Respiratory Lecture ILO’s Flashcards

Question

Diagnosis and investigation of asthma

Answer 1

Asthma is a clinical diagnosis Based upon a convincing history Supported by positive response to bronchodilator therapy Investigated using peak expiratory flow and spirometry

Answer 2

§ Stand up & take a deep breath in § Lips form a tight seal around plastic § Like blowing a dart § Don’t obstruct the tab § Best out of 3 attempts § Monitor throughout the day

Answer 3

Angina Heart problems Recent concussion Recent surgery on the brain, middle ear, sinuses, eyes, chest or abdomen Uncontrolled high or low blood pressure Pulmonary hypertension Pulmonary embolism Pneumothorax Late term pregnancy Aneurysms

Answer 4

§ FEV1 – Forced Expiratory Volume in 1 second. Normal >80% Predicted. § FVC – Forced Vital Capacity – total volume expired from maximal inspiration to maximal forced expiration. Normal >80% Predicted. § FEV1/FVC Ratio as a percentage § Normal: 70-80% § <70%: Obstructive Defect § >80%: Restrictive Defect § Patients will also have a predicted FEV1 and FVC value based on the predicted normal for a patient of the same age, sex and height. § % Your Value/Predicted Value = % Predicted FEV1 or FVC.

Answer 5

Obstructive= FEV1/FVC reduced <0.7 Airway collapse causes significant reduction in FEV1 Restrictive= FEV1/FVC >0.8 Significant reduction in FVC

Answer 6

Patient takes a deep breath in, which starts the graph at 0 Patient then forces air out Volume is measured in Litres along the X-Axis FEF – Forced Expiratory Flow FIF – Forced Inspiratory Flow Each are measured at 25%, 50% and 75% of FVC Different patterns of flow volume loops are seen in different conditions

Answer 7

Normal: PEF normal Pattern initially rapid, decreasing steadily Volume normal Restrictive: PEF normal or slightly reduced Pattern normal Volume reduced Obstructive: PEF reduced Pattern concaved Volume normal or reduced

Answer 8

A.K.A. Transfer Factor - DLCO Ability for gaseous transfer across the alveolar to the blood supply Transfer capacity of the lung, for uptake of carbon monoxide It is reduced in emphysema, acute asthma, anaemia and interstitial lung disease It is increased in chronic asthma, left heart failure, polycythaemia and exercise

Answer 9

Bronchodilator responsiveness assess whether your lung function improves with SABA therapy Spirometry is done before and 15 minutes after inhaling SABA Assesses any improvement in lung function – improvement suggests a diagnosis of Asthma or COPD

Answer 10

Aim to control symptoms – including nocturnal and exercise-induced Prevent exacerbations and need for rescue medication Achieve best possible lung function – aim for PEFR >80% predicted Minimise side- effects Maintain patients on lower possible dose of inhaled corticosteroid Investigate reasons for poor control, such as poor inhaler technique Patient education and empowerment is key

Answer 11

Short-acting B2-Agonists (SABA) • Salbutamol • Terbutaline Long-acting B2-Agonists (LABA) • Salmeterol • Formeterol Muscuranic Antagonists • Tiotropium • Ipratropium Inhaled Corticosteroids • Budesonide • Beclometasone • Fluticasone

Answer 12

§ MDI: Metered Dose Inhaler § Evohaler & Easibreathe § DPI: Dry Powder Inhaler § Turbohaler, Accuhaler, Easyhaler, Handihaler § SMI: Soft Mist Inhaler § Respimat

Answer 13

§ Salbutamol (SABA) – Blue § Beclomethasone (ICS) – Brown § Salmeterol (LABA) – Green § Fostair (LABA/ICS) – Pink § Seretide (LABA/ICS) – Purple

Answer 14

Introduce yourself and confirm patient details Explain what you will be doing and confirm patient understanding Explain what the inhaler is and why it is needed Explain how the inhaler works and when it should be used Demonstration of technique Observe patient and provide feedback

Answer 15

1. Hold inhaler upright, remove cap and shake well 2. Stand/sit up and tilt chin upwards 3. Breath out fully 4. Place lips around mouthpiece to get a good seal 5. Breath in slowly and steadily, whilst simultaneously pressing the canister on the inhaler 6. Continue to breathe in slowly until lungs feel full 7. Remove the inhaler from your mouth and seal your lips 8. Hold your breath for 10 seconds, then gently breath out

Answer 16

Leukotriene Receptor Antagonists • Montelukast Phosphodiesterase inhibitors and non-selective adenosine receptor antagonists • Theophylline • Aminophylline Oral Corticosteroids • Prednisolone

Answer 17

• Any difficulty sleeping due to symptoms? • Any asthma symptoms during the day? • Has your asthma interfered with your usual activities? Measurement of PEF or spirometry Review: flow or spirometry • Exacerbations in past 12 months • Any time off work or school • Use of oral corticosteroids Check inhaler technique Check patient adherence Patient ownership and use of an asthma action plan

Answer 18

Patients with acute severe or life- threatening asthma who have: § Persistent or worsening hypoxia § Hypercapnia § Acidosis § Exhaustion § Feeble respiration § Deteriorating PEF § Reduced GCS § Confusion § Respiratory arrest

Answer 19

Severe acute asthma Poor compliance to inhaler therapy Miss Crampton will have a primary care follow up

Answer 20

● Pneumonia ● Pneumothorax ● Pulmonary embolism ● Asthma ● Acute exacerbation of COPD ● Acute Respiratory Distress Syndrome ie covid sars ● Large airway obstruction: e.g. anaphylaxis, foreign body, epiglottitis

Answer 21

Cardiac Severe pulmonary oedema Acute myocardial infarction Cardiac arrhythmia Pericarditis and pericardial effusion

Answer 22

● COPD ● Emphysema ● Bronchiectasis ● Fibrosis ● Pleural effusion ● Lung cancer ● Asthma ● Hereditary lung disorders (e.g. cystic fibrosis) ● Pulmonary Tuberculosis

Answer 23

Left ventricular disease Heart valve disease (mitral & aortic stenosis) Arrhythmias Pericardial causes

Answer 24

● Onset & duration: When did it start? Acute or gradual? ● Timing: e.g. diurnal variation with asthma ● Severity: MRC scale / able to talk in full sentences? ● Course: worsening, improving, fluctuating? ● Exacerbating and relieving factors: on exertion? Inhaler? ● Previous Episodes? What has made you come in today?

Answer 25

1. Not troubled by breathless except on strenuous exercise 2. Short of breath when hurrying on a level or when walking up a slight hill 3. Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace 4. Stops for breath after walking 100 yards, or after a few minutes on level ground 5. Too breathless to leave the house, or breathless when dressing/undressing

Answer 26

● Cough: Productive? Colour? Volume? ● Wheeze: Time of day? Triggers? ● Haemoptysis: How much? ● Chest pain: SOCRATES ● Red Flags / Systemic: Fever? Night sweats? Unintentional Weight loss?

