Respiratory Disease

Question 1

What is a cough

Answer 1

Cough is a reflex response to airway irritation triggered by stimulation of airway cough receptors by irritants e.g. secretions or by conditions that cause airway distortion. Cough is often defined according to its duration.

Question 2

Acute cough

Answer 2

when present for up to 3-4 weeks

Question 3

Sub acute cough

Answer 3

when present for 3-8 weeks

Question 4

chronic cough

Answer 4

when present for greater than 8 weeks

Question 5

Cough referral

Answer 5

• Haemoptysis
  
  • Hoarseness
  • Peripheral oedema with weight gain
  • Prominent dyspnoea, especially at rest or at night
  • Smokers aged over 45 years with a new cough, change in cough , or coexisiting voice disturbance, and smokers aged 55-80 yrs who have 30 pck year smoking history and currently smoke or who have quit within the past 15 yrs
  • Systemic symptoms, such as fever or weight loss
  • Trouble swallowing
  • Vomiting
    A cough that persists longer than three weeks or recurs on a regular basis suggests there is a chronic nature to the cough and further investigation is necessary

Question 6

When an acute cough is caused by a RTI advise the following

Answer 6

• Acute cough usually persists for up to 3 to 4 weeks
  
  • How to manage symptoms:
  • Use paracetamol or ibuprofen
  • Honey 1+
  • Guaifenisin
    Cough suppressants

Question 7

cough referral to A&E

Answer 7

• A respiratory rate >30 bpm
  
  • Tachycardia >130 beats per minutes
  • Systolic blood pressure <90mmHg
  • Oxygen saturation <92%
  • PEV <33%
  • Altered level of cosciousness
    Use of accessory muscles

Question 8

Demulcents

Answer 8

Contain soothing substances such as syrup or glycerol and may be used to relieve dry irritating cough. Simplest and cheapest option may be honey and lemon.

Question 9

Expectorants

Answer 9

E.g. guaifenesin are claimed to promote expulsion of bronchial secretions but there is no evidence that any drug can specifically facilitate expectoration

Question 10

Suppressants

Answer 10

Suitable when theres no identifiable cause- useful for when its disturbing sleep. They may cause sputum retention and this may be harmful in patients with chronic bronchitis and bronchiectasis.

Question 11

Croup

Answer 11

Characterised by the sudden onset of a seal like barking cough, which may be accompanied by voice hoarseness. Symptoms are typically worse at night

Question 12

Croup Treatment

Answer 12

• Paracetamol or ibuprofen for fever
  *Corticosteroids

Question 13

What is a cold

Answer 13

The common cold is the conventional term used to describe a mild, self-limiting, viral, upper RTI characterised by nasal stuffiness and discharge, sneezing, sore throat and cough9. The first symptom is often a sore or irritated throat9. Nasal discharge is normally profuse and clear at first, becoming thicker and darker as the infection progresses, although this does not usually indicate that a bacterial infection is present9. Cough develops in about 30% of colds, typically after nasal symptoms have cleared9. In adults and older children symptoms usually last around 1 week and typically 10–14 days in younger children9.

Question 14

What is the most common cause of cold

Answer 14

Rhinovirus is the most common cause of cold9. About half of all colds are associated with this virus, although this proportion can increase to 80% in autumn months9. Other common viral pathogens include coronaviruses, parainfluenza, respiratory syncytial virus and adenovirus9. The viruses are transmitted via airborne droplets or by direct contact with infectious secretions

Question 15

Cold referral

Answer 15

• infants less than three months old as they are susceptible to secondary bacterial infection; you should also refer infants if they are having difficulty feeding
• any infant or older person who appears significantly more unwell than would be expected for a common cold or influenza; you may suspect pneumonia and should also ask questions to rule out meningitis and septicaemia
• children who may have a foreign body in their nose; purulent discharge, usually from only one side of the nose and without other cold symptoms is strongly suggestive of this
• acute sinus involvement at any age
  ear pain originating from the middle ear at any age

Question 16

Practical Advice Antibiotics

Answer 16

Antibiotics do not work in viral infections and they cause adverse effects; they also increase the risk of bacterial resistance in the community, which may affect the treatment of other diseases

Question 17

Practical Advice Hydration

Answer 17

Adequate fluid should be taken during the course of the illness. Very little evidence supports increased fluid intake in the management of common cold. It is important to maintain normal hydration as fluid loss is likely to be greater when fever and nasal discharge are present. it is therefore pragmatic to recommend that people should drink enough fluid to compensate for any increased fluid loss

Question 18

Practical Advice Nutrition

Answer 18

Nutritious food is recommended but no specific diet is necessary; reassure parents that it is common for children to lose their appetite for a few days when they have a cold but this is not a serious concern, and children with colds should eat only when they are hungry

Question 19

Practical Advice Rest

Answer 19

Adequate rest is advised but there is no recommendation on when a person should stay off work or school; in general, people should use how they feel as an indicator of how active they should remain. Normal activity will not prolong illness.

