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Core Curriculum > 4. Cough > Flashcards

4. Cough Flashcards

1
Q

Define Bronchiestasis and epidemiology

A

Permanent dilation of bronchi due to the destruction of the elastic and muscular components of the bronchial wall.It is often caused as a consequence of recurrent and/or severe infections secondary to an underlying disorder

1.06 to 1.3 per 100,000 population in UK

If suspected: When did you first notice the cough?
Do you have any medical conditions that affect your lungs?

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2
Q

Pathophysiology of Bronchiestasis

A

Neutrophils + T lymphocytes + Immune effector cells –> Cytokines, Proteases and ROS –> dilated airways, lots of mucus –> chronic inflam host response

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3
Q

Common causative organisms (4) of bronchiectasis

A

H. influenzae
S. pneumoniae
S. aureus
P. aeruginosa

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4
Q

Underlying disorders of bronchiectasis (4 categories)

A

NB: 7-50% idiopathic

Impaired drainage/clearance (genetic)
Airway obstruction
Defect in host defence
Post infectious

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5
Q

Impaired drainage/clearance (genetic) causes of bronchiectasis

A

cystic fibrosis, ciliary dyskinesia, alpha 1 anti-trypsin deficiency

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6
Q

Airway obstruction causes of bronchiectasis

A

Problem inside lumen (foreign body)

Problem in the wall (connective tissue disorder e.g. Rheumatoid Arthritis)

Problem outside (tumour)

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7
Q

Defect in host defence causes of bronchiectasis

A

immunosuppression, immunodeficiency

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8
Q

Post infectious causes of bronchiectasis

A
  • Childhood respiratory infections due to viruses (i.e., measles, influenza, pertussis)
  • Mycobacteriainfection or severe bacterial pneumonia
  • Exaggerated response to inhaledAspergillus fumigatus
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9
Q

RF of bronchiectasis

A 
Strong 
• cystic fibrosis
• host immunodeficiency
• previous infections
• congenital disorders of the bronchial airways
• primary ciliary dyskinesia
Weak
• alpha-1 antitrypsin deficiency
• connective tissue disease
• inflammatory bowel disease
• aspiration or inhalation injury
• focal bronchial obstruction
• tall, thin, white females, >60
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10
Q

Symptoms and Signs of bronchiectasis

A

Symptoms:

  • Persistent cough
  • Mucopurulent sputum (green or rusty coloured) - 2/3
  • SOB
  • Haemoptysis (less common - 50%)

Signs:

  • Crackles on auscultation (Squeaks and pops on inspiration)
  • Presence of underlying disorder
  • Fever

AE - change sputum colour and vol

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11
Q

Investigations for bronchiectasis

A

Observations (Pulse oximetry may show hypoxaemia)

  • CXR (first-line): tram track sign (dilated, thickened walls)
  • High-resolution CT (gold standard): Signet ring sign/ string of beads sign
  • FBC
    Neutrophilia = (presence of a superimposed infection or exacerbation)
    Eosinophils = aspergillosis
  • Sputum culture
  • Pulmonary function (reduced FEV1, elevated RV/TLC)
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12
Q

Other tests for underlying cause of bronchiectasis

A
  • Serum alpha-1 antitrypsin level
  • Sweat sodium chloride concentration and genetic testing for CFTR mutation analysis
  • Skin prick test for sensitivity toAspergillus fumigatusfor patients with elevated IgE
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13
Q

Management of bronchiectasis

A

Exercise, improved nutrition

Airway clearance therapy

  • Postural drainage
  • Percussion

Inhaled bronchodilator E.g. salbutamol
Inhaled hyperosmolar agent E.g. hypertonic saline –> less inflam med, +ve QoL and sputum bacteriology

Antibiotics in some pts

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14
Q

Prognosis and Complications of bronchiectasis

A

Prognosis:
Irreversible
Prognosis depends on severity and recurrence of exacerbations.

