Obstructive: bronchiectasis, obstructive sleep, cystic fibrosis apnoea,

Question 1

Define/causes of bronchiectasis?

Answer 1

Permanent dilation of the bronchi and bronchioles due to direct damage to the airway walls, e.g. focal infections.

Cause:
- immune over/under response
- congenital
- resp disease
- aspiration pneumonia
- mechanical obstruction (e.g. foreign body, tumour)

Question 2

Presentation of bronchiectasis?

Answer 2

Productive cough
Purulent sputum (foul smelling)
Haemoptysis
Clubbing
Dyspnoea
Pleuritic pain
Wheeze
Coarse inspiratory crackles
yellow dystrophic nails

Question 3

Diagnosis/IVx of bronchiectasis?

Answer 3

HRCT (high resolution CT)-DIAGNOSTIC

Spirometry (obstructive pattern)

Sputum culture (e.g. Haemophilus influenza)

Bronchoscopy (locates areas of obstruction, haemoptysis +/- sample tissue for culture)

CXR (thickened bronchial walls and cystic appearance, aka tramline and ring shadows)

Serum immunoglobulins – hypogammaglobulinaemia

Cystic fibrosis sweat test – cystic fibrosis

Aspergillus precipitins or skin prick test – ABPA

Question 4

Management of bronchiectasis?

Answer 4

Non-pharmacological:
- chest physiotherapy (postural drainage BD to aid mucus drainage)
- smoking cessation
- Speech and language input (if recurrent aspiration)

Medical:
- Sputum clearance (nebulised saline or mucolytic agents)
- Abx (prophylactic abx if >3 exacerbations)
- Bronchodilators (obstructive lung disease on spirometry)
- Corticosteroids (prednisolone)

Interventional:
- Surgical excision of localised area of disease
- Bronchial artery embolisation
- Lung transplant

Question 5

Define/causes of obstructive sleep apnoea (OSA)?

Answer 5

A sleep disorder caused by recurrent episodes of complete or partial collapse of the upper airway.

Leads to obstruction of airflow, hence apnoeic episodes.

Question 6

Risk factors of obstructive sleep apnoea (OSA)?

Answer 6

Obesity
Male sex
Smoking
Alcohol excess
Micrognathia
Neuromuscular disease

Question 7

Presentation of obstructive sleep apnoea (OSA)?

Answer 7

Snoring
Choking in sleep
Feeling sleepy during day time
Lack of concentration
Witnessed apnoeas
Unrefreshing sleep
Irritability/personality change
Morning headache

Question 8

Diagnosis/IVx of obstructive sleep apnoea (OSA)?

Answer 8

Sleep studies
- polysomnography (GOLD STANDARD)
- Overnight oximetry (screening tool)

Diagnosis:
≥5 episodes of apnoea
or
hypopnoea ≥10 seconds per hr of sleep

apnoea-hypopnoea index [AHI]:
Mild – AHI 5–14 per hour
Moderate – AHI 15–30 per hour
Severe – AHI >30 per hour

Question 9

Management of obstructive sleep apnoea (OSA)?

Answer 9

Lifestyle:
- Weight loss
- Smoking cessation
- Alcohol avoidance

CPAP (Continuous positive airway pressure)
- GOLD STANDARD
- maintains upper airway patency

Mandibular-advancement devices
- Aim to pull the mandible and tongue forward during sleep to prevent airway collapse

Question 10

Define/cause of cystic fibrosis?

Answer 10

An autosomal recessive condition caused by a mutation in chromosome 7 at the CFTR gene.

Affects mucus glands.

Question 11

Presentation of cystic fibrosis?

Answer 11

Recurrent chest infections
Meconium ileus (black stool <24hrs of birth)
Excessive Na and Cl in sweat.

Question 12

Diagnostic/IVx of cystic fibrosis?

Answer 12

Neonatal heel prick day between day 5 and day 9

Sweat test: sweat sodium and chloride >60mmol/L

Faecal elastase: evidence for abnormal pancreatic exocrine function.

Genetic screening: CF mutation

Question 13

Management of cystic fibrosis?

Answer 13

Depends on symptoms, as CF is a multisystem condition.

Regular lung function review

Chest physiotherapy: postural drainage and active cycle breathing techniques

Abx prophylactic
Nebulised mucolytics
Bronchodilators
Oxygen

Insulin replacement regime
Exocrine enzymatic replacement (Creon)
Vitamin A, D, E, K
Ursodeoxycholic acid (if liver affected)