Answer 27

Respiratory conditions? Cardiac conditions? Allergies? Other medical co-morbidities? Anxiety? Hospital admissions / ITU admissions? Drug history: Inhalers, steroids, diuretics, antibiotics, home oxygen Beta-blockers, amiodarone, nitrofurantoin, methotrexate, heroin

Answer 28

Social History ● Smoking: calculate pack years ● Recreational drugs: cannabis ● Baseline: activities of daily living ● Occupation: shipyard, miner, farmer ● Travel History ● Recent immobilisation

Answer 29

Investigations Pulse oximetry CXR ECG Lung function tests - eg, peak flow measurement, spirometry. Venous blood tests: FBC, brain natriuretic peptides (BNPs) Arterial blood gases Imaging: Echocardiogram. High-resolution CT scan V/Q scan. Radioallergosorbent test (RAST) measurement or skin prick testing to common aero-allergens

Answer 30

Interstitial Lung Disease Group of disorders that affect the lung interstitium (alveolar & capillary epithelium, basement membrane etc.) Cause fibrosis (scarring) and loss of elasticity of the lungs Interfere with gas transfer Symptoms: SOB, dry cough >200 causes. Examples: Idiopathic Pulmonary Fibrosis Hypersensitivity Pneumonitis Sarcoidosis Asbestosis Drug side effect e.g. methotrexate

Answer 31

Clinical Features IPF is reserved when no underlying cause exists Typically 50-70yrs Progressive exertional dyspnoea Bi-basal crackles on auscultation Dry cough Clubbing Low saturations / cyanosis Investigations ● Spirometry ● Reduced TLCO ● CXR ● High-Resolution CT: ○ Ground Glass ○ Honeycombing

Answer 32

● No cure ● Pulmonary rehab ● Few medications shown to benefit ● Pirfenidone (antifibrotic agent) may be useful- when caught early ● Supplementary O2 ● Lung transplant ● Poor Prognosis: life expectancy 3-4 years- progressive condition

Answer 33

• Multisystem chronic inflammatory condition • Non-caseating granuloma across body (predilection for lungs) • Mid 20s-Mid 40’s • Many present as an incidental CXR finding • 1/3 asymptomatic, 1/3 non-specific symptoms (lethargy, cachexia), 1/3 acute admission • Worse prognosis in black patients Sarcoidosis: Clinical Features Constitutional symptoms e.g. fevers, night sweats Lungs (90%) – cough, fever, SOB Erythema nodosum, lupus pernio (rash) Eyes (>20%) – anterior uveitis, dry eyes, glaucoma

Answer 34

• FBC: eosinophila, lymphopenia • ESR, PO4, ALP, Ca – can be raised • (unusual to have renal impairment) • If Ca high – check 24 hour urinary Ca – hypercalciuria • Serum ACE (up in 60%) • CXR 5 stages (0-4) • BAL – lymphocytes, raised CD4:CD8

Answer 35

Sarcoidosis: Management Test eyes in all new diagnoses Steroids Most resolve spontaneously, 20% can result in pulmonary fibrosis Osteoporosis protection, flu vaccine, stop smoking

Answer 36

Bronchiectasis Chronic airway inflammation with dilation of bronchi or their branches (larger bronchioles) Extra mucus is made in the abnormal airways which is not cleared due to loss of cilia escalator Collection of thick viscous mucus results in the patient becoming more prone to chest infections

Answer 37

• In ~ 1⁄2 of cases, a cause cannot be found • History of serious lung infection is the most common cause: e.g. tuberculosis, whooping cough, pneumonia or measles • Immunosuppression: e.g. AIDS, transplant patients, hypogammaglobulinaemia • Immune hyperactivity: e.g. Ulcerative colitis, Crohn’s disease and rheumatoid arthritis • Inherited diseases: e.g. cystic fibrosis an Kartageners syndrome • Airway Obstruction: bronchial ca, foreign body • Aspiration: e.g. GORD, chronic alcoholics

Answer 38

Bronchiectasis: Diagnosis Main symptom = cough with lots of phlegm Recurrent chest infections Mucus in the airway forms a broth for bacteria to grow Sputum turns green / yellow when infected Bad breath can indicate active infection Tiredness and poor concentration Wheeze (common) Breathlessness, particularly when exerting Occasional may cough up small amounts of blood from an inflamed airway Gold standard = C.T. imaging Width of the branching airways (bronchi) can be determined Widened bronchi seen on the CT scan can confirm bronchiectasis (signet rings) Chest X-ray: useful screening tool but limited sensitivity and specificity - ring shadows and tramlines Pulmonary MRI scanning is evolving (lack of ionising radiation) - developing in use for bronchiectasis of cystic fibrosis

Answer 39

Bronchiectasis: Management Antibiotics Respiratory physiotherapy Inhalers: Bronchodilator inhalers (SABAs and SAMAs) are used if wheezing and breathlessness are prominent in an acute attack Used only for those patients who find they help their symptoms. If they are not helpful they should be stopped Steroid inhalers are not recommended anymore for bronchiectasis unless there is underlying asthma Other medications: e.g. aminophylline or theophylline are occasionally used to help symptoms

Answer 40

Bronchiectasis: Management (Antibiotics) Mainstay of treatment Mild disease: occasional antibiotics would be prescribed When to prescribe: Worsening cough and breathlessness or systemically unwell May not be required if the phlegm turns green Most commonly amoxicillin (check local guidance & allergies) Long-term antibiotics: Severe cases, almost continuous infections Some antibiotics can administered via nebuliser: high doses of antibiotic directly into the airways Complications: antibiotic resistance, GI problems (e.g. diarrhoea) and genital fungal infections (e.g. candida)

Answer 41

Bronchiectasis: Management (Physio) The aim of physiotherapy and other exercise therapies is to help cough up and clear the mucus from the chest (airway clearance) This helps to prevent a build up of infected mucus Typically patients with bronchiectasis would be encouraged to get someone in their family to co perform their chosen airways clearance therapy for 20-30 minutes once or twice daily

Answer 42

Measuring how the volume in the lungs empties

Answer 43

Idiopathic pulmonary fibrosis

Answer 44

Height Weight

Answer 45

2) Kyphoscoliosis (extrathoracic restriction) 3) Cystic Fibrosis

Answer 46

4) FEV1/FVC Ratio <0.7

Answer 47

Severe COPD

Answer 48

Mild = FEV1 greater or equal to 80% of predicted Moderate = FEV1 50 - 80% of predicted Severe = FEV1 30-50% of predicted Very severe = FEV1 < 30% of predicted

Answer 49

a. The volume of gas measured from a slow, complete exhalation after a maximal inspiration, without a forced effort

Answer 50

FEV1 increase by 12%

Answer 51

Sputum sample CXR Spirometry Bloods Bronchiectasis

Answer 52

The volume of gas remaining in the lungs after a maximal exhalation

Answer 53

The maximum volume of air that can be inspired after reaching the end of a normal quiet expiration Tidal volume + inspiratory reserve volume

Answer 54

The extra volume of air that can be expired with maximum effort beyond the level reached at the end of normal, quiet expiration

Answer 55

The amount of air a person can expel from the lungs after a maximum inhalation. It is equal to the sum of inspiratory reserve volume, tidal volume, and expiratory reserve volume

Answer 56

The extra volume of air that can be inspired with maximal effort after reaching the end of a normal, quiet inspiration