Complications:
Haemoptysis
Respiratory failure
Cor pulmonale

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15
Q

25 yo F presents to A&E with 2d hx of productive cough, SOB and fever. The cough is worse at night. She’s reported having brought up green mucus for the last 2 days. O/E you hear crackles throughout. On further questioning you find out that she’s been diagnosed with cystic fibrosis at birth and has had these symptoms in the past.

What is the most likely diagnosis? 
Asthma
Pneumonia
Chronic sinusitis
Bronchiectasis
A

Bronchiectasis

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16
Q

25 yo F presents to A&E with 2d hx of productive cough, SOB and fever. The cough is worse at night. She’s reported having brought up green mucus for the last 2 days. O/E you hear crackles throughout. On further questioning you find out that she’s been diagnosed with cystic fibrosis at birth and has had these symptoms in the past.
What is the first line investigation for this patient?

Bloods (FBC, CRP)
CXR
CT
Pulmonary function

A

B because everyone gets CXR with these symptoms

CT is gold standard but only used if you have a high suspicion of Bronchiectasis

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17
Q

Define pneumonia

A

Inflammation of the alveoli which can be caused by bacteria, viruses or fungi. Inflammation results in air sacs filling with fluid or pus (+blood cells).

Alv. walls thickened by oedema

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18
Q

Pneumonia classification

A

Pneumonia can be classified by the causative organism or (more commonly) by where it was acquired

  • Community Acquired Pneumonia
  • Hospital Acquired Pneumonia
  • Aspiration Pneumonia
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19
Q

Community Acquired Pneumonia causative organisms

A 
Streptococcus pneumoniae
Haemophilus influenzae
--------
Staphylococcus aureus
group A streptococci
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20
Q

Hospital Acquired Pneumonia causative organisms

A 
Escherichia coli
Staphylococcus aureus(MSSA)
Klebsiella pneumoniae
Acinetobacter baumannii
Pseudomonas aeruginosa
Enterococcus Faecium
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21
Q

Atypical Pneumonias causative organisms

A

Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumophila
Coxiella burnetii(zootonic pathogen)

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22
Q

50 yo M smoker with multiple comorbidities (diabetes, HTN) presents to A&E with 1d hx of confusion and productive cough with yellow sputum. O/E he is apyrexial, BP 150/95 mmHG, HR 90 bpm, RR of 20 breaths per min. His oxygen saturation is 96% at rest. There are crackles at the left base.

What is the most likely organism that caused this?

Staphylococcus aureus
Mycoplasma pneumoniae
Streptococcus pneumoniae
Pseudomonas aeruginosa
Legionella pneumophila
A

Streptococcus pneumoniae

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23
Q

Pneumonia: 4 mechanisms of entry

A

Inhalation (viral + atypical)
Aspiration of URT secretions
Haematogenous from local infection (e.g. endocarditis)
Direct extension from local foci (TB via lymphatics)

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24
Q

Signs and Symptoms of pneumonia

A

Symptoms

  • Productive cough
  • Coloured sputum
  • SOB
  • Pain on inspiration
  • Pleuritic CP
  • Fever (+malaise + rigors)

Signs

  • Pyrexia, cyanosis, tachypnoea
  • Confusion
  • Chest examination: Dull percussion, bronchial breathing on auscultation, decreased chest expansion, increased VRes
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25
Q

Investigations for pneumonia

What 4 things can you tell from a CXR?

