Week 3/4 - D - Resp Tract infection - Tonsilitis, Quinsy, Epiglottitis, Acute airway obstruction, Sinusitis, Bronchitis, COPD, flu

Question 1

Respiratory tract infections affecting the upper respiratory tract - ie infections above the vocal cords *larynx and up) Common cold – coryza Sore throat – Pharyngitis Sinusitis Epiglottitis If thinking a patient has a sore throat, usually the diagnosis is clinical, what investigation can be carried out to diagnose the pathogen?

Answer 1

Can carry out a throat swab

Question 2

The majority of sore throats are caused by viruses but there can be bacterial causes What are the presenting symptoms of strep throat?

Answer 2

Presenting symptoms * Sore throat * Dysphagia * Pus * Exudate * Absence of cough * Fever * Swollen red tonsils

Question 3

What type of streptococcus usally causes strep throat?

Answer 3

Group A Strep (strep pyogenes) is the most common cause of strep throat

Question 4

People with a sore throat caused by strep are more likely to benefit form antibiotics. FeverPAIN, or Centor, criteria, are clinical scoring tools that can help to identify the people in whom this is more likely How is the FeverPAIN assessment carred out? What score is needed to start antibiotics by antibiotic man and NICE?

Answer 4

* Fever >38 degrees * Purulence (pharyngeal / tonsilar exudate) * Attended rapidly (3 days or less) * Inflamed tonsils * No cough or coryza Each is worth one point. Max of 5. Need a score of 4 or more to start antibiotics

Question 5

WHat is the CENT criteria for prescribing antibiotics What score does NICE recommend before starting antibiotics? What does the modified criteria include? (aka McIsaacs criteria)

Answer 5

Centor criteria * Cough absence * Exudate - Tonsils/pharyngeal * Nodes - cervical lymphadenopathy * Temperature >38 degrees celsius Each is worth one point. Max of 4. NICE recommends a score of 3 or 4 before starting antibiotics Modified score adds in * 1 point if aged 3-14 * -1 if aged >/=45

Question 6

What is the management of tonsillitis if prescribing antibiotics? What is given if pen allergic? (FeverPAIN >/=4) (Centor >/=3)

Answer 6

Prescribe patient Oral penicllin if able to swallow (Pen V - phenoxymethylpenicillin) IV penicillin if unable to swallow (Pen G - benzylpenicillin) If pen allergic - Clarithromycin

Question 7

A potentially life threatening complication of tonsilitis is a quinsy What is this and what are the symptoms?

Answer 7

Quinsy is a peritonsiliar abscess Patient presents with unilateral throat swelling Deviated uvula away from the mass Dysphagia Muffled voice Trismus - lcokjaw

Question 8

What is the treatment of a quinsy? If able to swallow or not swallow If pen allergic If symptoms persist after 48 hours antibiotic treatment

Answer 8

Benylpenicillin IV or Penicllin V oral If pen allergic prescribe Clindamycin (provides adequate anaeobic coverage) If symptoms persist after 48 hours, add metrondiazole to penicllin Treatment for 10 days

Question 9

Epiglottitis is a critical emergency as it can progress to complete airway obstruction What are the symptoms of epiglottitis?

Answer 9

* Sore throat * Fever * Dysphagia * Dyspnoea * Voice change – muffled voice * Drooling * Tender neck nodes NO COUGH USUALLY

Question 10

What are the main causative organisms for epiglottitis?

Answer 10

Historcaly it was haemophilus influenza B but due to the vaccine the rates have geeatly decreased Now most Group A B-haemolytic strep (step pyogenes) Also strep pneumonia and staph aureus

Question 11

What sign is seen on what type of xray in epiglottitis?

Answer 11

Thumb print sign is seen on a lateral neck radiograph showing a swollen inflamed epiglottis

Question 12

Due to epiglottitis potentially leading to a scernario where the airway closes - increasing stridor –> shows obstruction of airway, What are the initial management steps carried out to maintain the airway in any ACUTE AIRWAY OSTRUCTION?

Answer 12

Step 1 - give the patient oxygen or heliox (helium + oxygen)- may reduce work of breathing due to less dense air Step 2 - administer the patient nebulised adrenaline + IV steroids eg dexamethasone Hopefully this will have secured the airway - administer antibiotcs if eg epiglottitis

Question 13

ACUTE AIRWAY OBSTRUCTION Step 1 - give the patient oxygen or heliox (helium + oxygen)- may reduce work of breathing due to less dense air Step 2 - administer the patient nebulised adrenaline + IV steroids eg dexamethasone If these steps do not work, what is carried out? What is carried out in a patient who cannot be safely intubated?

Answer 13

* Endotracheal tube intubation is the next step in a patient who is not stable * Tracheotomy/cricothyroidotomy may be performed in an emergency in patients who cannot be safely intubated * This procedure allows oxygen to enter the lungs while bypassing the epiglottis.

Question 14

Why is trachesotomy preferred to cricothyroidotomy?

Answer 14

Cricothyroidotomy is a temporary measure until formal tracheostomy is available Cricothyroidotoym involves giving jet O2 - this only acts to oxygenate but not ventilate and therefore CO2 can build up

Question 15

What is carried out once the patient is stable and the airway is maintained to correctly diagnose the cause of the patients airway obstruction?

Answer 15

Once this has been achieved and the situation is thought to be safe, some tests may be carried out, such as: a flexible nasoendoscopy – a flexible tube with a camera attached to one end (laryngoscope) is used to examine the throat

Question 16

What is the treatment of epiglottitis?

Answer 16

Administer IV ceftriaxone

Question 17

What is the common cold also known as? What causes it? What are the symptoms?

