IPP: Respiratory

Question 1

What is the common cold?

Answer 1

The common cold is a mild, self-limiting, viral, upper respiratory tract infection characterized by nasal stuffiness and discharge, sneezing, sore throat and cough. No known treatment improves time course of infection.

Question 2

What is the most common cause of the cold?

Answer 2

Rhinovirus

Question 3

How is the cold transmitted?

Answer 3

Either by direct contact or aerosol transmission.

People can remain infectious for several weeks

Question 4

Symptoms of the cold

How long do symptoms last?

Answer 4

Symptom onset is sudden and peaks at 2-3 days, thereafter symptoms decreasing in intensity. Symptoms tend to last for a week (10-14 days in children) but can persist for up to 3 weeks.

Common symptoms:

• Sore throat
• Nasal congestion and discharge (rhinorrhea) – discharge becomes thicker and darker as infection proceeds
• Sneezing
• Cough
• Hoarse voice
• General malaise

Less common symptoms: fever, headache, myalgia, loss of taste and smell, eye irritability and a feeling of pressure in ears or sinuses

Question 5

Management for the cold

Answer 5

• Reassure that although symptoms distressing, the common cold is self-limiting and complications rare.
• Symptom relief and rest most important
• Adequate fluid intake
• Healthy food recommended
• Antibiotics and antihistamines ineffective and may cause adverse effects
• Paracetamol or ibuprofen as required (if <5 only if fever and distressed)
• OTC can be used to relieve symptoms
• Arrange follow-up appointment if symptoms worsen or persist

Question 6

See

Answer 6

Differentiating between the cold, flu, covid, hayfever and asthma

Question 7

What are causes of sore throats?

Answer 7

Most commonly caused by viral and occasionally bacterial infections:

• Cold
• Influenza
• Streptocococcal infection
• Infectious mononucleosis

Non-infectious are uncommon: physical irritation from acid reflux, hay fever or smoking.

less common causes include HIV, gonococcal pharyngitis, and diphtheria

Question 8

How long do symptoms typically last for?

Answer 8

Sore throat due to a viral or bacterial cause is a self-limiting condition. Symptoms resolve within 3 days in 40% of people, and within 1 week in 85% of people, irrespective of whether or not the sore throat is due to a streptococcal infection.

The symptoms of infectious mononucleosis usually resolve within 1–2 weeks although mild cases may resolve within days. However, lethargy continues for some time afterwards and in rare cases may continue for months or years.

Question 9

Who do throat infections typically occur in?

Answer 9

Acute throat infections most commonly occur in people aged 5–24 years

Question 10

Management of sore throat

Answer 10

Lifestyle Advice:

• Gargle warm salty water
• Plenty rest
• Eat cold or soft foods
• Suck on ice cubes/lollies
• Avoid smoking
• Regular paracetamol of ibuprofen to relieve pain and fever
• Adequate fluid intake to avoid dehydration

Additional management:

• Prescribe AB if appropriate:
  
  • FeverPAIN Centor clinical predication scores

Arrange specialist assessment for people with recurrent tonsillitis (More than 3 episodes in one year, 5 per year for 2 years or 3 per year for 3 years). May want tonsillectomy.

Admit patient immediately if breathing difficulties, clinical dehydration or immediate life-threating condition. Refer patient if suspected life-threatening condition but not immediate.

Question 11

What is allergic rhinitis?

Answer 11

Allergic rhinitis is an IgE-mediated inflammatory disorder of the nose which occurs when the nasal mucosa becomes exposed and sensitized to allergens. It is characterized by rhinorrhea, nasal congestion, sneezing & itching.

Question 12

What are the classifications of Allergic rhinitis?

Answer 12

It is important obtain an accurate history as may not be seasonal but perennial. Allergic rhinitis is classed according to:

• Seasonal: symptoms occur same time every year. If caused by grass and tree pollen allergens it is aka as hay fever.*
• Perennial: Symptoms occur throughout the year. Typically due to allergens from house dust mites and animal dander.*
• Persistent: Symptoms occur more than 4 days a week and more than 4 consecutive weeks.
• Occupational: symptoms due to allergens at work e.g. flour and baker.

Question 13

Complications of allergic rhinitis?

Answer 13

Impaired work performance, disturbed sleep, reduced concentration, possible asthma development, sinusitis and nasal polyps

Question 14

Diagnosis of allergic rhinitis

Answer 14

Suspected if classic symptoms after exposure to known allergen and/or possible associated allergic conjunctivitis, asthma or eczema.

Assessment of a person with suspected allergic rhinitis should include:

• The type, frequency, persistence, and location of symptoms.
• The severity and impact of symptoms.
• Housing conditions, pets, and occupation.
• Any drugs that may cause or aggravate symptoms.
• Any family history of atopy.
• Examination for signs and underlying causes of rhinitis, and/or associated conditions.