A 
Bloods (FBC, CRP)
- Neutrophil predominance = bacterial
- HCT = severity indicator
Sputum sample (Microscopy and culture)
Blood cultures (if severe)

CXR

  • Consolidation
  • Alveolar opacification
  • Air bronchograms (air-filled bronchi visible bc surr alv opacifies)
  • Lobar vs. multilobar
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26
Q

CURB-65

A 
CURB 65
- Confusion
- Urea > 7mmol/L
- Resp Rate >30
- BP < 90/60 mmHg
- >65
1 point for each

0-1: low severity; home Tx if possible
2: moderate severity; consider hospital Tx
>=3: severe; consider ITU

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27
Q

Mx of pneumonia

A
  1. Antibiotics
    - Low Severity: oral amoxicillin
    - Moderate: oral/IV amoxicillin + macrolide
    - High severity: IV Co-Amoxiclav + macrolide
  2. Oxygen (if sats low)
  3. Analgesics (if pleuritic CP)
  4. Fluids (if shocked/dehydrated)

Follow up CXR at 6 weeks to check for malignancy, masked by pneumonia.

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28
Q

Prognosis and Complications of pneumonia

A

Mortality
0-1: < 1%
2: 5-15%
3 or more: 20-50%

Complications:

  • Septic shock
  • C. difficile infection from antibiotic use
  • Death from heart failure, respiratory depression in the elderly or severely unwell.
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29
Q

Atypical Pneumonias definition

A

Atypical organisms - not detectable on Gram stain and cannot be cultured using standard methods.

Usually gives symptom complex: headache, low-grade fever, cough, and malaise

Constitutional symp > resp findings

Most cases = milder CAP, some, esp. L. pneumophilia –> severe, needs ICU admission

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30
Q

Diseases caused by Legionella

A

Legionella Pneumonia = Legionnaire’s Disease
Non-pneumatic legionella = Pontiac Fever

Legionella bacteria are found in aqueous environments - transmitted through inhalation of contaminated water dropletse.g. air conditioning, whirlpool spas, contaminated water supplies, recent plumbing work

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31
Q

Legionella presentation

A
  • Prodromal flu-like symptoms (fever, malaise, myalgia)
  • Dry cough (can become productive)
  • GI symptoms (nausea, D+V)
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32
Q

Legionella investigations

A

Sputum culture
Urinary antigen detection
Hyponatraemia
CXR – bi-basal consolidation

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33
Q

Legionella Tx

A

IV fluoroquinolones (ciprofloxacin) OR macrolide (clarithromycin)

34
Q

Pneumocystis Jirovercii (Previously known as P.carinii)

A

Causes pneumocystis pneumonia (PCP) - Opportunistic fungal infection and is an AIDS defining illness

  • Recurrent bacterial pneumonias = risk factor
  • Seen in HIV +ve patients
  • Significant weight loss = risk factor
35
Q

Pneumocystis Jirovercii CRX

A

Bilateral pulmonary infiltrates with pneumatoceles

36
Q

Pseudomonas Aeruginosum

A

Seen in patients with bronchiectasis or cystic fibrosis

HAP - improper hygiene (unclean hands, contaminated equipment)
–> pneumonia, bloodstream infx, UTI, surgical wound infx.

37
Q

Pseudomonas Aeruginosum Tx

A

Treatment – Piptazobactam (Piperacillin + Tazobactam)

38
Q

Mycoplasma Pneumonia symptoms and RF

A

Insidious onset (occasionally asymptomatic)

  • Persistent cough
  • Low grade fever
  • Red cell agglutinins and transverse myelitis

Commonly seen in close community settings e.g. boarding schools, universities, army bases

39
Q

Mycoplasma Pneumonia Investigations

A
  • CXR worse clinical picture than patient symptoms
  • PCR for suspected M. Pneumonia
  • Historically – cold agglutinins
40
Q

Mycoplasma Pneumonia Tx

A

Erythromycin/Clarithromycin

41
Q

Staph Aureus RF

A

Commonly seen in IVDU

Can arise from blood-borne spread of organisms from infected tissue can lead to septicaemia

42
Q

Staph Aureus Invx

A

CXR: Patchy areas of consolidation that break to form abscesses which appear as cysts

43
Q

Staph Aureus Tx

A

Treatment - Flucloxacillin (Vancomycin if MRSA)

44
Q

50 yo M smoker with multiple comorbidities (diabetes, HTN) presents to AE with 1d hx of confusion and productive cough with yellow sputum. O/E he is apyrexial, BP 150/95 mmHG, HR 90 bpm, RR of 20 breaths per min. His oxygen saturation is 96% at rest. There are crackles at the left base.

