Cough Flashcards
What are the causes of an acute dry and productive cough?
Acute dry cough:
- URTI - such as laryngitis, pharyngitis
- drugs - ACE inhibitors
Acute productive cough:
- pneumonia (LRTI)
- tuberculosis (TB)
What are the causes of chronic dry and productive cough?
Chronic dry cough:
- lung cancer
- GORD
- mesothelioma
Chronic productive cough:
- lung cancer
- bronchiectasis
- cystic fibrosis
What are the causes of mixed dry and productive cough?
Mixed dry cough:
- heart failure
- asthma
Mixed productive cough:
- heart failure
- COPD
What type of cough is usually present in heart failure?
- it is usually a dry cough
- it often produces rust-coloured sputum that signifies haemoptysis
- sometimes the cough may be productive
What type of cough is usually present in asthma?
- it is usually a dry cough
- it may be productive and produce sputum if there is an underlying infection
What is the definition of pneumonia?
What are the 3 different types?
an infection of the alveoli in the lungs
it is a lower respiratory tract infection
- community-acquired pneumonia
- atypical pneumonia
- hospital-acquired pneumonia
What are the 3 most common causes of community-acquired pneumonia?
- streptococcus pneumoniae
- haemophilus influenzae B
- moraxella catarrhalis
What are the common causes of atypical pneumonia?
- Mycoplasma pneumonia
-
Legionella pneumophila
- this is associated with faulty air conditioning systems
-
Chlamydia psittaci
- this is associated with keeping pet birds
- Chlamydia pneumoniae
What are the 3 most common causes of hospital-acquired pneumonia?
How is this defined?
- Staphylococcus aureus
- Pseudomonas aeruginosa
-
Klebsiella
- this is more common in alcoholics
HAP is defined as acquiring pneumonia after being in hospital for at least 48 hours
What is aspiration pneumonia and what causes it?
- caused by anaerobes from gut flora
- it occurs when food enters the lungs, often in stroke patients
What are the general risk factors for pneumonia?
- smoking
- travel
- being immunocompromised
What are the associated features of Staph aureus and Klebsiella causing hospital-acquired pneumonia?
they are both associated with cavitating lesions
it is a gas-filled area of the lung in the centre of a nodule or area of consolidation
this looks like an abscess with an air-fluid level inside
What specific feature is pneumonia caused by Mycoplasma pneumonia associated with?
it is associated with transverse myelitis
this is inflammation of both sides of one section of the spinal cord
What specific features is pneumonia caused by Legionella pneumophilia associated with?
- hyponatraemia and abnormal LFTs
What are the normal symptoms associated with typical pneumonia?
- fever
- shortness of breath (dyspnoea)
- cough that is productive and produces green sputum
-
pleuritic chest pain
- this is chest pain that is worse on inspiration
- confusion
What are the symptoms associated with atypical pneumonia?
- dry cough
- headache
- diarrhoea
- myalgia
- hepatitis
What clinical signs would you expect to be present on inspection of someone with pneumonia?
- signs of respiratory distress
- intercostal recession - seeing the ribs going in and out
- obviously tachypnoeic
-
peripheral / central cyanosis
- e.g. blue lips or nails
- observations will show raised HR and RR and reduced O2 sats
- patient will have a drop in BP if it is severe and they are heading towards sepsis
What would you expect to see on palpation, percussion and auscultation in someone with pneumonia?
Palpation:
- reduced chest expansion
Percussion:
- dull to percussion over areas of consolidation
Auscultation:
- coarse basal crepitations
- bronchial breathing
- increased vocal resonance
- when patient says “99”, it will sound louder over areas of consolidation
What key feature can make someone more susceptible to atypical organisms that cause pneumonia?
being immunocompromised
this can include someone who takes regular steroid medications
What investigations would be done in pneumonia?
Bedside tests:
- sputum MCS
Blood tests:
- FBC
- CRP
- ABG
- blood cultures
Imaging:
- chest X-ray
- also a pleural fluid sample can be taken via thoracentesis for MCS if a pleural effusion is present
What would the blood test results look like in someone with pneumonia?
- FBC shows high WCC
- CRP will be raised as it is a marker of infection
- ABG will show type 1 respiratory failure, which is a low O2
If atypical pneumonia is suspected, what additional tests are performed to identify the causative organism?
- serology should be performed
- urinary antigens and LFTs if legionella is suspected
- for mycoplasma, a blood film will show cold agglutins
What are the 2 different types of pneumonia on a chest X-ray?