Answer 57

The amount of air which moves in and out of the lungs during each respiratory cycle

Answer 58

The volume remaining in the lungs after a normal passive exhalation

Answer 59

The volume of air in the lungs at different phases of the respiratory cycle

Answer 60

Right-heart disease resulting from Pulmonary Hypertension Not a diagnosis, but a complication of another disease Numerous causes

Answer 61

Heart Failure is divided into systolic and diastolic Systolic heart failure–ventricles unable to pump blood hard enough during systole. Diastolic heart failure–ventricles unable to fill fully during diastole Can affect either ventricle, or both Biventricular heart failure CorPulmonale is when an issue with the lungs causes right-sided cardiac dysfunction which can lead to right-sided heart failure

Answer 62

Respiratory conditions such as COPD Lead to persistent hypoxia Hypoxia leads to pulmonary vasoconstriction Leads to increased resistance This causes pulmonary hypertension Pulmonary blood pressure goes to > 25mmHg

Answer 63

Damage to lung tissue • E.g. COPD Damage to pulmonary vessels • E.g. CTEPH Altered anatomy • E.g. Kyphoscoliosis

Answer 64

Acute: pulmonary embolism Chronic: COPD

Answer 65

CXR • Usually normal • May show pulmonary artery dilation in hila or a wedge infarct ECG • Sinus tachycardia • RA dilatation – tall peaked T waves in lead II • RV strain and dilatation – RBBB, R axis deviation, T wave inversion • S1Q3T3 rare ABG • Hypoxia • May show hypocapnia ECHO • Enlarged RV, Flattened intra-ventricular septum

Answer 66

Pulmonary vasoconstriction due to hypoxia/acidosis Initially intermittent, with exacerbations Becomes persistent Heart responds with muscular hypertrophy Increased pressure load – strain on RV RV dilates and reduces in function Blood forced back through tricuspid valve into RA Backup of blood into venous circulation

Answer 67

Raised pulmonary blood pressure makes it harder for the RV to pump blood into pulmonary circulation – back pressure RV is thin-walled and made for pumping blood against a low pressure In RVH,the muscle mass is increasing, eventually encroaching into the RV, meaning less space for blood to fill the RV -> diastolic heart failure The increase in muscle mass leads to an increase in oxygen demand as well as squeezing the coronary arteries Increased demand and reduced supply can lead to RV ischaemia This leads to weaker contractions and systolic heart failure Blood often forced backward through the tricuspid valve

Answer 68

Left-Sided Heart Failure can cause Pulmonary Hypertension but it would not cause Cor Pulmonale, as the cause is inherent in the heart, not the lungs Primary Right-Sided Heart Failure, which could occur following a RV MI, or Pulmonary Valve Stenosis – underlying defect is cardiac nor pulmonary. Pure right-sided heart failure is rare.

Answer 69

Shortness of Breath Fatigue Syncope Jugular Venous Distension Right Ventricular Heave Hepatomegaly Peripheral Oedema Chest pain (seen in RV ischaemia) Sudden death

Answer 70

Echocardiogram • Increased pressure in pulmonary arteries and RV dilatation/hypertrophy • Will show intra-cardiac shunts if present Spirometry • Assist diagnosis of underlying lung conditions Right-Heart Catheterisation – GOLD STANDARD • Measure pulmonary pressures • Assesses response to vasodilators

Answer 71

◦ Not very sensitive ◦ May show prominent pulmonary artery ◦ May show oligaemic (reduced blood flow) peripheral lung fields

Answer 72

ECG ◦Abnormalities reflect the presence of right ventricular hypertrophy, strain or underlying pulmonary disease ◦ Right-axis deviation ◦ Increased P wave amplitude in leads II, II and aVF (p-pulmonale) ◦ Right bundle branch block ◦ Low-voltage QRS

Answer 73

Treat the underlying cause O2 therapy – consider LTOT (pO2 <8kPa on RA) Diuretics Vasodilators for PH – e.g Sildenafil Venesection – in severe polycythaemia

Answer 74

◦ Poor prognosis ◦ LTOT improves prognosis ◦ Prognosis is worse in COPD patients with PH vs. COPD patients without PH ◦ In COPD Patients with a mild degree of Pulmonary Hypertension (20- 35mmHg) - 50% mortality at 5 years

Answer 75

D dimer - will increase as sign of a clot CXR Bloods - FBC, U+E ECG- T wave inversion lead 2-4, RBBB, sinus tachycardia, RAD

Answer 76

Type 1: Low oxygen -> Cell death due to hypoxia (will kill you first) Aetiology: Shunt (Pneumonia), Diffusional (Covid), V/Q mismatch (PE), Ventilation (Coma), Altitude Mx: Oxygen, CPAP/PEEP, treat underlying disease, lung transplant

Answer 77

Type 2: High carbon dioxide +/- low oxygen (2 things) Cell death from acidaemia Ventillational++ (Low RR, Low TV, bronchoconstriction) Coma, Opioids, COPD, Asthma Mx: Ventilate patient (awake with BIPAP, asleep with endotracheal tube), bronchodilators, treat underlying disease, lung transplant

Answer 78

Increase temp Decrease ph Increase CO2 Increase 2, 3 DPG Therefore oxygen is more readily released at the tissues Low affinity for oxygen at the tissues

Answer 79

Decrease in temperature Increase in pH Decrease in CO2 Decrease in 2,3 DOG Increased affinity for O2 so oxygen is not released readily at the tissues

Answer 80

Patient is improving Can half FiO2 as don’t need PaO2 of 20, just need 10kPa And unnecessarily high FiO2 is bad for lungs and wastes oxygen supplies

Answer 81

Increase breathing rate Kidneys excrete more H+ or HCO3- CO2 +H2O<< carbonic anhydrase >>H2CO3 << >> H+ + HCO3-

Answer 82

Carbon dioxide (4.7-6.0 kPa) Resp Acidosis (CO2 >6.0 kPa) Hypoventilation (low TV, low RR): fatigue/coma/opiates Bronchoconstriction (Asthma/COPD) Resp Alkalosis (CO2<4.7) Hyperventilation (high TV, high RR), panic attacks, pregnancy, high altitude, drug toxicity

Answer 83

Bicarbonate (22-26 mmol/l) Base excess (BE) (+2/-2 mmol/l)...high values correlate with high bicarb (amount of strong acid or base that must be added to normalise pH) Metabolic Acidosis (BC<22): BE<-2 Causes: AGMA- lactic acidosis, ketoacidosis, renal insufficiency NAGMA- renal tubular acidosis, GI loss of H3CO3, GI fistulas Metabolic Alkalosis (BC>26): BE>+2 Causes: vomiting (loss of H+), hypovolemia, diuretics Cushing syndrome, hyperaldosteronism

Answer 84

Low O2 in the blood

Answer 85

• Intrapleural pressure is pressure in the pleural cavity. Usually a little less than atmospheric pressure (negative) • Transpulmonary pressure is the difference between intrapleural pressure and alveolar pressure.

