What is the treatment for an adult patient with crackles in the lungs and feeling unwell, with no specified past medical history?

Treatment of Crackles and Feeling Unwell in Adults

You must obtain a chest radiograph immediately to differentiate pneumonia from other causes, as this fundamentally determines treatment—community-acquired pneumonia requires antibiotics while many other causes of crackles do not. 1

Initial Assessment and Diagnostic Approach

Critical Red Flags to Rule Out First

Before proceeding with treatment, directly ask about and examine for these danger signs that require urgent intervention 1:

• Hemoptysis (any blood in sputum)
• Severe dyspnea or respiratory distress
• Suspected foreign body aspiration (abrupt onset of cough)
• Signs suggesting lung cancer (especially if smoker, age >50, weight loss)
• Fever with systemic illness (suggests pneumonia or serious infection)
• Hypoxemia (check oxygen saturation if available)

Physical Examination Findings

The presence and timing of crackles helps narrow the diagnosis 1:

• Late inspiratory crackles at lung bases suggest pneumonia, especially if accompanied by fever, tachypnea (>25 breaths/min), and dullness to percussion 1
• Fine late inspiratory crackles that persist suggest interstitial lung disease or pulmonary fibrosis 1
• Early-to-mid inspiratory crackles suggest bronchiolitis or small airway disease 1
• Crackles that clear with coughing are less concerning and may represent secretions 1

Mandatory Initial Investigations

Every patient with crackles and feeling unwell requires 1:

1. Chest radiograph (PA and lateral) - This is non-negotiable as it differentiates pneumonic from non-pneumonic illness and identifies complications
2. Oxygen saturation measurement - Identifies hypoxemia requiring supplemental oxygen
3. Temperature, respiratory rate, blood pressure, heart rate - Assess severity

Treatment Based on Most Likely Diagnosis

If Community-Acquired Pneumonia is Suspected

Clinical features suggesting pneumonia: fever >38°C, productive cough, pleuritic chest pain, new focal chest signs (crackles, bronchial breathing, dullness), tachypnea, and duration of symptoms <24 hours 1

Outpatient Treatment (Non-Severe CAP)

Start empiric antibiotics immediately if pneumonia is clinically suspected 1:

• First-line: Amoxicillin 1g three times daily for 5-7 days 1
• If penicillin allergic or atypical pathogen suspected: Macrolide (clarithromycin 500mg twice daily or azithromycin 500mg once daily for 3-5 days) 1, 2
• Supportive care: Rest, adequate fluid intake, avoid smoking, simple analgesia (paracetamol) for pleuritic pain 1

Arrange clinical review at 48 hours to reassess response 1

Hospital Admission Criteria

Admit if any of the following are present 1:

• Respiratory rate ≥30 breaths/min
• Oxygen saturation <92% on room air
• Systolic BP <90 mmHg or diastolic BP ≤60 mmHg
• Confusion or altered mental status
• Age >65 years with comorbidities
• Multilobar involvement on chest X-ray

Inpatient treatment for severe CAP 1:

• IV β-lactam (ceftriaxone 1-2g daily or cefotaxime) PLUS IV macrolide (azithromycin) or fluoroquinolone
• Supplemental oxygen to maintain SpO2 >92% 1
• IV fluids if volume depleted 1

If Acute Bronchitis (Non-Pneumonic Lower Respiratory Tract Infection)

Clinical features: Acute cough with or without sputum, normal chest examination or scattered crackles/wheezes, no focal consolidation, no high fever, normal or mildly elevated respiratory rate 1

Treatment is primarily supportive 1:

• No antibiotics indicated - acute viral bronchitis is self-limiting 1
• Symptomatic relief: Honey and lemon, simple fluids, rest 1
• Cough suppressants (if cough is distressing): Dextromethorphan 60mg for maximum effect, or simple linctus 1
• Avoid codeine/pholcodine - no greater efficacy than dextromethorphan but more side effects 1

If Acute Exacerbation of COPD (in Known COPD Patient)

Treatment 1, 2:

• Increase bronchodilators (short-acting β2-agonists and anticholinergics)
• Oral corticosteroids (prednisolone 30-40mg daily for 5-7 days)
• Antibiotics if increased sputum purulence: Amoxicillin or doxycycline or macrolide 1

If Crackles Persist Without Clear Diagnosis

Consider and investigate for 1:

• Organizing pneumonia (BOOP) - bilateral patchy infiltrates, responds to corticosteroids 1
• Interstitial lung disease - progressive dyspnea, fine late inspiratory crackles, requires HRCT and specialist referral 1
• Heart failure - bilateral basal crackles, elevated JVP, peripheral edema, requires echocardiogram
• Drug-induced cough - if on ACE inhibitors, stop immediately 1

Common Pitfalls to Avoid

1. Do not assume viral bronchitis without chest X-ray if patient has fever, focal signs, or is elderly - pneumonia can present subtly in older adults 1

2. Do not delay antibiotics in suspected pneumonia - if illness appears life-threatening or hospital admission will be delayed >2 hours, give first antibiotic dose immediately 1

3. Do not prescribe antibiotics for simple acute bronchitis - this promotes resistance without benefit 1

4. Do not ignore persistent crackles beyond 6 weeks - requires chest X-ray and consideration of chronic conditions like interstitial lung disease, bronchiectasis, or malignancy 1

5. Beware of atypical presentations in elderly patients - pneumonia may present with confusion, falls, or failure to thrive rather than respiratory symptoms 1