Question 20

Paracetamol

Answer 20

Paracetamol is a suitable first-line choice for most patients9. The use of paracetamol is based mainly on historical evidence9, as a Cochrane review has concluded that further large-scale, well-designed trials are needed to determine whether this intervention is beneficial in the treatment of adults with the common cold12.
Care must be taken to avoid duplication of doses of paracetamol as it is contained in many prescribed and OTC preparations. Patients, or their parents, or carers should be counselled on the maximum dose and total daily dose of paracetamol depending on their age and other risk factors.

Question 21

Ibuprofen

Answer 21

Ibuprofen may be recommended as an alternative first-line treatment to paracetamol9. The choice between these two agents should be made considering the medical history and preferences of the patient.
Ibuprofen is contra-indicated in patients:
* who have previously shown hypersensitivity reactions in response to aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs)
* who have an active or previous peptic ulcer
* who have active or a history of upper gastro-intestinal bleeding or perforation related to NSAID therapy
* who have severe hepatic failure, renal failure or heart failure.
* varicella infection
Patients who are pregnant should be advised to avoid use of NSAIDs available without prescription from week 20 of pregnancy unless advised by their healthcare professionals. NSAIDs should not be taken during the third trimester of pregnancy (after 28 weeks of pregnancy) as they can in some cases cause labour to be delayed or last longer than expected. It can also have potential effects on the unborn baby’s kidneys and heart

Question 22

steam

Answer 22

Steam inhalation may help to relieve congestion although care should be taken to avoid scalding. Sitting in the bathroom with a running hot shower is a safe option.

Question 23

saline

Answer 23

Saline nose drops (0.9% w/v) may ease nasal stuffiness by helping to liquefy mucous secretions, although there is little evidence to support their effectiveness9.
Saline nasal irrigation may relieve the symptoms of nasal congestion; however, more robust research is required. Nasal saline is safe but can cause minor adverse effects, such as irritation or a burning sensation, particularly with products using higher flows or concentrations9.
Gargling with salt water may help to relieve sore throat or nasal congestion; however, their recommended use is generally based on anecdotal evidence

Question 24

Menthol

Answer 24

Menthol lozenges and menthol vapour rubs are marketed for the relief of nasal congestion.
Menthol lozenges have little effect on nasal congestion using objective measurements; however, they may create the sensation of improved airflow and as a result patients may feel there is an improvement9.
Vapour rubs have been shown to be beneficial in children with bronchitis but evidence for their efficacy in the common cold is lacking. However, some children like the sensation of the rub and may experience symptom relief

Question 25

Vitamin C and Zinc

Answer 25

Vitamin C and zinc supplements are used at times in an attempt to treat and/or prevent the common cold9.
The available evidence for vitamin C suggests that it has an effect only when taken at large doses as prophylactic treatment and the benefit is likely to be small14.
The use of vitamin C and zinc to treat and/or prevent the common cold is not supported by NICE

Question 26

Topical decongestants

Answer 26

Topical nasal decongestants may help relieve congestion and can improve breathing and help promote sleep9. They are of limited value because they can give rise to rebound congestion (rhinitis medicamentosa) on withdrawal, due to secondary vasodilation with a subsequent temporary increase in nasal congestion5.
Intranasal drops and/or sprays containing ephedrine hydrochloride, xylomethazoline and oxymethazoline are available5. These drugs may cause a hypertensive crisis if used during treatment with a monoamine oxidase inhibitor (MAOI)

Question 27

Oral decongestants

Answer 27

Oral decongestants, e.g. pseudoephedrine, may not be as effective as topical preparations but do not cause rebound congestion on withdrawal9. There is little evidence to support the use of decongestants in the common cold and they are classified in the BNF as less suitable for prescribing5.
Oral decongestants should be used with caution in people with diabetes, hypertension, hyperthyroidism, susceptibility to angle-closure glaucoma, prostatic hypertrophy and ischaemic heart disease and should be avoided in people taking MAOIs, or who have taken MAOIs in the preceding two weeks, due to the possibility of hypertensive crisis.
In the light of reports of misuse of pseudoephedrine and ephedrine in the manufacture of the Class A drug methylamphetamine (crystal meth), pharmacists should be extra vigilant in the supply of these products15.
At the time of writing the MHRA and the EMA are currently reviewing the evidence relating to the very rare risk of posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS) associated with medicines containing pseudoephedrine

Question 28

Echinacea

Answer 28

A Cochrane Review published in 2014 concluded that ‘echinacea products have not been shown to provide benefits for treating colds, although it is possible there is a weak benefit from some echinacea products: the results of individual prophylaxis trials consistently show positive (if non-significant) trends, although potential effects are of questionable clinical relevance’16.
The MHRA in August 2012 advised that echinacea-containing products should not be used in children under 12 years of age, stating that ‘the perceived benefits are outweighed by the potential risks in this age group and there is a low risk of severe allergic reactions

Question 29

oral combinations

Answer 29

Oral antihistamine-decongestant-analgesic combinations have some general benefit in adults and older children with the common cold, yet these benefits must be weighed against the risk of adverse effects