Answer 86

Depressed breathing = hypoventillation / blocking the gas exchange Causing a ventilation perfusion mismatch as: Blood and gases aren’t going into the alveoli in the correct proportion Too much blood/ too little ventilation Too much ventilation/ too little blood

Answer 87

APEX: (lungs pull more as less supported) Ventilation: • More negative intrapleural pressure • Larger trans mural pressure gradient • Alveoli with larger volume • Smaller Compliance • Less Ventilation Perfusion: Lower intravascular pressures Higher resistance Less blood flow BASE: Ventilation: • Less negative intrapleural pressure • Smaller Ptp • Alveoli with smaller volume • Larger Compliance • More Ventilation Perfusion: Greater vascular pressure Lower resistance Greater blood flow

Answer 88

Ventilation perfusion mismatch or V/Q defects are defects in the total lung ventilation/ perfusion ratio. It is a condition in which one or more areas of the lung receive oxygen but no blood flow, or they receive blood flow but no oxygen. This happens if you have an obstructed airway, such as when you’re choking or if you have an obstructed blood vessel such as a blood clot in your lung.

Answer 89

Upper Respiratory Tract Infections • Usually always viral • Viruses include: – Respiratory syncitial virus (RSV) – Adenovirus – Rhinovirus – Coranovirus – Influenza (A,B,C) – Para-influenza

Answer 90

Influenza (flu)

Answer 91

Influenza (ie. Flu) • Caused by influenza which belong to orthomyxovirus group of viruses • RNA viruses • 3 types: A, B and C • Winter epidemics; or all year epidemics if close to equator • Influenza A responsible for pandemics – Aquatic birds act as natural reservoirs, several other animals can become infected – Spanish flu 1918, Bird flu 2004 • Influenza B responsible for more local, less severe outbreaks – Mostly humans act as reservoirs – Little antigenic diversity

Answer 92

Influenza: Symptoms • Initially fever, muscle aches, rigors • Later may develop: headache, sore throat, dry cough, conjunctivitis, photophobia • When symptoms resolve usually a phase of malaise/lethargy- usually occurs for weeks but can take months!!

Answer 93

Influenza: Investigations • Tests usually not necessary • Naso-pharyngeal swabs • PCR Could test on: Vulnerable Going into hospital Immuno compromised

Answer 94

• Bronchitis • Viral pneumonia or secondary bacterial pneumonia • Sinusitis • Otitis media • Encephalitis • Pericarditis

Answer 95

(Supportive) • Bed rest • Paracetamol, NSAID • In severe cases requiring hospital admission antibiotics may be given to prevent side effects (bacterial pneumonia) • Oseltamivir (Tamiflu) and Zanamivir (Relenza): – Active against influenza A + B – Recommended in UK for those over 65 years and under 65’s if “at risk” (immunosupressed, chronic respiratory disease etc.) – Reduce length of illness – Not clear whether reduce rate of complications/hospital admission

Answer 96

• WHO tries to predict strain of influenza which will cause most suffering/cause biggest endemics • Vaccine formed depending on these strains • Immunity lasts just over a year • Vaccine available to: – >65 years – Pregnancy – Certain medical conditions (chronic lung diseases, CKD, diabetes, heart disease, immunosuppressive states) – Very overweight – Living in long-stay residential care home – Receive carer’s allowance/main carer for someone/Front line health care and social care worker

Answer 97

Acute coryzal illness (common cold)

Answer 98

Acute Coryza (Common Cold) • Usually caused by rhinovirus – Others: coranovirus, RSV, para-influenza

Answer 99

• Complications: otitis media, pneumonia,

Answer 100

Pharyngitis

Answer 101

Viral (majority) • Commonly caused by adenovirus • Can occur in the flu (influenza virus) • Can occur in acute coryza (rhinovirus, RSV, para-influenza etc.) • EBV- causes infectious mononucleosis • Herpes simplex- ulcers (labial/buccal ulcers and vesicles, gingivostomatitis Bacterial Causes • Group A beta-haemolytic streptococcus (GAS) • Diphtheria (grey membrane on throat) Fungal Causes (rare) • Candida albicans – usually underlying cause e.g. Immunosupression, steroid use

Answer 102

• Non usually required • Rapid antigen testing for GAS or influenza – Negative test does not exclude ! • Throat culture (for bacteria) • Bloods if required Rapid test for step A if required

Answer 103

FeverPAIN GAS vs Viral - Fever>38degreesC 1 - Purulence (pharnygeal/tonsillar exudate) - Attend rapidly (3 days or less) 1 - Severe Inflamed tonsils 1 - No cough or coryza 1 A score of 0 or 1 is associated with a 13% to 18% likelihood of isolating streptococcus. A score of 2 or 3 is associated with a 34% to 40% likelihood of isolating streptococcus. A score of 4 or 5 is associated with a 62% to 65% likelihood of isolating streptococcus.

Answer 104

Centor Criteria - Tonsilar exudate 1 - Tender anterior cervical lymphadenopathy or lymphadenitis - History of fever (>38degreesC) 1 - Absence of cough 1 A score of 0, 1 or 2 is thought to be associated with a 3 to 17% likelihood of isolating streptococcus. A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating streptococcus.

Answer 105

• Treatment: – Supportive (salt water gargling, medicated lozenges, anaesthetic sprays) – Antibiotic treatment not required if bacterial infection • Phenoxymethylpenicillin (Clarithromycin= alternative) – Delayed antibiotic prescription – Give antibiotics if: marked systemic upset, at risk of serious complications, valvular heart disease, region of higher prevalence of rheumatic fever – Consider treatment with antibiotics if: high Centor or FeverPAIN score, immunosuppressed and other at risk co-morbidities (including history of rheumatic fever)

Answer 106

Laryngitis

Answer 107

• Inflammation of larynx • Sore throat, fever, cough • In addition pain on swallowing and pain when speaking and hoarse voice • Commonest cause is rhinovirus – Others: Influenza, parainfluenza, RSV • Bacterial causes: Group A strep, streptococcus pneumoniae • Self-limiting • Treatment:Supportive – Antibiotics rarely needed

Answer 108

• Causes: Majority viral • Bacterial Causes (30%): – Group A beta-haemolytic streptococcus – Very rarely: Mycoplasma pnemoniae, diphtheria • Symptoms: Dysphagia, lymphadeonopathy, haliotosis • Treatment: Supportive - Antibiotics: If given Penicillin V - Corticosteroids can reduce inflammation - Tonsillectomy indicated if recurrent (>5 attacks a year for at least 2 years; quinsy with recurrent tonsillitis) Do the fever test to see if likely of bacterial or viral

Answer 109

• Presentation: Along with tonsillitis symptoms may have trismus (pain on closing mouth) • Should be referred urgently to ENT for management (consideration of surgery)

Answer 110

Infective Mononucleosis (Glandular fever)

Answer 111

Infective Mononucleosis • Aka Glandular Fever • Commonly affects adolescents and young adults • Caused by ebstein barr virus (EBV) – DNA virus part of the herpes group of viruses • Incubation period: 4-5 weeks