Question 15

Management of allergic rhinitis

Answer 15

Initial management:

• Support and information sources
• Possible use of nasal irrigation with saline
• Allergen avoidance techniques
• As required intranasal antihistamine or non-sedating oral AH or intranasal chromone
• Regular intranasal CCS during periods of allergen exposure for moderate-severe persistent symptoms or if initial treatment ineffective.
• Arrange review 2-4 weeks if symptoms persist as management may need stepped up.

Management of refractory allergic rhinitis:

Possible add-on treatments, such as an intranasal decongestant, intranasal anticholinergic, combination intranasal antihistamine and corticosteroid, or leukotriene receptor antagonist, depending on the nature of symptoms, the person’s age, and personal preferences.

A short course of oral corticosteroid for severe, uncontrolled symptoms that are significantly affecting quality of life.

Referral to an allergy or ear, nose, and throat specialist should be arranged if:

• There are red flag features suggesting an alternative or serious diagnosis.
• There are persistent symptoms despite optimal management in primary care.
• Allergen avoidance techniques such as house dust mite or animal dander avoidance are being considered, as allergy testing may be needed.
• The diagnosis is uncertain, as allergy testing may be needed.

Question 16

What is Croup?

Answer 16

Croup is a viral condition that can present in children from ages of 3 months to 6 years. Although most common in the second year of life.

Question 17

What are symptoms of croup?

Answer 17

Characterized by the sudden onset of a seal-like barking cough usually accompanied by stridor (predominantly inspiratory), hoarse voice and respiratory distress due to upper-airway obstruction.

Symptoms worsen at night and there may be a fever.

There is often a preceding 12-48 hour history of a non-specific cough, rhinorrhea and fever.

Question 18

What symptoms are present in:

A) mild

B) Moderate

C) Severe

Croup?

Answer 18

Some symptoms presented under ‘coup’. The symptoms can be divided into the following:

Mild: seal-like barking cough with no stridor or sternal/intercostal recession at rest.

Moderate: seal-like barking cough with stridor and sternal recession at rest; no agitation or lethargy.

Severe: seal-like barking cough with stridor and sternal/intercostal recession associated with agitation or lethargy.

Question 19

What are symptoms of an imending respiratory failure?

Answer 19

Symptoms of impending respiratory failure include increasing upper airway obstruction, sternal/intercostal recession, asynchronous chest wall and abdominal movement, fatigue, pallor or cyanosis, decreased level of consciousness. The degree of chest wall recession may diminish with the onset of respiratory failure as the child tires.

Question 20

When should a child be admitted with croup?

Answer 20

A child should be immediately admitted when presenting with moderate or severe croup, or impending respiratory failure.

Question 21

What is the management for croup?

Answer 21

All states of croup are treated with single oral dose of dexamethasone (0.15mg/kg). If child too unwell either inhaled budesonide (2mg nebulized as single dose) or IM dexamethasone (0.6mg/kg as single dose) are possible alternatives.

Croup is usually self-limiting and symptoms resolve in 48hr. If being managed from home paracetamol or ibuprofen can be used for fever & pain. If any deterioration seek urgent medical advice.

Mild croup can typically be managed from home

Question 22

Mild croup can usually be managed form home. When should a parent think about admitting their child?

Answer 22

Mild croup can usually be managed at home. However, reasons for admission include: chronic lung disease, congenital heart disease, neuromuscular disorders, immunodeficiency, age under three months, inadequate fluid intake, factors that might affect a carer’s ability to look after a child with croup, and longer distance to healthcare, in case of deterioration.

Question 23

What is influenza?

How can this be distiguished from the cold?

Answer 23

Influenza(flu) is a viral infection that produces respiratory symptoms which are accompanied by systemic symptoms e.g. malaise, myalgia, fever. These systemic symptoms do not normally occur with just a common cold and therefore their presence is a good way of discriminating between the common cold and influenza.

Question 24

How is diagnosis of influenza made?

Answer 24

Diagnosis can only be confirmed by lab testing – but suspected if influenza circulating and person has high fever.

Rapid influenza testing should be done for patients with complicated influenza (start antiviral treatment immediately) and testing should also be done if a patient develops symptoms despite prophylaxis or persistent infection while on antiviral treatment to identify potential antiviral resistance.

Question 25

What are symptoms of uncomplicated influenza?

When do symptoms typically appear?

Answer 25

Incubation period approx. 2 days. Uncomplicated symptoms:

Cough, nasal discharge, fever, GI symptoms, generalized symptoms (headache, malaise, arthralgia), ocular symptoms, sore throat and no clinical features of complicated influenza. See NICE guidelines for symptoms in children.

Question 26

What are compliacated influenza symptoms?