How should we treat this patient?

Admit and give IV co-amoxiclav + macrolide
Admit and give oral amoxicillin
Admit for observations
Give him a smoke cessation leaflet
Send home with oral amoxicillin and advise to return if he becomes severely unwell

A

CURB-65 = 1

Send home with oral amoxicillin and advise to return if he becomes severely unwell

45
Q

What signs would you expect on physical examination of someone with pneumonia?

A. Deviated Trachea, ↓ expansion, Dull to percussion
B. Bronchial Breathing, ↓ expansion, ↓ vocal resonance
C. Pyrexia, ↓ expansion, ↑ vocal resonance
D. Dull to Percussion, ↑ expansion, Pyrexia

A

C. Pyrexia, ↓ expansion, ↑ vocal resonance

46
Q

A 55 year old man has a 3 day history of shivering, general malaise & productive cough and is vomiting. The x-ray shows right lower lobe consolidation. He is diagnosed with a moderate pneumonia, what is the first line therapy?

A. Oral Amoxicillin
B. IV Co-Amoxiclav + Clarithromycin
C. Doxycycline
D. IV Amoxicillin + Clarithromycin

A

D. IV Amoxicillin + Clarithromycin

47
Q

A 71 year old Gentleman is brought in by his carer with a 4 day history of a fever and a cough. As you go to examine him he shouts and asks that you leave his bedroom. His RR is 32, BP 95/55. The lab phones you a hour later and let’s you know his urea is 7.8. Where would you manage this patient?

A. Admit and treat
B. Treat at home
C. Consider ITU
D. Refer for palliative care

A

C. Consider ITU

48
Q

25M presents to A&E with a fever and a cough. He says he has been generally unwell over the last year. O/E he is acutely SOB with a RR of 28. You also note an incidental finding of purple patches on his nose. What is the most likely causative organism?

A. Pseudomonas Aeruginosa
B. Strep Pneumoniae
C. Pneumocystis Jiroveci
D. Mycoplasma pneumoniae

A

C. Pneumocystis Jiroveci

49
Q

55M presents with a cough and fever. He recently travelled to New York to speak at a conference. After bloods revealed Na+: 130, you decide to test the urine. What is the most likely causative organism?

A. Haemophilus Influenza
B. Pseudomonas Aeruginosa
C. Legionella Pneumophilia
D. Pneumocystis Jiroveci

A

C. Legionella Pneumophilia

50
Q

10F presents to A&E with a fever and a cough and O2 sats: 92%. Her parents don’t seem worried as they are used to bringing her into hospital for treatment for her respiratory condition.
What is the most likely causative organism?

A. Pseudomonas Aeruginosa
B. Haemophilus Influenzae
C. Staph Aureus
D. Coronavirus

A

A. Pseudomonas Aeruginosa

51
Q

A known IVDU is brought into A&E, he was found unconscious by two friends who were worried he might have overdosed. You notice an abscess in his groin. Temp: 39, HR 120, BP 90/50. You immediately admit him.
What is the most likely causative organism?

A. Haemophilus Influenzae
B. Staph Aureus
C. Coronavirus
D. Legionella Pneumophilia

A

B. Staph Aureus

52
Q

Define tuberculosis

A

An infectious disease caused byMycobacterium tuberculosis. In many cases,tuberculosisbecomes dormant before it progresses to active TB.

It is communicable in this form, but may affect almost any organ system including the lymph nodes, CNS, liver, bones, genitourinary tract, and GIT

Recent travel? Night sweats?

53
Q

Epidemiology of TB

A
  • 9th leading cause of death worldwide.
  • 85% of deaths in African Region and South-East Asia Region.