Answer 112

Infective Mononucleosis (glandular fever) : Symptoms • Fever, headache, malaise, sore throat • Inflamed tonsils with white patches • Palatal petichiae • Transient macular skin rash – 90% who receive Ampicillin develop rash • Cervical lymphadenopathy • Splenomegaly • Hepatitis • Complications – Meningitis, Encephalitis, Myocarditis, Neuropathy, chronic fatigue syndrome (5 times more likely compared to other causes of URTI), haemolytic anaemia, thrombocytopenia No contact sport for 3 months

Answer 113

Infective Mononucleosis: Diagnosis • Paul Bunnel Test/Monospot Test/Heterophil Antibody Test: – Rapid test which gives results quickly – Detects heterophile antibodies (IgM) that agglutinate sheep erythrocytes – False positive in viral hepatitis, Hodgkin’s lymphoma, acute leukaemias, malaria • FBC/Blood Film: Lymphocytosis – Atypical mononuclear cells • Specific Ig Mantibodies • EBV PCR

Answer 114

• Supportive treatment • Majority is self-limiting • Steroids may be needed if neurological complications or marked haemolysis and thrombocytopenia

Answer 115

• Infection in paranasal sinuses • Commonly viral infections (98%) • Usually always associated with some URTI • Bacterial Causes: Strep pneumoniae, Haemophilus influenzae, Staph

Answer 116

• Symptoms: Frontal headache, rhinnorhoea, facial pain and tenderness, fever

Answer 117

• Treatment: Nasal decongestants, Abx (Co-Amoxiclav), Nasal corticosteroids, steam inhalation

Answer 118

• Complications (rare): Meningitis, Orbital cellulitis/abscess, brain abscess

Answer 119

Acute bronchitis

Answer 120

• Commonly caused by RSV – Others= rhinovirus, para-influenzae • Bacterial causes include Strep pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae • Risk Factors: Tobacco smoke, pollution, COPD • If underlying lung disease or smoker more likely to have bacterial cause

Answer 121

• Symptoms:Productivecough,wheeze • Treatment: Supportive (usually self limiting and resolves in 4-8 days) – Abx usually not needed

Answer 122

• Streptococcus 30.4% • Mycoplasma 12.6% • Chlamydia 12.6% • Legionella 4.7% • Haemophilus Inf. 4.4% • Enterobacteriaceae 3.1% • Staphylococcus Aur. 0.5% • Other pathogens 20% • Not known 39.5%

Answer 123

Pneumonia • Infection/consolidationinthealveoli Classification • Location- Lobar vs bronchopneumonia – Lobar: Within the whole of one or more lobes – Bronchopneumonia: Affects lobules of lungs with bronchi and bronchioles - more diffuse consolidation • Hospital vs Community Acquired • Atypical pneumonia • Aspiration pneumonia • Ventilator acquired

Answer 124

Bronchopneumonia • Infection diffuse throughout lobules and usually in bronchioles and bronchus • More diffuse • Differentiated from bronchitis as signs of pneumonia such as bronchial breathing, patchy changes on CXR, harsh breath sounds • Typically elderly patients with other medical conditions develop • Commoner in underlying lung disease • Common terminal event

Answer 125

Aspiration Pneumonia • Acute aspiration of gastric contents into lungs • Gastric acid can destroy lining of lungs • Causes: Impaired consciousness, reflux oesophagitis, poor swallow, oesophageal stricture • Persistent pneumonia can lead to anaerobic infection • Can progress to lung abscess or bronchiectasis

Answer 126

Hospital Acquired • Hospital Acquired: At least 48 hours into hospital admission – Usually gram negative baccillus (ie. Rod shaped) such as Pseudomonas and enterobaccili (such as Klebsiella) – Staphyloccocus aureus – MRSA – Pseudomonas – Klebsiella

Answer 127

Pneumonia: CXR • CXR consolidation may lag behind symptoms • Consolidation may remain on the CXR for several weeks when the patient is recovered • Follow-up CXR usually done at 6-8 weeks and persistence of consolidation at this point usually implies a bronchial abnormality (usually carcinoma with persisting infection)

Answer 128

• Investigations: – CXR – Blood Tests: FBC, U+E, CRP (inflammatory markers), LFTs, Blood Cultures, ABG • Mycoplasma antibodies – Urine for legionella and pneumococcal antigen – Sputum MC+S (microscopy, culture + sensitivity) • Management (Varies between trusts, this is only a guide): – Community Acquired: • CURB-65 1= Oral Amoxicillin • CURB-65 2= Oral Amoxicillin + Clarirthromycin • CURB-65 3-5= IV Co-Amoxiclav + Clarithromycin – Hospital Acquired: Co-Amoxiclav, IV Cephalosporin if severe – Aspiration: Co-Amoxiclav – Follow-up CXR in 6-8 weeks

Answer 129

• ie. Pneumococcal pneumonia • Commonest bacterial pneumonia • Gram +ve diplococci • Commoner in elderly, alcoholics, post-splenectomy, immuno-suppressed • Almost always a preceding viral infection • Followed by fever, pleuritic chest pain, cough productive of rusty coloured sputum • CXR= Lobar consolidation • Urine send for pneumococcal antigen • Treatment: Penicillin based Abx or cephalosporins • Prevention: Pneumococcal vaccine, 5 yearly

Answer 130

• Staphylococcus aureus – Uncommon cause – Usually preceded by influenza infection – Risk if elderly, IV drug users, patients with long-term IV catheters, immunosuppression – Typically gives bronchopneumonia with cavities which later can form abscesses and empyema can develop

Answer 131

– Rare – Typically occurs in elderly, diabetics, alcoholics – Usually causes severe pneumonia (typically bronchopneumonia, and affects upper lobes) – Can cause a cavitating pneumonia, lead to abscesses

Answer 132

• Chlamydia pneumoniae – Outbreaks in institutions and families – Person-to-person spread (not via animal reservoir) – Causes pharyngitis, laryngitis, sinusitis, followed by pneumonia – CXR= Segmental infiltrates

Answer 133

• Chlamydia psittaci – Causes psittacosis – History of exposure to birds- especially parrots – Causes headache, fever, dry cough, lethergy, arthalgia, hepato-splenomegaly

Answer 134

• Haemophilus influenzae: – Frequent cause of exacerbation of chronic bronchitis in COPD and can lead to pneumonia if COPD.

