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Core Curriculum > 5. Chronic Cough > Flashcards

5. Chronic Cough Flashcards

1
Q

Define Asthma

RF

A

Chronic inflammatory airway disease characterised by intermittent airway obstruction and hyper-reactivity

  • History of atopy
  • Family History
  • Smoker
  • Occupation
  • Pets
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2
Q

Symptoms and signs of chronic asthma

A

Symptoms:

  • Recurrent episodes of cough, wheeze, SOB
  • Variation (worst in morning & evening)

Signs:
General Inspection: Nasal polyposis; May be normal

Auscultation:
Wheeze

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3
Q

Investigations for chronic asthma

When do you Dx it?

A

Spirometry (FEV1: FVC ratio)

  • FEV1% (FEV1/FVC) < 70% –> trial asthma Tx
  • PEFR varies by at least 20% for 3 days in a week over several weeks or PEFR increases by at least 20%
  • Reversibility: 12% pre- and post-bronchodilator spirometry (Give SABA in spiro)

PEFR (if spiro unavailable)
Bloods

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4
Q

Asthma Mx

A

1: inhaled SABA (salbutamol)
2: + inhaled low dose CS (beclomethasone)
3: inhaled LABA (salmeterol) + increased dose CS
4. Trials: theophylline, oral BA, oral leukotriene ag (montelukast)
5. oral CS

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5
Q

On each visit to the GP, it’s important to check the following for asthma…

A
  • Inhaler technique and adherence
  • Symptoms (adjust medication as needed)

Promote:

  • Smoking cessation
  • Weight loss
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6
Q

Acute asthma: moderate

A
  • Increasing symptoms
  • PEF >50-75% best or predicted
  • No features of severe
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7
Q

Acute asthma: severe

A

Moderate + any one of:

  • PEF 33-50% best or predicted
  • RR >25/min
  • HR >110/min
  • inability to complete sentences in one breath
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8
Q

Acute asthma: life-threatening

A

Severe asthma + any one of the following:

Clinical signs:

  • Altered conscious level
  • Exhaustion
  • Arrhythmia
  • Hypotension
  • Cyanosis
  • Silent Chest
  • Poor respiratory effort

Measurements:

  • PEF <33% best or predicted
  • SpO2 < 92%
  • PaO2 <8 kPa
  • ‘Normal’ PaCO2 (4.6-6.0kPa)
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9
Q

Acute asthma: Near fatal

A

Raised PaCO2 and/or requiring mechanical ventilation w/ raised inflation pressures

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10
Q

Acute Asthma Invx

A

Basic observations (e.g. HR, SpO2)

Measure and record PEF

O2 saturation and maintain SpO2 at 94-98%

ABG - *repeat ABG if PaO2 <8kPa, unless SpO2 >92%; or initial PaCO2 is normal or raised; or if patient deteriorates

Serum theophylline concentration should be taken if aminophylline is continued for >24 hours

Serum K+ and glucose

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11
Q

Acute Asthma Mx

A

1) O2
2) Neb. Salbutamol 5mg + Oral Pred 40-50mg + IV Hydrocortisone 100mg
- Neb. Ipratropium Bromide, 0.5mg (added for acute-severe or life-threatening asthma, or poor response to salbutamol therapy)
3) IV Magnesium sulphate + senior help
4) IV Aminophylline
5) ITU + intubation

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12
Q

Acute Asthma Invx

A

Basic observations (e.g. HR, SpO2)

Measure and record PEF

O2 saturation and maintain SpO2 at 94-98%

ABG - *repeat ABG if PaO2 <8kPa, unless SpO2 >92%; or initial PaCO2 is normal or raised; or if patient deteriorates

Serum theophylline concentration should be taken if aminophylline is continued for >24 hours

Serum K+ and glucose

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13
Q

Acute Asthma Mx

A

1) O2
2) Neb. Salbutamol 5mg + Oral Pred 40-50mg + IV Hydrocortisone 100mg
- Neb. Ipratropium Bromide, 0.5mg (added for acute-severe or life-threatening asthma, or poor response to salbutamol therapy)
3) IV Magnesium sulphate + senior help
4) IV Aminophylline
5) ITU + intubation