Answer 17

Coryza - viral inflammation of the nasal passages * Blocked or runny nose * Sore throat * Headahce * Coughs * Sneezing

Question 18

What viruses causes the common cold and what are complications of the common cold? What is the treatment?

Answer 18

Viruses usually causative are * Rhinoviruses * Adenovirus * Respiratory syncytial virus Usually self-limiting Can cause sinusitis or acute bronchitis

Question 19

Common cold can precede an acute sinusitis (aka acute rhinosinusitis) What are the symptoms here? What is the usual cause and treatment?

Answer 19

Symptoms of sinusitis Dull constant ache over frontal and maxillary sinus Post-nasal drip and occasionally tooth ache Mostly due to viral aetiology and usually self limiting within 10 days

Question 20

What would make you think the sinusitis was bacterial and what is the treatment (if pen allergic also)?

Answer 20

If the sinusitis is bacterial - * Initial improvement of symptoms but gets worse * Probably would persist for longer than 10 days * Purulent nasal discharge * Fever Treat with Penicllin V (if pen allergic doxycycline)

Question 21

As previously stated, common cold complications can potentially lead to sinusitis What other condition can it precede? Aka the cold of the chest

Answer 21

Common cold can precede both sinusitis and acute bronchitis (aka the cold of the chest)

Question 22

Bronchitis is an infection of the main airways of the lungs (bronchi), causing them to become irritated and inflamed. What are the symptoms of acute bronchitis?

Answer 22

Symptoms Productive cough Sore throat May have a transient wheeze Fever is uncommon

Question 23

What is the recommended treatment of acute bronchitits?

Answer 23

Acute bronchitis is usually caused by a virus and therefore antibiotics are not usually indicated * Analgesia, hydration and time

Question 24

Acute COPD exacerbation What are the symptoms of an acute COPD exacerbation?

Answer 24

Reported symptoms are Worsening dyspnoea Worsening cough Increased sputum production and viscosity Change in sputum colour More wheezy

Question 25

What signs on examination are evident in an acute COPD exacerbation? Advanced COPD leads to high pressure on the lung arteries, which strains the right ventricle of the heart, what symptoms may happen due to this in patient with an exacerbation?

Answer 25

Patient may be in respiratory distress Wheeze Coarse crackles May be cyanosed In advanced disease may have (worsening) ankle oedema due to cor pulmonale - lung disease causing RVF

Question 26

What is the management of a COPD exacerbation if in primary care? (usually mild or moderate exacerbation)

Answer 26

Bronchodilator inhalers - ipratropium and salbutamol Antibiotics may be required - 1st line amoxicillin, 2nd line doxycycline Short course of steroids may be needed eg oral prednisolone

Question 27

Severe exacerbation patients usually need hospital admission What is investigated and how is it managed?

Answer 27

Pulse oximetry ABG and CXR if patient is in hospital FBC, CRP, ECG if hospital also ISOAP Ipratropium and Salbutamol nebulised (bronchodilators and reduced mucus secretion) Give O2 if sats Give antibiotics if there is an increase in sputum production/viscosity/purulence (or CXR evidence) Prednisolone oral or IV hydrocortisone

Question 28

Influenza, commonly known as “the flu”, is an infectious disease caused by an influenza virus. How is it spread an what is the presentation?

Answer 28

Flu is spread through air droplets Presentaiton Fever, high and abrupt onest up to 40 degrees Malaise Myalgia Headahce Cough DIarrhoea

Question 29

Classical flu is caused by influenza a and influena b viruses Which type is able to cause a pandemic?

Answer 29

Influenza A may cause a pandemic It has a faster rate of mutation than influenza B which cannot cause a pandemic

Question 30

What are the complications of flu disease?

Answer 30

Primary influenzal pneumonia - seen most during pandemic years Secondary bacterial pneumonia - more common in infants, elderly and immunocompromised Bronchitis Otitis media - initial presentation especially in children

Question 31

What is the treatment of flu?

Answer 31

Treatment of flu is bed rest, fluids and paracetamol usually NICE says antivirals are only given in patients at risk of complications and when flu circulating and early in disease.

Question 32

What are the antivirals of choice? Which patients are high risk? (6 categories)

Answer 32

Oseltamivir - 1st line, zanamivir - 2nd line High risk patients * Adults over 65 years * Children under 6 months * Pregnant women * Immunosuppressed patients * BMI >40 * People with chronic diseases (specific ones)

Question 33

Flu is usually made on a clinical basis. Testing usually limited to seasonal outbreaks and public health surveillance How is diagnosis of the flu carried out?

Answer 33

Direct detection of the virus is usually by examining swabbed samples * Nasopharyngeal swab in viral transport medium * Throat swabs in virus transport medium They are analysed by viral PCR or rapid antigen testing

Question 34

Preventing of flu is aimed through the use of vaccinations What are the two types of vaccines, how are they different?

Answer 34

Killed vaccine - virus grown and then inactivated and combined with an adjuvant Live attenuated vaccine - contains a weakened version of the virus

Question 35

What does the killed flu vaccine contain and who is it given to?

Answer 35

Currently ontains 2 different influenza A viruses and one or two influenza B viruses Given annually adult patients at risk of complications (age>65, age, BMI>40, pregnant, chronic disease, immunosuppressed) Given to children aged 6months to 2 years at risk of complications Given to health care workers

Question 36

Killed vaccination given to: Given annually adult patients at risk of complications (age>65, age, BMI>40, pregnant, chronic disease, immunosuppressed) Given to children aged 6months to 2 years at risk of complications Given to health care workers Who is the live attenuated vaccination given to?

Answer 36

The live attenuated flu vaccine given intra-nasally to children aged 2-17