Case 7 SAP

Question 1

Describe the management of anaphylaxis

Answer 1

Assess ABCDE. If anaphylaxis suspected, give 0.5ml IM adrenaline. If no change after 5 minutes, give a repeat dose of adrenaline. Keep reassessing ABCDE.

Question 2

What effects does giving adrenaline have on anaphylaxis?

Answer 2

Relieves airway obstruction from mucosal oedema (alpha 1), inotropic and chronotropic effects relieve hypotension and shock (beta 1), relieves bronchoconstriction and decreases mediator release (beta 2)

Question 3

What can also be given for anaphylaxis?

Answer 3

O2 for hypoxia, IV fluids for hypotension and shock, inhalers for bronchospasm, nebulised adrenaline for laryngeal oedema.

Question 4

What is given for bronchospasm/obstruction in COPD?

Answer 4

β2 agonists (SABA and LABA), methylxanthines (theophylline), selective PDE4 inhibitor roflumilast, cholinergic antagonists (LAMA)

Question 5

Describe the COPD treatment pathway

Answer 5

1st: stop smoking, vaccines, pulmonary rehabilitation if needed, self-management plan, treatment for comorbidities
2nd: start inhaled therapies (SABA or SAMA) if 1st line complete, needed to relieve breathlessness, and patient has been trained to use inhalers
3rd: offer LABA and LAMA if exacerbations despite treatment and no asthma/steroid responsiveness OR consider LABA + ICS if asthmatic features or steroid responsiveness
4th: consider LABA + LAMA + ICS

Question 6

Describe the asthma treatment pathway

Answer 6

1st: low dose ICS with a SABA
2nd: low dose ICS, LTRA with a SABA
3rd: low dose ICS, LABA with or without LTRA with a SABA
4th: low dose ICS plus a LABA within a MART regimen, with or without LRTA
5th: moderate dose ICS plus LABA
6th: high dose ICS plus LABA and SABA
7th: moderate ICS with trial of additional drug with SABA and LABA
8th: send to asthma expert

Question 7

Describe acute bronchitis

Answer 7

a lower respiratory tract infection which causes inflammation in the bronchial airways. Annual incidence 44 per 1000 adult population. Most episodes occur during autumn or winter. Avoid cigarette smoke, chemicals, dust, and air pollution to help prevent. Most are viral but can be bacterial.

Question 8

Describe pneumonia

Answer 8

an infection of the lung tissue in which the air sacs in the lungs become filled with microorganisms, fluid, and inflammatory cells, affecting the function of the lungs. Defined as the presence of clinical signs and symptoms along with radiological changes that are consistent with pneumonia. 220,000 diagnosed annually, incidence of community-acquired pneumonia (CAP) is 5-10 per 1000 adult population. Can be prevented by immunization, adequate nutrition, and by addressing environmental factors.

Question 9

Most common causes of CAP

Answer 9

streptococcus pneumoniae (gram positive rod), haemophilus influenzae (gram negative bacilli or coccobacilli), and staphylococcus aureus (gram positive cocci) are the most common causative agents of CAP. Strep is the most common cause, haemophilus is common in people with COPD, and staph is common in people with recent influenza diagnosis or severe illness.

Question 10

Signs and symptoms of pneumonia

Answer 10

acute illness, fever, cough, mucopurulent sputum, haemoptysis, breathlessness, pleuritic pain, abnormal chest x-ray, confusion in the elderly, crackles, and bronchial breathing. May get rust coloured sputum with strep pneumoniae.

Question 11

Risk factors for pneumonia

Answer 11

aged over 65, living in a residential home, COPD, exposure to cigarette smoke, alcohol misuse, antacids, and contact with children.

Question 12

List the atypical pneumonias

Answer 12

mycoplasma pneumoniae and legionella species (gram negative bacilli).

Question 13

Describe hospital acquired pneumonia

Answer 13

similar symptoms to CAP. Defined as new onset cough with purulent sputum in patients who are beyond two days after initial admission. Significant mortality risk in elderly with co-morbidities.

Question 14

Describe diagnosis of pneumonia

Answer 14

clinical judgement as no combination of signs or symptoms is clearly diagnostic, cough is predominant symptom, chest x-ray required to confirm (normal for bronchitis, abnormal for pneumonia). Sputum culture, blood culture, and test to identify the bacterium. Can also test for antigens in urine (strep, legionella), antibodies in the blood (staph a), ELISA/PCR/IgM antibodies detection (M pneumoniae).

Question 15

Scoring system for pneumonia

Answer 15

CURB65 score (confusion <8, plasma urea >7, resp rate >30, BP <90/<60, aged >65). Score of 0-1 = outpatient, 2 = admit to hospital, 3 = ICU.

Question 16

Treatment of pneumonia

Answer 16

often wide spectrum given until causative agent identified. Give amoxicillin for 0 – 2 CURB65 CAP, give co-amoxiclav for 3 – 5. First choice HAP is co-amoxiclav as mild and low risk of resistance.