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14
Q

A 17 year-old girl presents to the local A&E complaining of worsening shortness of breath, despite use of what she describes as her ‘blue inhaler’. On examination her oxygen saturations are 95%, she is afebrile and has a BP of 101/67. The attending physician takes an ABG and the results are shown below. Grade the severity of this patient’s asthma attack.

pH: 7.25
pCO2: 7.4 kPa (4.5-6.0)
pO2: 10.4 kPa (>10.5)
HCO3: 23 mmol/l

A. I cannot tell from the information available
B. Moderate
C. Acute severe
D. Life threatening
E. Near fatal
A

E. Near Fatal - pCO2 increased

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15
Q

A 26-year-old bus driver presents to the GP complaining of a worsening shortness of breath. On examination, the patient is afebrile, has a BP of 110/85 and has a marked wheeze on auscultation. The only medications the patient is on is Salbutamol, PRN. What is the next most appropriate treatment step as per the treatment guidelines for this condition?

A

Add an inhaled low-dose corticosteroid to her medications, taken OD

Note – patients on OD ICS should ensure they wash their mouth after taking the inhaler to reduce the likelihood of developing candidiasis in the mouth (this is why you check the mouth in the resp. exam!)

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16
Q

COPD definition

A

Preventable and treatable disease state characterised by airflow limitation that is not fully reversible. It encompasses both emphysema and chronic bronchitis

RF: smoking, FHx (A1ATdef)

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17
Q

Causes of Clubbing

A

Most common is idiopathic (50%)

Respiratory causes:
Malignancy Interstitial lung disease
Empyema lung abscess Cystic fibrosis
NOT COPD

CVS causes:
Malignancy (Tetralogy of Fallot)
Infective (bacterial) Endocarditis	
Congenital cyanotic heart disease
Atrial myxoma

GI causes:
Malignancy Coeliac’s disease
IBD
Cirrhosis

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18
Q

Clubbing signs

A

Boggy nail bed
Loss of Lovibond’s angle (should be less than 180 degrees)
‘Drumsticking’ of fingers
Increased longitudinal curvature of nail

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19
Q

Respiratory Causes of Clubbing

A

Most common is idiopathic (50%)

Respiratory causes:
Malignancy			
Interstitial lung disease
Cystic Fibrosis
Empyema lung abscess		
NOT COPD
20
Q

Chronic COPD Medical Mx

A

Mild: SAMA (Ipratropium Bromide) OR SABA (salbutamol) PRN

Moderate: Add LA counterparts
LAMA: tiotropium
LABA: salmeterol

Severe:
LAMA + LABA or LABA + inhaled corticosteroid (ICS)
E.G. Symbicort (Budesonide (ICS) and Formoterol (LABA))

Very severe:
LAMA + LABA + ICS

21
Q

COPD Investigations

A
  • Spirometry
  • Bloods, ABG
  • CXR

Others:

  • Serial peak flow measurements: to exclude asthma if diagnostic doubt remains
  • Alpha-1 antitrypsin (A1AT): if early onset, minimal smoking history or family history
  • Transfer factor for carbon monoxide (TLCO): if symptoms seem disproportionate to the spirometric impairment
  • CT scan of the thorax: investigate abnormalities seen on a chest radiograph + assess suitability for surgery
  • ECG or Echocardiogram: assess cardiac status if features of cor pulmonale
22
Q

Chronic COPD Mx

A

Mild: SAMAn (Ipratropium Bromide) OR SABA (salbutamol) PRN

Moderate: Add LA counterparts
LAMA: tiotropium
LABA: salmeterol

Severe:
LAMA + LABA or LABA + inhaled corticosteroid (ICS)
E.G. Symbicort (Budesonide (ICS0 and Formoterol (LABA))

Very severe:
LAMA + LABA + ICS

23
Q

Chronic COPD Other Mx

A

General Management

  • Smoking cessation
  • Annual influenza vaccination
  • Pneumococcal vaccination

Improved Survival

  • Smoking cessation
  • Long-term O2 therapy (15hrs/day)
  • Lung volume reduction surgery
24
Q

When do you give LT O2?