10% of latent (no clinical, bacteriological, radiographic evidence of active TB) –> active disease

54
Q

Aetiology of TB

A

2 conditions:
Infection with Mycobacterium tuberculosis
Inadequate immune system (immunosuppression from medication, another disease e.g. HIV)

Transmitted via aerosol droplets.

55
Q

RF of TB

A
  • Recently travelled to Asia, Latin America or Africa
  • Immunosuppression
  • Malnutrition
  • Alcoholism
56
Q

Pathophysiology of TB

A
  • Droplet nuclei with bacilli are inhaled, enter the lung, and deposit in alveoli.
  • Macrophages and T lymphocytes act together to try to contain the infx by forming granulomas
  • In weaker immune systems, the wall loses integrity and the bacilli are able to escape and spread to other alveolar or other organs
57
Q

Symptoms and Signs of TB

A 
Symptoms:
- Cough (2-3 week duration;
Dry --> productive)
- Drenching night sweats
- FLAWS
- Haemoptysis <10% of patients (usually advanced stage)

Signs:

  • Fever
  • Crackles, bronchial breathing on auscultation
  • Erythema nodosum (painful raised erythematous nodules over pre-tibial region)
58
Q

Investigations for TB

A
  • Observations
  • CXR (Fibronodular opacities on the upper lobes)
  • Sputum smear:
    For acid-fast bacilli
    Using Ziehl-Neelson staining
    On Lowenstein-Jensen agar
  • Sputum culture (8wks to grow)
  • Nucleic acid amplification test (NAAT) - <8hrs but low specificity/availability
  • Biopsy: caseating granulomas.
59
Q

Definition and epidemiology of lung cancer

A

Carcinoma (malignancy of epithelial cells) arising from cells lining the lower respiratory tract.

13% all cancer cases, leading cause of cancer deaths (17.6), 3rd C in Europe

Any fever? Change in energy levels? Change in appetite?…. Do you/have you ever smoked?

60
Q

4 main categories of lung cancer

A

1) Small cell
2) Non-small cell (80% of all lung carcinomas)
- Adenocarcinoma (45% of NSCLC, peripheral in lungs)
- Squamous cell carcinoma (25-30%, later mets)
- Large cell carcinoma (10% - centrally)
3) Metastases (more common than primary; C: breast, colon)
4) Mesothelioma

Some too poorly differentiated for classification

61
Q

RF for lung cancer

A
  • Increasing age
  • Smoking tar-based cigarettes (85% of lung carcinomas)
  • Exposure to tobacco smoke, radon gas, or asbestos
  • COPD
62
Q

Small cell lung cancer

A
  • 15% of primary lung cancer
  • Strongest association with smoking
  • Arise in central lung
  • Rapid growth, highly malignant
  • May produce endocrine hormones (e.g. ACTH or ADH)
63
Q

Adenocarcinomas

A
  • Most common type in never-smokers
  • Most common type in women (especially female smokers)
  • Arise in peripheral lung
  • Most common type to have pleural involvement
64
Q

Squamous cell lung cancer

A

25% of primary lung cancer

  • Most commonly occurs in male smokers
  • Strong association with smoking
  • Arise in central lung
  • May produce PTHrP
65
Q

Large cell lung cancer

A
  • 10% of primary lung cancer
  • Can arise centrally or peripherally
  • Poor prognosis
66
Q

Lung cancer symptoms

A
  • (f)LAW(s)
  • Cough!
  • Haemoptysis
  • SOB
  • Paraneoplastic syndromes bc ectopic endocrine hormones e.g. Cushings, SIADH, osteoporosis/abnormal fractures or bone pain from excess ectopic PTHrp.
67
Q