Question 17

List the endemic fungi causing respiratory tract infections

Answer 17

histoplasma capsulatum (causes histoplasmosis, mid-central and eastern half of USA, found in bat and bird faeces), coccidioides immitis (causes coccidioidomycosis, central and South America, found in soil), and Paracoccidioides brasiliensis (causes Paracoccidioidomycosis, central and South America, water borne). All generally have no/mild symptoms.

Question 18

List the opportunistic fungi

Answer 18

candida (causing candidiasis), mucor species (causing mucormycosis), cryptococcus neoformans (causing cryptococcosis), and aspergillus species (causing aspergillosis).

Question 19

Describe aspergillosis

Answer 19

localised pulmonary infection in people with underlying lung disease, allergic broncho-pulmonary disease, allergic sinusitis, and allergic alveolitis. Can cause necrotising inflammation, oedema, bleeding, and formation of granulomas. Caused by inhaling mould from soil, compost, rotting leaves, plants, trees, crops, dust, damp building, and air conditioning systems.

Question 20

Who do fungal infections typically infect?

Answer 20

especially problematic in the immunocompromised. About 15% of HIV patients admitted to hospital in the UK will suffer a nosocomial pulmonary infection and 5-10% of these will be opportunistic fungal pneumonias.

Question 21

How are fungal pneumonias treated?

Answer 21

antifungal drugs (ending in -azole), but in advanced cases surgical debridement may be necessary – the removal of dead, damaged, or infected tissue.

Question 22

List the common viral causes of RTIs

Answer 22

adenoviruses, rhinoviruses, coronaviruses, paramyxoviruses (RSV and human para-influenza viruses), and orthomyxoviruses (influenza A, B, and C).

Question 23

Describe HPIV

Answer 23

important cause in children, four well recognised types HPIV1-4, spread as rhinovirus, mostly causing mild disease with symptoms including malaise, fever, cough, and sore throat.

Question 24

Describe symptoms of influenza

Answer 24

abrupt onset, shivering, malaise, headache, aching limbs and back, high fever approx. 39C – many symptoms could be the result of the cytokine storm released by infected cells.

Question 25

Treatment and prevention of influenza

Answer 25

Treatment: neuraminidase inhibitors (Tamiflu/oseltamivir and Relenza/zanmivir) but use is controversial and for high-risk groups. Prevention: hand hygiene, inactivated vaccine containing range of H and N subunits that is reformulated at intervals to match prevalent strains.

Question 26

Describe the types of influenza

Answer 26

three types defined by serology of internal matrix protein and nucleoprotein. A – epidemics and pandemics, infect animals and humans, designated based on the antigenic relationship of external spike proteins e.g. H1N1, H5N1. H1 – H17 = haemagglutinin, N1 – N9 = neuraminidase. B – milder epidemics. C – normally mild disease in children.

Question 27

Describe avian flu H5N1

Answer 27

has been spreading among poultry and wild birds for 25 years and recently started spreading to mammals. 868 human infections with 457 deaths – no human-human transmissibility yet so calls to start vaccine development.

Question 28

Describe the environmental impact of MDIs

Answer 28

puffer type inhalers that mix the medicine with a gas in the canister. The gas is HFC (hydrofluorocarbon) and is a potent greenhouse gas that contributes to global warming. They have up to a 30x greater carbon footprint than DPIs and are overused in the UK. If MDI is necessary, then ensure using the lowest puff : strength ratio (e.g. 1 puff of 200mcg rather than 2 puffs of 100mcg).

Question 29

Describe inhaler recycling

Answer 29

even when inhaler has run out of medicine it continues to leak harmful propellant into the atmosphere. Instead of putting the empty inhaler in the bin, bring back to a local pharmacy that will either recycle it or will dispose of it via waste medicine management.

Question 30

Describe the implications of poorly controlled asthma

Answer 30

carbon footprint up to 8 times higher. Overuse of SABA if poorly controlled which can lead to increased propellant use (MDI) and increased plastic waste (both MDI and DPI). Requires more appointments so the carbon footprint of the appointment increases (e.g. driving to the appointment). Increased risk of hospitalisation, especially acute care, which is more resource intense and generates a large carbon footprint. More likely to need additional medication including antibiotics which increases plastic waste and can contribute to antibiotic resistance.

Question 31

Short-term impact of air pollution on lung disease

Answer 31

rapid onset of symptoms, including irritated airways, feeling out of breath, and coughing. High levels of pollution can also cause an asthma attack or COPD exacerbation.

Question 32

Long-term impact of air pollution on lung disease

Answer 32

can contribute to the development of some lung conditions including lung cancer and asthma. Estimated that air pollution contributes to up to 36,000 early deaths in the UK every year.

Question 33

Occupational links to asthma

Answer 33

: healthcare, agricultural, food plant workers, carpenters, and chemical industry workers are more at risk for work-related asthma. Most are caused by repeated, long-term exposure but a severe, single exposure to a hazardous agents can damage the lung – most are preventable. Agents include allergens, antibiotics, latex, proteolytic enzymes, platinum salts, acid anhydrides and polyamine hardening agents.

