4. Cough Flashcards
Define Bronchiestasis and epidemiology
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?
Pathophysiology of Bronchiestasis
Neutrophils + T lymphocytes + Immune effector cells –> Cytokines, Proteases and ROS –> dilated airways, lots of mucus –> chronic inflam host response
Common causative organisms (4) of bronchiectasis
H. influenzae
S. pneumoniae
S. aureus
P. aeruginosa
Underlying disorders of bronchiectasis (4 categories)
NB: 7-50% idiopathic
Impaired drainage/clearance (genetic)
Airway obstruction
Defect in host defence
Post infectious
Impaired drainage/clearance (genetic) causes of bronchiectasis
cystic fibrosis, ciliary dyskinesia, alpha 1 anti-trypsin deficiency
Airway obstruction causes of bronchiectasis
Problem inside lumen (foreign body)
Problem in the wall (connective tissue disorder e.g. Rheumatoid Arthritis)
Problem outside (tumour)
Defect in host defence causes of bronchiectasis
immunosuppression, immunodeficiency
Post infectious causes of bronchiectasis
- Childhood respiratory infections due to viruses (i.e., measles, influenza, pertussis)
- Mycobacteriainfection or severe bacterial pneumonia
- Exaggerated response to inhaledAspergillus fumigatus
RF of bronchiectasis
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
Symptoms and Signs of bronchiectasis
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
Investigations for bronchiectasis
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)
Other tests for underlying cause of bronchiectasis
- 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
Management of bronchiectasis
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
Prognosis and Complications of bronchiectasis
Prognosis:
Irreversible
Prognosis depends on severity and recurrence of exacerbations.
Complications:
Haemoptysis
Respiratory failure
Cor pulmonale
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
Bronchiectasis
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
B because everyone gets CXR with these symptoms
CT is gold standard but only used if you have a high suspicion of Bronchiectasis
Define pneumonia
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
Pneumonia classification
Pneumonia can be classified by the causative organism or (more commonly) by where it was acquired
- Community Acquired Pneumonia
- Hospital Acquired Pneumonia
- Aspiration Pneumonia
Community Acquired Pneumonia causative organisms
Streptococcus pneumoniae Haemophilus influenzae -------- Staphylococcus aureus group A streptococci
Hospital Acquired Pneumonia causative organisms
Escherichia coli Staphylococcus aureus(MSSA) Klebsiella pneumoniae Acinetobacter baumannii Pseudomonas aeruginosa Enterococcus Faecium
Atypical Pneumonias causative organisms
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella pneumophila
Coxiella burnetii(zootonic pathogen)
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
Streptococcus pneumoniae
Pneumonia: 4 mechanisms of entry
Inhalation (viral + atypical)
Aspiration of URT secretions
Haematogenous from local infection (e.g. endocarditis)
Direct extension from local foci (TB via lymphatics)
Signs and Symptoms of pneumonia
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
Investigations for pneumonia
What 4 things can you tell from a CXR?
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
CURB-65
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
Mx of pneumonia
- Antibiotics
- Low Severity: oral amoxicillin
- Moderate: oral/IV amoxicillin + macrolide
- High severity: IV Co-Amoxiclav + macrolide - Oxygen (if sats low)
- Analgesics (if pleuritic CP)
- Fluids (if shocked/dehydrated)
Follow up CXR at 6 weeks to check for malignancy, masked by pneumonia.
Prognosis and Complications of pneumonia
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.
Atypical Pneumonias definition
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
Diseases caused by Legionella
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
Legionella presentation
- Prodromal flu-like symptoms (fever, malaise, myalgia)
- Dry cough (can become productive)
- GI symptoms (nausea, D+V)
Legionella investigations
Sputum culture
Urinary antigen detection
Hyponatraemia
CXR – bi-basal consolidation
Legionella Tx
IV fluoroquinolones (ciprofloxacin) OR macrolide (clarithromycin)
Pneumocystis Jirovercii (Previously known as P.carinii)
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
Pneumocystis Jirovercii CRX
Bilateral pulmonary infiltrates with pneumatoceles
Pseudomonas Aeruginosum
Seen in patients with bronchiectasis or cystic fibrosis
HAP - improper hygiene (unclean hands, contaminated equipment)
–> pneumonia, bloodstream infx, UTI, surgical wound infx.