Answer 135

• Anaerobes: – Usually occur if there is an underlying condition such as diabetes – Often associated with aspiration

Answer 136

Viral Pneumonia • Very uncommon • Usually due to influenza A virus – Others: adenovirus, measles, CMV, varicella zoster • SARS (Severe Acute Respiratory Syndrome): – Due to coranovirus – High mortality rate – Outbreak in 2003

Answer 137

Atypical cause of pneumonia • Colonizes water tanks up to 60 degreesC • Causes outbreaks in hotels (hotel air conditioning/hot water systems) • Flu-like symptoms precede chest symptoms (usually dry cough) • CXR: Bi-basal consolidation, lymphopenia • Complications: D+V, hepatitis, hyponatraemia, haematuria • Diagnosis: Plasma serology – Urine testing for legionella antigen • Treatment: Macrolide e.g. Clarithromycin, Erythromycin +/- Rifampicin • Mortality= 10%

Answer 138

Mycoplasma pneumonia • Epidemics usually occur every 4 years • Usually occurs in teens and those in 20s • Commoner in boarding institutions • Generalize malaise, headache, arthalgia before chest symptoms • CXR= Reticulo-nodular shadowing or patchy consoldiation • Investigations: Mycoplasma serology (ie. blood test for Mycoplasma IgM) – Cold agglutins- can cause haemolytic anaemia • Complications: Skin rash/erythema multiforme, myocarditis/pericarditis, haemolytic anaemia/low platelets, neurological abnormalities, GI symptoms • Treatment: Macrolides e.g. Clarithromycin, Erythromycin

Answer 139

Complication of erythema multiforme Erythema Multiforme -Typically target lesions, raised, round, can appear oedemartous - Severe cases involve oral mucosa causing Steven Johnson Syndrome (severe Causes Drugs: NSAIDs, sufonamides, anti-conulsants, Allopurinol Infections: Herpes simplex, Mycoplasma, Orf, BCG, Idiopathic Non-Hodgkins lymphoma, leukaemia, multiple myeloma

Answer 140

Lung Abscess • Localised infection in the lung within a cavity • Cavitation on CXR and usually with fluid level • Causes: – Aspiration (anaerobes) – Foreign body ingestion – Bronchial carcinoma – Staphylococcus or klebsiella pneumonia – Septic emboli (usually from staphylococcus) cause multiple metastasis • Additional sign may include finger clubbing • 20-30% develop empyema

Answer 141

Empyema • Presence of pus within pleural cavity • Usually from bacterial spread from a severe pneumonia or rupture of lung abscess into pleural space • 70% of empyema have anaerobes but usually mixed flora found • Investigations: Obtain sample of infection via: • Pleural tap, bronchoscopy, percutenous transthoracic aspiration – Ultrasound and CT chest • Treatment: Chest drain – Antibiotics (usually for several weeks)

Answer 142

• CXR= Lobar consolidation • Urine send for pneumococcal antigen • Treatment: Penicillin based Abx or cephalosporins • Prevention: Pneumococcal vaccine, 5 yearly

Answer 143

Klebsiella pneumoniae: – Rare – Typically occurs in elderly, diabetics, alcoholics – Usually causes severe pneumonia (typically bronchopneumonia, and affects upper lobes) – Can cause a cavitating pneumonia, lead to abscesses

Answer 144

• Chlamydia pneumoniae – Outbreaks in institutions and families – Person-to-person spread (not via animal reservoir) – Causes pharyngitis, laryngitis, sinusitis, followed by pneumonia – CXR= Segmental infiltrates

Answer 145

Chlamydia psittaci – Causes psittacosis – History of exposure to birds- especially parrots – Causes headache, fever, dry cough, lethergy, arthalgia, hepato-splenomegaly

Answer 146

Haemophilus influenzae: – Frequent cause of exacerbation of chronic bronchitis in COPD and can lead to pneumonia if COPD.

Answer 147

Legionella pneumophilia • Colonizes water tanks up to 60 degreesC • Causes outbreaks in hotels (hotel air conditioning/hot water systems) • Flu-like symptoms precede chest symptoms (usually dry cough) • CXR: Bi-basal consolidation, lymphopenia • Complications: D+V, hepatitis, hyponatraemia, haematuria • Diagnosis: Plasma serology – Urine testing for legionella antigen • Treatment: Macrolide e.g. Clarithromycin, Erythromycin +/- Rifampicin • Mortality= 10%

Answer 148

Mycoplasma pneumonia • Epidemics usually occur every 4 years • Usually occurs in teens and those in 20s • Commoner in boarding institutions • Generalize malaise, headache, arthalgia before chest symptoms • CXR= Reticulo-nodular shadowing or patchy consoldiation • Investigations: Mycoplasma serology (ie. blood test for Mycoplasma IgM) – Cold agglutins- can cause haemolytic anaemia • Complications: Skin rash/erythema multiforme, myocarditis/pericarditis, haemolytic anaemia/low platelets, neurological abnormalities, GI symptoms • Treatment: Macrolides e.g. Clarithromycin, Erythromycin

Answer 149

Aspiration

Answer 150

Acute coryza

Answer 151

Acute laryngitis

Answer 152

Acute epiglottis

Answer 153

Bronchopneumonia

Answer 154

Infectious mononucleosis

Answer 155

Coronavirus

Answer 156

Herpes simplex virus

Answer 157

Adenovirus

Answer 158

Influenza A

Answer 159

Ebstein-barr virus Infectious mononucleoise

Answer 160

Streptococcus pneumoniae Right lower lobe pneumonia

Answer 161

Assess caused by Staphylococcus aureus Probably because of excess IV use

Answer 162

Mycoplasma pneumoniae pneumonia

Answer 163

Legionella pneumoniae

Answer 164

Chlamydophila psittaci

Answer 165

Klebsiella

Answer 166

Aspiration of stomach contents

Answer 167

Do CURB-65 score IV Co-Amoxiclav and oral Clarithromycin

Answer 168

Neural stimulus to breathe Respiratory mechanics • Respiratory muscle/ thoracic cavity effectiveness Airway resistance Elastic recoil of lungs Gas exchange interfaces • Lungs to blood • Blood to tissues

Answer 169

Physically dissolved (10%) Bound to Hb (30%) • Carbaminohaemoglobin (HbCO2) • Binds to globin rather than haem part As bicarbonate (60%) • CO2 +H2O=H+ +HCO3- • Driven by enzyme carbonic anhydrase in erythrocytes • Generates acid which triggers respiration

Answer 170

Safe in uncomplicated Type 1 Respiratory Failure • Pneumonia,pneumothorax,PE,shock Oxygen low Carbon dioxide low or normal Respiratory centres functioning normally Little risk of hypoventilation or carbon dioxide retention Give 100% oxygen or 15L/min via mask

Answer 171

Used where patients are at risk of CO2 retention, or low O2 requirements Blunting of hypercapnic drive due to overproduction of bicarbonate and mopping up of excess H+ Drive to breathe now from hypoxic stimulus Too much oxygen can cause hypoventilation and worsening of CO2 retention Patient may carry oxygen alert card with documented target saturations

Answer 172

O2 delivery methods Wall oxygen - Readily available in hospital Up to 15L/min Oxygen cylinders - Medium (2L/min) or high (4L/min) flow Oxygen concentrators - More economical than cylinder and Useful for LTOT

Answer 173

• Comfortable • Easy to wear • Non-obstructive to eating and drinking • Should only go up to 4L/min • Unable to control exact inspired O2 concentration • Can lead to dry nasal mucosa • Used in LTOT Not good for mouth breathers

Answer 174

Controlled O2 therapy ¡ Put a number of L/min through a valved mask to achieve a specific concentration ¡ Colour-coded O2 concentration range: ¡ Blue: 24%V = 2L ¡ White: 28%V = 4L ¡ Yellow: 35%V = 8L ¡ Red: 40%V = 10L ¡ Green: 60%V = 15L Good for COPD patients as very controlled

Answer 175

O2 DELIVERY METHODS – NON- REBREATHE MASK Rebreather Around 1/3 patient’s exhaled air goes into reservoir bag. Rebreathed CO2 acts as respiratory stimulus Non-rebreather One way valves means most exhaled air escapes so inhaled oxygen concentrations are higher Emergency O2 therapy A+E or ambulance 15 litre non rebreather = about 85% oxygen Emergency scenario where patient is hypoxic