Lung cancer signs

A
  • Horner’s syndrome (ptosis, anhydrosis, miosis): pancoast tumour (apex) compresses cervical SNS nerves
  • Cachexia
  • Anaemia
  • Clubbing
  • Paraneoplastic syndromes
  • May have wheeze, crackles, dullness to percussion, reduced breath sounds
68
Q

Lung cancer investigations

A

Observations

CXR
- A negative CXR does not rule out cancer

CT

Sputum cytology

  • Low sensitivity so not routinely used but necessary when determining chemotherapy susceptibility
  • Better for central tumours

Bronchoscopy

Biopsy
- Often required for definitive diagnosis

69
Q

Differentiate SCLC on CXR

A

SCLC: central mass, hilar lymphadenopathy, pleural effusion

NSCLC: variable; may detect single or multiple pulmonary nodule(s), mass, pleural effusion, lung collapse, or mediastinal or hilar fullness

70
Q

Mesothelioma definition

A

Malignant mesothelioma is an aggressive epithelial neoplasm arising from the pleural lining, abdomen, pericardium, or tunica vaginalis.

As a consequence of environmental exposure: asbestos fibres (80%) e.g. from shipyard/construction job; RF: chronic radiation

Do you have a regular job?

71
Q

DDx Asbestosis and methothelioma

A

NB: [Asbesto]sis = Diffuse interstitial fibrosis of the lung

Asbestosis develops from asbestos fibers lodging in the alveoli; strong correlation to smoking

Mesothelioma develops from asbestos fibers lodged in the lining of the lungs; weak correlation to smoking

72
Q

Symptoms and Signs of Mesothelioma

A

Latency period 20-40 years
Dry cough
SOB

Signs:
Muffed breath sounds on auscultation (pleural effusion)

73
Q

Mesothelioma investigations

A
  • CXR

- CT (Thickened pleural plaques; Fibrosis from asbestosis)

74
Q

Asbestosis investigations

A
  • CXR
  • CT
    “Advanced asbestosis appears as excessive whiteness” in the lung tissue.
    Severe: honeycomb appearance
75
Q

Discriminators for Bronchiectasis, TB, Lung Cancer, Mesothelioma and Pneumonia

A

Bronchiectasis: Long duration, Underlying disorder, Inspiratory squeaks and pops, Signet-ring sign (CT)

TB: Recent travel/exposure, Granulomas on CXR, Sputum smear described

Lung cancer (general): Insidious, Weight loss, Age, Smoking history

Mesothelioma: Exposure

Pneumonia: Signs of infection

76
Q

Cystic fibrosis

A

One of the most common potentially lethal inherited diseases in Caucasians.
It affects about 1 in 2500 live births
Autosomal recessive
Defect in the Cystic Fibrosis Transmembrance Conductance regulator on chromosome 7.

77
Q

CF aetiology

A

Bronchial mucosa: a failure of chloride transport -> secretions of abnormal viscosity –> reduced mucociliary clearance -> LT buildup of viscid muscus –> airways blockage + focus for infection

Inflammation targeting this fails to clear infection –> resultant cycle of infection and inflammation –> LT lung damage, bronchiectasis, distal airway obstruction, respiratory failure and eventually death due to a short coma brought about by respiratory failure.

Clubbing

78
Q

CF Monitoring

A

Serial measurements of FEV1 will decrease with time and indicate the extent and severity of the disease.

79
Q

Typical organisms infecting CF pts

A

Pseudomnas Aeruginosa
Staph Aureus
Strep Pneumoniae
H influenzae

80
Q

Complications of CF

A

As the cycle of infection and inflammation progresses, lung damage worsens with parenchymal destruction and interference with gas exchange –> eventually: hypoxia, hypercapnoea, cor pulmonale

Additionally, pts can suffer from haemoptysis, due to hypertrophy of the bronchial vessels
Pneumothoraces

81
Q

What Abx can you give for Bronchiectasis

A

Amox, Clarythro, trimethoprim/sulphamethoxazole

Pseudomonas - fluoroquinolone/aminoglycoside

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