Lobar pneumonia:
- this affects one or more sections (lobes) of the lungs
Bronchopneumonia:
- this affects patches throughout both lungs
What type of pneumonia is shown in this image?
this image shows lobar pneumonia
What type of pneumonia is shown here?
this image shows bronchopneumonia
this is shown by patchy / heterogenous consolidation
What are air bronchograms?
they are black translucent lines overlying consolidation
the alveoli are full of pus so air builds up in terminal bronchioles behind the alveoli
air is black on x-ray
What scoring system is used to determine the severity of pneumonia?
CURB-65 score
- C - Confusion = 8
- U - Urea > 7 mmol/L
- R - Respiratory rate > 30
- B - Blood pressure < 90/60 mmHg
- Age > 65
Score of 1 = GP
Score of 2 = A&E (+ short stay)
Score of 3+ = admission (+/- consider ICU)
What is involved in the acute management of pneumonia?
- give oxygen and make sure the patient is sitting upright
- IV fluids to restore BP
- IV painkillers (for pleuritic chest pain)
- IV antibiotics
- CPAP if required
What antibiotics are used to treat community-acquired pneumonia and atypical pneumonia?
Community-acquired:
- typically amoxicillin is given and co-amoxiclav in severe cases
Atypical:
- a macrolide such as clarithromycin is given
- commonly amoxicillin + clarithromycin are given as you are often not sure what exactly is causing the pneumonia
What antibiotics are typically given to treat hospital-acquired pneumonia?
How is this treatment different to that of CAP / atypical?
you need to know what is causing the infection before prescribing the antibiotic for HAP
- flucloxacillin is given if it is Staphylococcus aureus
- vancomycin is given if it is MRSA
- tazocin + gentamicin is given if it is Pseudomonas aeruginosa
What antibiotic is given to treat aspiration pneumonia?
metronidazole
this is used against anaerobic bacteria and protozoa
What are the potential complications of pneumonia?
- pleural effusion
- lung abscess - often in Staph aureus infections
-
empyema
- this is pus in the pleural cavity
- sepsis
What is a lung abscess and what are the 3 main symptoms of a lung abscess that has occurred as a complication of pneumonia?
- it involves necrosis of the pulmonary tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection
- swinging fevers
- persistent pneumonia
- foul-smelling sputum
What is the definition of tuberculosis infection?
Who are you most likely to catch TB from and why?
infection by _Mycobacterium tuberculosis_, which causes multi-systemic disease
you are more likely to catch TB from relatives than strangers as it requires prolonged exposure
What are the 3 / 4 stages of TB infection?
Primary:
- this is the initial infection
- it is often asymptomatic, but there can be pulmonary symptoms
Latent:
- asymptomatic infection
Post-primary:
-
reactivation of infection when the individual becomes immunocompromised
- this can be due to steroid use, increasing age, etc.
- this leads to severe symptoms
Miliary:
- lymphohaematogenous dissemination of TB
- it spreads across the body and causes disease everywhere
What are the risk factors for TB?
- travel
- South Asians / India / Bangladesh
- immunocompromised individuals e.g HIV infection
What are the general signs and symptoms of TB?
- FLAWS
- fever, lethargy, appetite loss, weight loss, night sweats
- shortness of breath
- productive cough that produces green sputum
- haemoptysis
- lymphadenopathy
What are complications of TB that affect the lungs and brain?
Lungs:
- TB pneumonia (LRTI)
- pleural effusion
Brain:
- meningitis
What are the complications of TB affecting the abdomen and skin?
Skin:
- erythema nodosum
- clubbing
Abdomen:
- peritonitis
- ascites
What are the potential complications of TB affecting the heart and spinal cord?
Heart:
- pericardial effusion
- constrictive pericarditis
- normocytic anaemia
Spinal cord / bones:
- Pott’s disease
- spinal cord compression
- osteomyelitis
What are the complications of TB affecting the reproductive organs and kidneys?
Reproductive organs:
- epididymo-orchitis
- infertility
Kidneys:
- renal failure
- Addison’s disease (adrenal insufficiency)
What bedside tests are performed to identify TB infection?
How long does this take?
- sputum MCS is performed - 3 samples are needed
- microscopy with Ziehl-Neelsen stain
- culture takes 6 - 8 weeks
- because culture takes so long, treatment needs to be started blind as you won’t know what agents the TB is susceptible to
What blood tests would be taken in suspected TB infection?
What results are expected?
- FBC
- CRP
- ABG
- blood cultures
- HIV
- would expect raised WCC and CRP as infection markers
- ABG should show type 1 respiratory failure (low O2)
What other tests are done in the investigation of TB?
- lymph node biopsy which will show caseating granuloma
- mantoux / tuberculin skin test (TST)
How is TB identified on a chest X-ray?