Answer 176

O2 DELIVERY METHODS – HIGH-FLOW O2 • High-Flow Nasal Cannula • Wide-bore nasal cannula • O2 driven through a humidified circuit otherwise conc would be too high causing nose bleed • Delivers up to 100% O2 therapy • Improves work of breathing Very thick nasal cannula T1 resp failure Usually HDU

Answer 177

NIV - non invasive ventilation Obstructive sleep apnoea patients- splints airways open to stop hypoxia BIPAP/CPAP ¡ Tight fitting mask that supplies higher than atmospheric pressure to splint open airways and prevent them from collapsing ¡ Can be used with/without oxygen ¡ CPAP ¡ Pressure constant throughout respiratory cycle ¡ Used in neonates, mild obstructive sleep apnoea ¡ BIPAP ¡ Pressure drops during expiration phase to encourage more movement of air in and out of lungs ¡ Used in hypercapnic respiratory failure, severe OSA

Answer 178

Exacerbation of longstanding lung disease • Eg. COPD, cystic fibrosis, other fibrosis Severe kyphosis • Restrictive lung defect caused by physical inabilty to fully inflate lungs Respiratory muscle weakness • Eg. Motor neurone disease Overdose of drugs causing respiratory depression • Opiates/ benzodiazepines

Answer 179

Patients at risk of developing Type 2 Respiratory Failure: • COPD • Kyphoscoliosis • Motor Neurone Disease ¡ Initially give controlled concentration of 28%V and adjust appropriately ¡ Aim for oxygen saturations of 88-92% ¡ Monitor patient condition and ABG’s regularly for signs of CO2 retention and acidosis ¡ May require BIPAP (biphasic positive airways pressure)

Answer 180

15L non rebreather aim for >94% ABG = Type 1 respiratory failure Possible causes: PE, asthma, pneumonia, pneumothorax

Answer 181

Bronchodilator 15L non rebreather T1 resp failure T2 resp failure Controlled O2 therapy

Answer 182

Cor pulmonale ABG would show increased CO2 O2 therapy- 15L non rebreather, do ABG to see if CO2 retainer Further treatment- cut off is 7.3 for normal but 8 for pulmonary hypertension, do echo to see if right sided HF

Answer 183

Respiratory rate of more than 30 breaths per minute. • Tachycardia greater than 130 beats per minute. • Systolic blood pressure less than 90 mmHg, or diastolic blood pressure less than 60 mmHg (unless this is normal for them). • Oxygen saturation less than 92%, or central cyanosis (if the person has no history of chronic hypoxia). • Peak expiratory flow rate less than 33% of predicted. • Altered level of consciousness. • Use of accessory muscles of respiration (particularly if the person is becoming exhausted). • Features of foreign body aspiration

Answer 184

Time definitions for cough • Acute • < 3 weeks • Sub-acute • 3 – 8 weeks • Chronic • > 8 weeks

Answer 185

What are the causes of an acute cough? Respiratory causes: • URTI • Foreign body aspiration • Pulmonary embolism • Pneumothorax • Acute bronchitis • Pneumonia • Acute asthma • Exacerbation of COPD • Pertussis (whooping Cough) • Lung cancer Non Respiratory Causes • Aortic aneurysm Cardiac failure – pulmonary oedema • GORD

Answer 186

• Upper Airway Syndrome • Pertussis • Acute Bronchitis • Asthma • COPD • COVID 19 • Allergies • Heart Failure • Side Effect ACE Inhibitors • Foreign Body Aspiration • PE • Pneumothorax • Lung Ca • URTI • Bronchitis • Pneumonia • Pertussis • Bronchiectasis • Post Infectious Cough • TB • Smokers Cough • GORD • Heart Failure • Interstitial Lung Disease

Answer 187

• Started suddenly or developed over time? • Did anything trigger the cough? • How long has cough lasted? • When do you cough? • Is the cough worse when you exercise • Are you breathless even when your not coughing? • Have you got any chest pain when you are coughing? • Are you coughing up any phlegm (mucus)? • What colour is the phlegm? • Is there any blood in the phlegm? • Do you generally feel ill? • Do you have a high temperature? • Has there been any unintentional weight loss? • Any recent contacts with anyone with Tuberculosis? • Are you a smoker or recent smoker? • What is your current and past occupation if retired? • Have you started any new medication recently particularly for high blood pressure? • Travel/Hotels

Answer 188

ACUTE CAUSE Includes: • Sinusitis • Rhinitis • Pharyngitis • Laryngitis • Usually self diagnosed • Cough usually develops after nasal symptoms have cleared and can take up to 3 weeks to resolve Children • Restlessness or irritability • Nasal congestion/discharge and sneezing — severe nasal congestion may interfere with feeding, breathing, and sleep • Cough — occasionally, vomiting may follow a bout of coughing. • Fever Management • Fluid, healthy food, rest • Paracetamol/NSAID • Safety net

Answer 189

Foreign Body Aspiration • Vary from life-threatening obstruction and death to non-specific symptoms of cough, wheezing, fever, haemoptysis, or dyspnoea. • large objects can completely occlude the trachea and result in asphyxiation and death • small objects can lodge in the lower lobar airways and cause wheezing and coughÒatelectasis, post- obstructive pneumonia, bronchiectasis, or lung abscess. • Can lead to misdiagnosis of asthma, reactive airways disease, bronchitis, or pneumonia. • The right lower lobe of the lung is the more common site – right bronchus is wider and steeper than the left - objects to enter more easily than the left side At risk groups • Children, >70 years • Stoke, dementia • Impaired cough reflex • medications, alcohol, drugs Present with • Acute intractable cough • Followed by side effects

Answer 190

Foreign Body Aspiration • Investigations • CXR • Most aspirated objects are radiolucent • Non-specific findings that suggest foreign body aspiration include atelectasis, pneumonia, air trapping, and pneumomediastinum. Bronchiectasis, lung abscess, and empyema are usually late findings. • A normal chest x-ray does not rule out foreign body aspiration, and CT scan or bronchoscopy is warranted for confirmation. • CT • More sensitive, non invasive Investigation/Management • Bronchoscopy • Flexible for stable • Rigid for unstable

Answer 191

Post Infectious Cough • Sub acute cough (3-8 weeks) • Following URTI • Can be dry or productive • Thought to be • Inflammatoryresponse • Increased sensitivity • Normal respiratory examination • Diagnosis is clinical and one of exclusion • Investigations to consider • CXR - normal • Sputum sample • Explain that the cough may persist for several months and advise the person to re-attend for assessment if the cough does not improve after 2 months.

Answer 192

Pertussis (whooping cough) • Resurgence of pertussis in highly vaccinated populations, the disease continues to be a public health and medical concern. • Three stages: catarrhal, paroxysmal, and convalescent. cough may persist for several months • Initial symptoms may be similar to a cold, with rhinorrhoea and lacrimation, or a dry cough followed by episodes of severe coughing. Fever may be absent or low-grade. • There may be vomiting after coughing, or an inspiratory whoop • Inspiratory whooping is a characteristic symptom • Bordetella pertussis • Notifiable disease!