Answer 26

Complicated influenza symptoms: signs that require hospital admission, lower RTI, CNS involvement or significant exacerbation of underlying medical condition.

Question 27

What is influenza caused by?

What types of infection is there?

Answer 27

Influenza is an acute respiratory illness caused by RNA viruses of the family Orthomyxoviridae (influenza viruses). There are three types of influenza virus:

Influenza A occurs more frequently and is more virulent. It is responsible for local outbreaks, larger epidemics and pandemics.

Influenza B often co-circulates with influenza A during the yearly outbreaks. Generally, influenza B causes less severe clinical illness, although it can still be responsible for outbreaks.

Influenza C usually causes a mild or asymptomatic infection similar to the common cold.

Question 28

What is the management for influenza?

Answer 28

Antiviral drugs (oseltamivir or zanamivir) not recommended unless at risk of developing serious complications or patient is in ‘at risk’ group.

These patients should be prescribed antiviral treatment if national surveillance scheme indicates virus circulating and they can start treatment in 48hr of symptom onset (36hr if zanamivir in children).

Patients should stay hydrated, take paracetamol/ibuprofen to relieve symptoms and stay off work until worst of the symptoms have resolved

Question 29

What patients are classed as in the at risk group

Answer 29

Patients at risk:

Over 65 or under 6 months, pregnant, chronic respiratory, heart, kidney, liver or neurological diseases. Diabetes, obese or immunosuppressed.

Question 30

When should a patient be admitted to hospital in relation to influenza?

Answer 30

Urgent admission to hospital should be considered if:

• A complication such as pneumonia occurs.
• The person has a concomitant disease that may be affected by influenza (for example, type 1 diabetes).
• There is suspicion of a serious illness other than influenza (for example, meningitis).

Question 31

What are the classifications of coughs in relation to time-scale?

Answer 31

Coughs can be acute (<3 weeks), sub-actue (3-8 weeks), chronic (>8 weeks).

Question 32

What are causes of coughs?

Answer 32

Acute is normally caused by viral upper RTI. Other causes include:

• Acute bronchitis
• Covid-19
• Pneumonia
• Exacerbation of asthma or COPD

Sub-acute mainly caused by post-infectious cough. Chronic cough mainly caused by smoking, ACE inhibitors, asthma, gastro-esophageal reflux disease

Question 33

What diagnosis should occur for coughs?

Answer 33

The cause should be determined by taking a thorough history, examination, and investigation (where appropriate):

This should include pulse oximetry (if the person is acutely unwell), peak expiratory flow rate (if asthma is known or suspected), pertussis serology (if whooping cough is suspected), C-reactive protein test (if pneumonia is suspected), and spirometry and chest X-ray (if there is chronic cough of uncertain cause).

Question 34

What is the management for coughs?

Answer 34

Should be treated based on underlying cause. In addition:

• Rest
• Stay hydrated
• Hot lemon and honey

Although cough remedies are available for both productive and non-productive coughs, there is limited evidence to support the use of cough suppressants and expectorants – can supply OTC

Question 35

What is whooping cough and who does it infect?

Answer 35

Highly infectious bacterial disease caused by Bordeteela pertussis. Affects infants and young children.

Question 36

How is whooping cough transmitted and what is the incubation period?

Answer 36

Incubation period is 7 days an person is infectious for 3 weeks after symptom onset

Question 37

What is the diagnosis of whooping cough?

Answer 37

A clinical diagnosis of whooping cough should be made if the person has:

Clinical features consistent with whooping cough, particularly if they are not fully immunized, or have been in contact with a person who is confirmed or suspected of having whooping cough.

Had an acute cough for 14 days or more without another apparent cause, and has one or more of the following: inspiratory whoop, post-tussive vomiting, or paroxysmal cough.

Question 38

What is the management of whooping cough?

Answer 38

MANAGEMENT

Notifiable disease – notification form needs submitted within 3 days.

People who are seriously unwell should be admitted to hospital

Antibiotic (usually macrolide e.g. erythromycin or clarithromycin) prescribed if suspected or confirmed whooping cough with onset of cough within previous 21 days.

Rest, adequate fluid intake and paracetamol or ibuprofen.

Children and healthcare workers should be advised to stay off nursery, school, or work until 48 hours of appropriate antibiotic treatment has been completed, or 21 days after onset of symptoms if not treated. Close contacts may require antibiotic prophylaxis.

Question 39

Symptoms of whooping cough?

Answer 39

There are 3 phases of symptoms (see NICE guidelines).

The first symptoms of whooping cough are similar to those of a cold, such as a runny nose, red and watery eyes, a sore throat, and a slightly raised temperature. Intense coughing bouts start about a week later. The bouts usually last a few minutes at a time and tend to be more common at night.