- patchy / heterogenous consolidation
- bi-hilar lymphadenopathy
- upper lobe scarring tends to suggest a past infection
- there may be evidence of cavitating lesions and/or pleural effusions but these are less characteristic
How is miliary TB identified on chest X-ray?
widespread nodular shadowing
this represents severe TB with very poor prognosis
In this scenario, what type of oxygen would you prescribe the patient?
15L of oxygen via a non-rebreather mask
- target sats are between 94 - 98%
- 2L of oxygen via a nasal cannula would be given when the patient’s sats were around 94-95%
- when sats are extremely low, you want to give high flow oxygen via a non-rebreather mask
What is the definition of bronchiectasis?
it is a chronic condition that causes permanent dilation of the airways
- there is dilation of both the bronchi and the bronchioles
- this takes time to develop as recurrent infection and inflammation are required to break down the airways and make them dilate
- the cell walls are damaged and there is increased mucus production
What are the congenital causes of bronchiectasis?
- cystic fibrosis
- primary ciliary dyskinesia (Kartagener’s syndrome)
- Young’s syndrome
What triads characterise the symptoms of primary ciliary dyskinesia and Young’s syndrome?
Primary ciliary dyskinesia:
- bronchiectasis
- sinusitis
- situs inversus
- this is where all of the organs are located on the wrong side of the body
Young’s syndrome:
- bronchiectasis
- sinusitis
- infertility
What are the acquired causes of bronchiectasis?
-
infection
- pneumonia
- tuberculosis
- measles
- pertussis
- someone having a lot of infections is more likely to get bronchiectasis as recurrent inflammation breaks down the airway walls
- can also be caused by lung cancer
What are the symptoms associated with bronchiectasis?
- symptoms are similar to TB / pneumonia except there is a LOT of sputum production
- chronic cough and production of copious green sputum
- haemoptysis
- weight loss
- shortness of breath
- fever
What signs are present on inspection and auscultation in bronchiectasis?
- clubbing is present on inspection
- basal crepitations are heard on auscultation
What are the 4 different causes of basal crepitations?
- heart failure
- pneumonia
- bronchiectasis
- idiopathic pulmonary fibrosis
What type of infections are people with bronchiectasis more susceptible to?
they are more susceptible to superimposed “extra” infections as their airways are not working as well
these superimposed infections can be caused by:
- Pseudomonas aeruginosa
- Streptococcus pneumoniae
- Haemophilus influenzae
What bedside tests, blood tests and imaging would be done in investigations for bronchiectasis?
Bedside tests:
- sputum MCS
- sweat test to diagnose cystic fibrosis
- genetic testing for PCD / Young’s syndrome
Bloods:
- FBC
- CRP
- ABG
- blood culture
Imaging:
- CXR may be used but the best way to diagnose bronchiectasis is with a high resolution CT (HR-CT)
What will the blood test and ABG results show in bronchiectasis?
- FBC will show high WCC
- CRP will be elevated
- ABG may show type 1 respiratory failure with low O2
or type 2 respiratory failure with low O2 + high CO2
What is the classical feature seen on HR-CT in bronchiectasis?
the classic feature is the Signet ring sign
What are the possible complications of bronchiectasis?
-
recurrent infections
- large, dilated airways are more susceptible to infections
- cor pulmonale (RHF)
- respiratory failure
What is involved in the conservative management for bronchiectasis?
it is an irreversible condition so the aim of supportive management is to prevent complications
- exercise and good diet
- annual influenza vaccination
-
airway clearance of mucus
- chest physiotherapy
- high frequency oscillation devices
- nebulised hypertonic saline
What is the pharmacological treatment for bronchiectasis and when may this be given?
- if there is an acute infection, IV antibiotics are given
- prophylactic oral antibiotics are given to prevent infecton
this is usually azithromycin
What is the definition of lung cancer and what are the 2 different types?
it is a malignant neoplasm of the lung
- primary originates from the lung
-
secondary metastasises from another organ
- most commonly the breast / colorectal cancer
What are the 4 different types of primary lung cancer?
- small cell lung cancer
-
non-small cell lung cancer
- adenocarcinoma
- squamous cell carcinoma
- large cell carcinoma
What type of cells does each type of lung cancer originate from?
- small cell lung cancer originates from endocrine cells
- adenocarcinoma originates from goblet cells
- squamous cell carcinoma originates from squamous epithelial cells
- large cell carcinoma originates from epithelial cells
What are the hormonal / location associations of SCLC, adenocarcinoma and SqCC?