Answer 193

COPD • Asthma • Cough variant asthma • Allergies • Upper airway cough syndrome • Gastroesophageal reflux • Medication side effects • Cancer • TB Post nasal drip

Answer 194

• CHRONIC Cause • Cough present for > 8 weeks • Non productive • Presence of abnormal sensations arising from the throat - patients describe something stuck in the throat • There are no definitive tests • A trial of empirical therapy • antihistamine • plus a decongestant • Recommended to confirm the diagnosis in the presence of a supportive history and exam • Chlorphenamine 4 mg orally every 4-6 hours, maximum 24 mg/day plus pseudo ephedrine 60mg orally every4-6hours, maximum 240 mg/day; 120 mg orally (extended- release) twice daily Approximately 60% of patients improve with this approach •improvement is usually seen within 2 weeks

Answer 195

• Gastroesophageal reflux disease(GORD) is a common cause of chronic cough • Risk factors • Smokers, alcohol, NSAIDs, diet • May not have typical reflux symptoms • Cough, throat clearing, voice changes, worse on lying flat • Trial of PPIs

Answer 196

• ACE inhibitor cause a non productive cough in 5-20% of patients, affecting women more than men • The effect is not dose related, and the cough can occur after one week or to six months after therapy has been initiated. • The cough should spontaneously resolve a few days to several weeks after the ACE inhibitor is discontinued. • A four week trial of withdrawal is usually sufficient to determine whether the medication caused the cough • Cough related to ACEI usually subsides within 2 weeks but some reports suggest up to four weeks

Answer 197

Suspected lung Ca Patient must have a CXR within 2 weeks if: • Cough • Fatigue • Shortness of breath • Chest pain • Weight loss • Appetite loss • 2 of the above unexplained or.. • 1 of the above unexplained and have ever smoked • CXR 2 weeks: Age >40 and any of... • Persistent or recurrent chest infection. • Finger clubbing. • Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy. • Chest signs consistent with lung cancer. • Thrombocytosis

Answer 198

Mesothelioma CXR within 2 weeks if: • Cough • Fatigue • Shortness of breath • Chest pain • Weight loss • Appetite loss • 2 of the above unexplained or.. • 1 of the above unexplained and have ever smoked • 1 OF THE ABOVE AND ASBESTOS EXPOSURE

Answer 199

• A cough that lasts more than three weeks should be thoroughly investigated • Systemic symptoms – fever sweats, weight loss (possible Tuberculosis, lymphoma, bronchial carcinoma) • Coughing up blood (haemoptysis) could be sign of tuberculosis, bronchial carcinoma. • Cough associated with copious sputum production (might indicate bronchiectasis) • Night sweats associated with coughing (consider Tuberculosis and also consider lymphoma) • Associated with significant dyspnoea (heart failure, COPD, Fibrotic lung disease) • Hoarseness. Laryngeal problem • 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 coexisting voice disturbance • Trouble swallowing.

Answer 200

• From a small amount of blood-streaked sputum • To massive bleeding with life-threatening consequences due to airway obstruction and haemodynamic instability. • Mild haemoptysis: <30 mL over 24 hours • Frank or moderate haemoptysis: ≥30 mL and <600 mL over 24 hours • Massive haemoptysis: 600 mL or more over 24 hours • Consider >150 mL haemoptysis as life-threatening, as this volume of blood could flood the conducting airways completely

Answer 201

• Most important to confirm that the bleeding is from the lungs. • Is there any bleeding from the nose/pharynx? • Any dental problems? • Any gastro-oesophageal reflux? • Any vomiting? • Is the blood mixed with the sputum?

Answer 202

• Is it frothy and pink sputum (suggests heart failure?) • Purulent or rusty coloured suggests a bacterial infection • Any suggestion of infection in sputum? Is the sputum yellow/green coloured sputum? • Any possible exposure to tuberculosis? (check recent travel) • White sputum with blood streaks might suggest possible tumour • Frequency of haemoptysis (recurrent?) – any suggestion of recurrent bleeding might suggest malignancy • Has blood in the sputum over a prolonged time led to anaemia? Any obvious signs and symptoms of anaemia • Past medical history & drug history – any known bleeding tendencies or medications that could cause these? • Any clues to possible undiagnosed malignancy (smoking history?)

Answer 203

Common causes • Acute Bronchitis • Chronic Bronchitis (COPD) • Pneumonia • Lung Cancer • Metastasis • Pulmonary Embolism • Infections can cause haemoptysis by causing necrosis of adjacent bronchial vessels or local mucosal ulceration. • In bronchiectasis - recurrent inflammatory destruction and healing lead to bronchopulmonary vascular anastomoses. • Cardiac • In left ventricular failure and mitral stenosis, blood-streaked sputum is caused by rupture of pulmonary veins or capillaries, or by anastomoses between the bronchial and pulmonary arteries distended by elevated intravascular pressure or pulmonary venous hypertension. Neoplastic. (Cancer) • increase in the bronchial artery supply to the region of the tumour. • Haemoptysis results from necrosis, mucosal invasion, or direct local invasion of a blood vessel. • Massive haemoptysis • invasion into a blood vessel and its adjacent airway results in vascular airway fistula.

Answer 204

Severe Acute Respiratory Distress Syndrome Coronavirus-2 Infection with the SARS-CoV-2 virus Spread by aerosols, small droplets and surfaces Diagnosis: reverse transcription PCR of nasopharyngeal and oropharyngeal swab samples

Answer 205

¡ Fever ¡ Dry Cough ¡ Fatigue ¡ Change in sense of smell/taste ¡ Shortness of Breath ¡ Myalgia ¡ Up to 1/3 of cases are totally asymptomatic ¡ Some patients continue to experience symptoms for over 12 weeks – Long COVID

Answer 206

Covid causes livid congestion so liver function markers rise

Answer 207

Respiratory alkalosis Type 1 resp failure as hyperventilating

Answer 208

Pneumonia Acute Respiratory Distress Syndrome Multi-Organ Failure VTE – prevalence of approximately 8% in initial wave Superadded bacterial infection – prevalence of approximately 7% in initial wave Long covid

Answer 209

RECOVERY Trial – Dexamethasone and Tocilizumab Dexamethasone approved for use in July 2020 – reduces 28-day mortality in patients requiring O2 Tocilizumab approved for use in March 2021 (Steroids to treat the cytokines storm)

Answer 210

Level 1 Care •Ward-Based Care •For example: O2 via a venturi mask, IV Antibiotics/IV Fluids Level 2 Care (single organ support) •May be ward-based or High- Dependency Unit •For example: Continuous Positive Airway Pressure (CPAP) or Nasal High-Flow O2 (NHF) Level 3 Care •Intensive Care Unit •For example: Inotropic Support, Intubation and Ventilation (multi organ failure)

Answer 211

DIFFICULT COMMUNICATION ¡ SPIKES Setting (no interruptions) Perception (what do you know so far) Invitation (are you happy for me to proceed) Knowledge (deliver news pause do you understand) Empathy Summary (next steps)