A 
pO2 of < 7.3 kPa 
OR
pO2 of 7.3 - 8 kPa and one of the following:
- Secondary polycythaemia
- Nocturnal hypoxaemia
- Peripheral oedema
- Pulmonary hypertension
25
Q

Acute COPD (Infective exacerbation) Mx

A

1) Blue Venturi 24% O2
2) Neb. Salbutamol 5mg + Ipratropium Bromide, 0.5mg Oral Pred 40-50mg + IV Hydrocortisone 100mg
3) IV Amoxicillin
4) IV 500mg Aminophylline
5) BiPAP (NIV)

26
Q

2 types of Non-Invasive Ventilation (NIV) and what they’re used for

A

CPAP (Continuous Positive Airway Pressure) – tx. T1 respiratory failure (e.g. sleep apnoea)

Bi-PAP (Bi-level PAP) – tx T2 respiratory failure (e.g. COPD)

27
Q

A 72-year-old man attends the GP complaining of increased shortness of breath and a cough productive of clear sputum. The GP notes the gentleman has a history of diagnosed COPD and decides to review his medications. The man hands the GP two inhalers, one a SABA and the other a LABA. After conducting spirometry, the GP calculates an FEV1 of 40% expected. What is the next most appropriate treatment step?

A

Replace the SABA with a LAMA

28
Q

Which of the following is not a respiratory cause of clubbing?

  • Squamous cell lung cancer
  • Interstitial lung disease
  • COPD
  • Cystic fibrosis
  • An empyema (lung abscess)
A

COPD

29
Q

ILD definition

A

Interstitial lung disease (ILD) is an umbrella term for a large group of disorders that cause scarring (fibrosis) of the lungs. The scarring causes stiffness in the lungs which makes it difficult to breathe. ILD conditions can include for example:
IPF, HP (EAA), Sarcoidosis, Pneumoconiosis

30
Q

General symptoms/signs of ILD

A
  • Dry cough
  • Restrictive picture
  • Clubbing (rare in EEA)
  • Fine, bi-basal inspiratory crepitations (except silicosis: reduced BS)

NB: Fine crackles = ‘snow-crunching’ sounds - to do with air bubbling through exudate (so is caused by stuff like pneumonia)

31
Q

Idiopathic pulmonary fibrosis definition and RF

A
  • Genetically predisposed host (e.g. surfactant protein mutations); recurrent alveolar damage results in cytokine release, activating fibroblasts, differentiating into myofibroblasts and increased collagen synthesis
  • Drugs: bleomycin, methotrexate, amiodarone

Risk Factors: smoking, occupational exposure to metal/wood, chronic micro-aspiration, animal/vegetable dusts

32
Q

Idiopathic pulmonary fibrosis symptoms and signs

A
  • SOB on exertion
  • Dry cough
  • NO WHEEZE
  • Clubbing
  • Fine, bibasal insp crepitations
  • RHF signs (late)
33
Q

Idiopathic pulmonary fibrosis Investigations

A

Bloods, ABG, BIOPSY

CXR – ground-glass, reticulonodular, cor pulmonale, honeycombing (for late pres)

High-resolution CT - ground-glass (for early pres)

Lung function tests (restrictive pattern)

NB: Biopsy is the gold-standard but not always appropriate. High-resolution CT is usually appropriate

34
Q

Hypersensitivity Pneumonitis / Extrinsic Allergic Alveolitis Aetiology

A

Inhalation of antigenic organic dusts containing microbes
Examples:
- Bird-keeper/pets
- Plumber
- Farmer’s (mouldy hay with thermophilic actinomycetes); Pigeon’s (bloom of bird feathers);
- Mushroom Worker’s (compost with thermophilic actinomycetes);
- Humidifier (water-containing bacteria);
- Maltworker’s (barley with aspergillus clavatus)

Most ILDs are very similar; they differ by a little bit in each history (for example, here the major give away is the occupation)