Small cell LC:
- associated with SIADH, which causes hyponatraemia as the body retains too much water
- associated with ectopic ACTH that causes Cushing’s syndrome
Adenocarcinoma:
- usually affects the peripheral lung
- is less associated with smoking than the other types
Squamous cell carcinoma:
- associated with PTH-related peptide (PTHrp), which increases calcium and decreases phosphate
What are the risk factors for primary lung cancer?
- smoking
-
asbestos exposure
- particularly squamous cell carcinoma
What are the symptoms of lung cancer?
Primary tumour:
- cough - can be dry or productive
- haemoptysis
- shortness of breath
Systemic signs:
- weight loss
- loss of appetite
- night sweats
What symptoms can be caused by local invasion of lung cancer?
- a pancoast tumour in the apex of the lung can cause horner’s syndrome by compressing the sympathetic trunk
compression of the left recurrent laryngeal nerve produces a bovine cough
- potential superior vena cava obstruction
- this is an emergency as blood is not returning to the heart
What are the most common sites for lung cancer to metastasise to and how might these present?
Bone:
- presents with bone pain and fractures
Brain:
- presents with headaches and blurred vision as a result of raised ICP
Liver:
- presents with hepatomegaly
Lymphadenopathy
How will lung cancer present on inspection, percussion and auscultation?
Inspection:
- clubbing
- lymphadenopathy
Percussion:
- dull percussion over the tumour
Auscultation:
- crepitations may be present
- increased vocal resonance
- when the patient says “99”, it will sound louder over the tumour
What are the 4 causes of respiratory clubbing?
- bronchiectasis
- idiopathic pulmonary fibrosis
- lung cancer
- tuberculosis
What bedside tests and blood tests are performed to investigate lung cancer?
What results might be seen?
Bedside tests:
- sputum MCS
Bloods:
- FBC
- calcium (bone mets or PTHrp)
- ALP (bone mets)
- LFTs (liver mets)
What imaging / biopsy investigations are performed in lung cancer?
Imaging:
- chest X-ray
- CT CAP or PET scan is used for staging the cancer
BIopsy:
- needed to confirm the diagnosis
- performed via bronchoscopy
- or via transthoracic needle if the cancer is in the periphery of the lung
How is lung cancer staged?
Stage 1:
- cancer is found within the lung only
Stage 2:
- cancer is found within the lung and nearby lymph nodes
Stage 3:
- cancer is in the lung and the lymph nodes in the centre of the chest
Stage 4:
- cancer has spread to both lungs, into the area around the lungs or to distant organs
How is primary lung cancer identified on chest X-ray?
- there is consolidation that is usually heterogenous
- (bi-hilar lymphadenopathy)
- (pleural effusion)
- (cavitating lesions - usually present in SqCC)
What does secondary lung cancer look like on chest X-ray?
- there are many coin-shaped lesions that are referred to as cannonball mets
What is atelectasis and why can it occur in lung cancer?
- atelectasis is the collapse or closure of the lung leading to reduced or absent gas exchange
- it can affect part or all of one lung
- if the cancer starts obstructing the bronchioles, air cannot get to the alveoli to inflate them so the lung begins to collapse
How can atelectasis (lower lobe collapse) be identfied on chest X-ray?
- a triangular opacity behind the heart is visible
- this is the “sail sign” where the dense edge of the collapsed left lower lobe has been squashed into a sail shape
- a double left heart border is also present
(x-ray shows left lower lobe collapse)
How can atelectasis (total lung collapse) be identified on chest x-ray?
- there is tracheal deviation towards the direction of the collapse
- there is mediastinal shift towards the direction of the collapse
- the spine can be seen very clearly as the heart has deviated
- this x-ray shows total left lung collapse and the arrows show the edge of the lung
What is mesothelioma?
a malignant neoplasm of mesothelial cells of the pleura
it is a rare condition
What are the risk factors for mesothelioma?
asbestos exposure
What are the symptoms associated with mesothelioma?
- a cough that is dry
- shortness of breath
- weight loss
- loss of appetite
- night sweats
What sign is present on auscultation in mesothelioma?
pleural friction rub
this sounds like walking on fresh snow
What bedside tests, blood tests and imaging would be done in the investigation for mesothelioma?
Bedside tests:
- sputum cytology
- pleural fluid cytology via thoracocentesis
Bloods:
- FBC
- calcium (bone mets or PTHrp)
- ALP (bone mets)
- LFTs (liver mets)
Imaging:
- CXR
- CT PAP or PET scan for staging
Biopsy
How can mesothelioma be identified on CXR?
- there is pleural thicking
- pleural plaques may be visible due to asbestos
- sometimes pleural effusions may occur
