia. Other factors together, like high temperature longer than 5 days, not feeding, not drinking, signs of breathing difficulty, ribs or tummy sucking in, high breathing rate per minute and how the child looks and behaves in general give you a much better chance to diagnose pneumonia in children than the stethoscope.

Even worse when the parent expects the doctor to be able to tell how the child will be in 3 days time when the family is leaving for a holiday. I am really sorry, I am just a doctor and can only tell whether the child needs medical intervention right now, and I only have a stethoscope not a crystal ball to see what will happen in the future. We need to take it day by day and if the child develops any of the above worry signs they need to be reassessed.

All this information about chest infection and what a doctor can and cannot do might come to you as a massive shock, but yes, medicine has its limitations and the stethoscope is not a magic wand even if we doctors tend to use it like that…

It is time to demystify medicine and use it wisely.

I hope you will get better soon!