35
Q

Hypersensitivity Pneumonitis symptoms and signs

A

Acute ± chronic hx
SOB on exertion
Dry cough
Fever

Clubbing (rare)
Mild pyrexia (acute phase: may mimic atypical pneumonia)
Bi-basal, fine, inspiratory crepitations

36
Q

Hypersensitivity Pneumonitis Investigations

A

Bloods, ABG

CXR – often normal (can have ground-glass, reticulonodular, cor pulmonale, honeycombing)

High-resolution CT - ground-glass

Lung function tests (restrictive pattern)
Broncho-alveolar lavage – increased cellularity

37
Q

Pneumoconiosis Investigations

A

CXR:
Simple = micro-nodular mottling
Complicated = bilateral lower zone reticulonodular shadowing and pleural plaques (asbestosis is fibrotic changes, not just plaques); nodular opacities, micronodular shadowing; eggshell calcification (silicosis)

CT – fibrotic changes

Lung function tests (restrictive pattern)

38
Q

Pneumoconiosis symptoms and signs

A

Long latency
Can be asymptomatic (simple) or symptomatic (complicated)
Dry Cough, SOB
Signs of RHF

Asbestosis

  • Clubbing
  • Bi-basal, inspiratory crepitations

Silicosis
- Decreased BS

39
Q

Pneumoconiosis Investigations

A

CXR:
Simple = micro-nodular mottling
Complicated = bilateral lower zone reticulonodular shadowing and pleural plaques (asbestosis is fibrotic changes, not just plaques); nodular opacities, micronodular shadowing; eggshell calcification (silicosis)

CT – fibrotic changes

Lung function tests (restrictive pattern

40
Q

A 65-year-old man with a medical background of benign prostatic hyperplasia, presents to the GP with a 1 week history of worsening shortness of breath on exertion. He has a temperature of 38.5C, reports no weight loss but does mention some mild fatigue from his ‘pet pigeons keeping him up all night’ recently. On auscultation, the GP can determine fine, bi-basal inspiratory crackles. What is the most likely diagnosis?

COPD
Lung cancer
Bronchiectasis
Hypersensitivity pneumonitis 
Idiopathic pulmonary fibrosis
A

Hypersensitivity pneumonitis

38.5C
pigeons
insp crackles

41
Q

Sleep apnoea definition and RF

A

Characterised by recurrent collapse of pharyngeal airway and apnoea (cessation of airflow for >10s) during sleep; followed by arousal from sleep
(Common)

Obesity (advise lose wt), smoker, alcohol
Fatigue
Truck Driver
Enlarged tonsils
Macroglossia
Marfan’s syndrome
42
Q

Sleep apnoea symptoms and signs

A
  • Chronic Fatigue
  • Snoring
  • Unrefreshed sleep

Enlarged tonsils
Macroglossia
Marfan’s syndrome

43
Q

Sleep apnoea investigations

A

Sleep study - polysomnography (airflow monitoring; respiratory effort; pulse oximetry and heart rate
TFTs

44
Q

A tall 26-year-old woman comes into the GP complaining of chronic fatigue. Upon further questioning she reports that she ‘can never get a good night’s sleep’ and that she tends to fall asleep a lot at her workplace as a call centre customer service representative. She also mentions that she thinks it may have something to do with a condition her mother had. The only significant finding upon examination is patches of stretchy skin, especially around the neck area. What is the most likely underlying condition leading to disrupted sleep?

A. Obesity
B. Bad sleeping position
C. Marfan’s syndrome
D. Down’s syndrome
E. Chronic fatigue syndrome
A
  • Marfan’s syndrome leading to obstructive sleep apnoea

Condition her mother had
Stretchy skin

45
Q

CVS Causes of Clubbing

A 
CVS causes:
Malignancy (Tetralogy of Fallot)
Infective (bacterial) Endocarditis	
Congenital cyanotic heart disease
Atrial myxoma
46
Q

GI Causes of Clubbing

A

Malignancy
Coeliac’s disease
IBD
Cirrhosis

Core Curriculum (19 decks)

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