Question 34

Exercise and cold air with asthma

Answer 34

Physical exercise and cold air –> increased ventilation –> increased mouth ventilation –> respiratory induced water loss –> increased extracellular osmolarity –> influx of intracellular calcium –> activation of phospholipases –> mast cell degranulation –> exercise induced asthma. Wheeze afterwards, epithelial lining fluid of the bronchi becomes hyperosmolar.

Question 35

Allergen exposure with asthma

Answer 35

allergen exposure can lead to immediate asthma (reaches max in 15-20 minutes and subsides in 1 hour) or can be late-phase reaction with a more prolonged and sustained attack – can be for several weeks after the exposure.

Question 36

Drugs in causing
asthma

Answer 36

NSAIDs trigger asthma in approx. 5%. Beta blockers can lead to bronchoconstriction and airflow limitation in asthmatics.

Question 37

Describe mycoplasma pneumoniae

Answer 37

M pneumoniae (walking pneumonia) is one of the smallest known free living organisms and lacks a rigid cell wall (so no gram stain). Transmission comes from airborne droplets through close contact. Frequently mild and self-resolving, common in children and teenager

Question 38

Describe legionella

Answer 38

Legionella caused by inhalation of contaminated aerosols. Presence associated with cooling towers, air conditioning units, fountains, hot tubs, and shower heads

Question 39

Symptoms of rhinoviruses

Answer 39

nasal congestion, sneezing, cough, sore throat, rarely fever

Question 40

Describe transmission of rhinoviruses

Answer 40

respiratory route, hand to mouth, and contaminated surfaces. 2-3 day incubation period, optimum growth temperature 33C

Question 41

Describe the rhinovirus type

Answer 41

non-enveloped RNA
approx 100 serological types
cause approx 80% common colds

Question 42

Describe the adenovirus type

Answer 42

non-enveloped DNA
51 known serotypes
7 species A-G

Question 43

Describe the adenovirus type

Answer 43

non-enveloped DNA
51 known serotypes
7 species A-G
cause approx 5-10% RTIs

Question 44

Symptoms of adenoviruses

Answer 44

cold-like, pharyngitis, bronchitis, pneumonia, diarrhoea, fever, conjunctivitis, acute respiratory disease
death is rare but infections can be problematic in immunocompromised people

Question 45

Describe the spread of adenoviruses

Answer 45

commonly cause outbreaks in crowded environments (so new military recruits are vaccinated)
respiratory route, hand to mouth, contaminated surfaces, close personal contact, faecal/oral

Question 46

RSV virus type

Answer 46

paramyxovirus, enveloped, ssRNA (positive sense)

Question 47

Epidemiology of RSV

Answer 47

most common cause of bronchitis in infants
approx 20,000 hospital admissions of infants per year in UK

Question 48

Symptoms of RSV

Answer 48

similar to common cold in most cases, 25-40% <1 year old show signs of bronchiolitis or pneumonia
may cause death in elderly or immunocompromised

Question 49

Spread of RSV

Answer 49

droplets. re-infection common, incubation period of roughly 5 days. hand hygiene important to prevent.

Question 50

What is given to infants susceptible to RSV?

Answer 50

Palivizumab (monoclonal anitbody)

Question 51

Influenza virus types

Answer 51

orthomyxoviruses
enveloped negative RNA with segmented genomes

Question 52

Neuraminidase

Answer 52

enzyme on surface of influenza, antigenic and aids release from infected cells

Question 53

Haemagglutinin

Answer 53

influenza antigenic glycoprotein that binds to target cell receptors

Question 54

Transmission and replication of influenza

Answer 54

respiratory route
2-3 day incubation period
replicated in epithelial cells of respiratory tract so cilia are destroyed
generally short-lived but can be dangerous for at-risk groups

Question 55

Describe human coronaviruses

Answer 55

enveloped ssRNA
mild infections - malaise, nasal discharge, no fever/cough, rarely sore throat
3 day incubation

Question 56

3 other coronaviruses known to cause severe disease

Answer 56

MERS-CoV, SARs-CoV, SARs-CoV-2
bats or mammals may be natural hosts

Question 57

Symptoms of SARs-CoV-2

Answer 57

Fever, new and continuous cough, SOB, fatigue, loss of appetite, loss of smell, and loss of taste. Other, less common symptoms include headache, muscle pain, sore throat, nasal congestion, chest pain, nausea and vomiting, diarrhoea, and skin rashes especially in younger people

Question 58

Nirmatrelivir

Answer 58

Anti-viral for coronaviruses. 3C-like protease inhibitor

Question 59

Ritonavir

Answer 59

Anti-viral for coronaviruses. Inhibits the metabolism of protease inhibitors

Question 60

Remdesivir

Answer 60

Anti-viral for coronaviruses. Terminates RNA transcription

Question 61

Molnupiravir

Answer 61

Anti-viral for coronaviruses. Inhibits RNA polymerase

Question 62

Non-anti-viral treatments for coronaviruses

Answer 62

Tocilizumab (monoclonal antibody) and dexamethasone (corticosteroid)

Question 63

Which bacteria cause hospital acquired pneumonia?

Answer 63

Caused by gram negative rods (E. coli, klebsiella species, pseudomonas species, Acinetobacter baumanii), anaerobic bacteria (Enterobacter), and strep pneumoniae.