Pseudomonas Aeruginosum Tx
Treatment – Piptazobactam (Piperacillin + Tazobactam)
Mycoplasma Pneumonia symptoms and RF
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
Mycoplasma Pneumonia Investigations
- CXR worse clinical picture than patient symptoms
- PCR for suspected M. Pneumonia
- Historically – cold agglutinins
Mycoplasma Pneumonia Tx
Erythromycin/Clarithromycin
Staph Aureus RF
Commonly seen in IVDU
Can arise from blood-borne spread of organisms from infected tissue can lead to septicaemia
Staph Aureus Invx
CXR: Patchy areas of consolidation that break to form abscesses which appear as cysts
Staph Aureus Tx
Treatment - Flucloxacillin (Vancomycin if MRSA)
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
CURB-65 = 1
Send home with oral amoxicillin and advise to return if he becomes severely unwell
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
C. Pyrexia, ↓ expansion, ↑ vocal resonance
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
D. IV Amoxicillin + Clarithromycin
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
C. Consider ITU
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
C. Pneumocystis Jiroveci
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
C. Legionella Pneumophilia
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. Pseudomonas Aeruginosa
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
B. Staph Aureus
Define tuberculosis
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?
Epidemiology of TB
- 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
Aetiology of TB
2 conditions:
Infection with Mycobacterium tuberculosis
Inadequate immune system (immunosuppression from medication, another disease e.g. HIV)
Transmitted via aerosol droplets.
RF of TB
- Recently travelled to Asia, Latin America or Africa
- Immunosuppression
- Malnutrition
- Alcoholism
Pathophysiology of TB
- 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
Symptoms and Signs of TB
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)
Investigations for TB
- 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.
Definition and epidemiology of lung cancer
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?
4 main categories of lung cancer
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
RF for lung cancer
- Increasing age
- Smoking tar-based cigarettes (85% of lung carcinomas)
- Exposure to tobacco smoke, radon gas, or asbestos
- COPD
Small cell lung cancer
- 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)
Adenocarcinomas
- 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
Squamous cell lung cancer
25% of primary lung cancer
- Most commonly occurs in male smokers
- Strong association with smoking
- Arise in central lung
- May produce PTHrP
Large cell lung cancer
- 10% of primary lung cancer
- Can arise centrally or peripherally
- Poor prognosis
Lung cancer symptoms
- (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.
Lung cancer signs
- 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
Lung cancer investigations
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
Differentiate SCLC on CXR
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
Mesothelioma definition
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?
DDx Asbestosis and methothelioma
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
Symptoms and Signs of Mesothelioma
Latency period 20-40 years
Dry cough
SOB
Signs:
Muffed breath sounds on auscultation (pleural effusion)
Mesothelioma investigations
- CXR
- CT (Thickened pleural plaques; Fibrosis from asbestosis)
Asbestosis investigations
- CXR
- CT
“Advanced asbestosis appears as excessive whiteness” in the lung tissue.
Severe: honeycomb appearance
Discriminators for Bronchiectasis, TB, Lung Cancer, Mesothelioma and Pneumonia
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
Cystic fibrosis
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.
CF aetiology
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
CF Monitoring
Serial measurements of FEV1 will decrease with time and indicate the extent and severity of the disease.
Typical organisms infecting CF pts
Pseudomnas Aeruginosa
Staph Aureus
Strep Pneumoniae
H influenzae
Complications of CF
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
What Abx can you give for Bronchiectasis
Amox, Clarythro, trimethoprim/sulphamethoxazole
Pseudomonas - fluoroquinolone/aminoglycoside