Question 30

Coughs and colds in children- guidance

Answer 30

The MHRA have reviewed the benefits and risks of children’s cough and cold remedies and in 2009 announced a comprehensive package of measures to promote the safer use of these products19. OTC cough and cold medicines that contain the following active ingredients are affected by the advice:
* antitussives, e.g. dextromethorphan
* expectorants, e.g. guaifenesin and ipecacuanha
* nasal decongestants, e.g. ephedrine, oxymetazoline, phenylephrine, pseudoephedrine and xylometazoline
* antihistamines, e.g. brompheniramine, chlorphenamine, diphenhydramine, doxylamine, promethazine and tripolidine19.
Cough and cold remedies containing these ingredients should not be used in children under six years of age as the balance of benefits and risk has not been shown to be favourable19. Medicines to treat coughs and colds in older children (6 to 12 years of age) can be considered after the basic principles of best care have been tried20.
In 2023, the MHRA withdrew pholcodine-containing cough and cold medicines due to safety concerns and because it was concluded that the potential risks outweighed the benefits10. In 2024, codeine linctus was re-classified from a Pharmacy (P) medicine to a prescription-only medicine (POM) due to the risks of abuse, dependency and overdose

Question 31

coughs in children

Answer 31

Children may cough when they have a cold because of mucus trickling down the back of the throat22. If the child is feeding, eating and breathing normally and there is no wheezing, a cough is not usually anything to worry about22.
If the cough continues for a long time, especially if it is more troublesome at night or is brought on by running about, the GP should be contacted to rule out asthma22.
To ease a child’s cough they should be given plenty of warm clear fluids to drink. If the child is over one, a warm drink of honey and lemon can be tried22. Cough medicines containing glycerol and paediatric simple linctus can also be used, depending on the age of the child and actual product licensing restriction

Question 32

colds in children

Answer 32

The following suggestions on how to treat colds in children are offered by the NHS 22:
* saline nasal drops can help loosen dried nasal secretions and relieve a stuffy nose
* make sure they drink plenty of fluids
* if your child has a fever and/or pain, paracetamol or ibuprofen can help
* encourage the whole family to wash their hands regularly to help stop the cold spreading

Question 33

allergic rhinitis symptoms

Answer 33

sneezing, nasal itching, nasal discharge and nasal congestion23. Associated eye symptoms such as bilateral itching, redness and tearing may also be experienced

Question 34

allergic rhinitis practical advice

Answer 34

• put Vaseline around your nostrils to trap pollen
• wear wraparound sunglasses to stop pollen getting into your eyes
• shower and change your clothes after you have been outside to wash pollen off
• stay indoors whenever possible
• keep windows and doors shut as much as possible
• vacuum regularly and dust with a damp cloth
• buy a pollen filter for the air vents in your car and a vacuum cleaner with a special HEPA filter
• don’t cut grass or walk on grass
• don’t spend too much time outside
• don’t keep fresh flowers in the house
• don’t smoke or be around smoke – it makes your symptoms worse
• don’t dry clothes outside – they can catch pollen
  don’t let pets into the house if possible – they can carry pollen indoors

Question 35

allergic rhinitis treatment

Answer 35

Oral antihistamines reduce rhinorrhoea and sneezing but are usually less effective for nasal congestion23. People needing to concentrate, e.g. on driving or sitting exams should avoid sedating oral antihistamines, e.g. chlorphenamine or promethazine5. Non-sedating antihistamines, e.g. loratadine, cetirizine and acrivastine are more appropriate choices in these instances5. The age and weight of children must be considered when selecting products.
Intranasal corticosteroids can be used to treat more persistent hay fever symptoms or associated nasal congestion5. To prevent symptoms the sprays should be used before exposure to the allergen31. Beclometasone, fluticasone, triamcinolone and budesonide nasal sprays are currently available without prescription and can be sold to adults over the age of 18 years 13,26,27.
Sodium cromoglicate is a mast cell stabiliser available as eye drops. It is effective for ocular symptoms

Question 36

pregnancy rhinitis

Answer 36

Pregnancy often exacerbates rhinitis but care is needed in the selection of drugs to relieve symptoms. Allergen avoidance should be the first step if that is possible as most manufacturers of antihistamines advise avoiding their use during pregnancy5.
If symptoms become unbearable, topical treatments, e.g. nasal sprays or eye drops are the safest to use as systemic absorption is minimal. Medical opinion should be sought.

Question 37

allergic rhinitis referrals

Answer 37

• nasal blockage in the absence of rhinorrhoea, nasal itch and sneezing – refer to GP for examination to check for nasal polyps, deviated nasal septum and mucosal swelling
• if unilateral nasal discharge, especially in a young child refer to check for a trapped foreign body
• if symptoms are not controlled after following the steps noted above, refer to GP
• contact lens wearers should be advised that their contact lenses may exacerbate their eye symptoms – they should be advised to visit their optometrist
  those who have an eye problem that needs urgent attention – they should be advised to visit an optometrist or Eye Casualty as appropriate