//Respiratory//

Question 1

What is a cough?

Answer 1

Reflex response to airway irritation - triggered by stimulation of airway cough receptors either by irritants or conditions that cause airway distortion

Question 2

What are the 3 types of coughs?

Answer 2

Acute - < 3weeks
Subacute - 3-8 weeks
Chronic - > 8 weeks

Question 3

What are possible causes of acute cough?

Answer 3

Most commonly - viral upper respiratory tract infection 
Acute bronchitis 
Pneumonia 
AE of asthma/ COPD/ bronchiectasis 
Pneumothorax 
Pulmonary embolism

Question 4

What are possible causes sub-acute cough?

Answer 4

Most commonly post-infectious i.e. after infection with Mycoplasma pneumonia or bordetella pertussis

Question 5

What are possible causes of chronic cough?

Answer 5

Smoking, ACEI, upper airway cough syndrome (aka post-nasal drip), asthma, GORD, eosinophilic bronchitis

Question 6

What are possible causes for cough (generally)?

Answer 6

Bronchiectasis 
Bronchitis 
COPD
Cough variant asthma
Environment/ occupation 
Foreign body aspiration 
HF
Interstitial lung disease
Lung cancer 
Obstructive sleep apnoea 
Pertussis 
Pulmonary TB 
Somatic cough syndrome 
Thoracic aortic aneurysm

Question 7

What investigations can be used to determine the cause of cough ?

Answer 7

Pulse oximetry - if pt acutely unwell
Peak expiratory flow rate - if asthma known/ suspected
Pertussis serology - if whooping cough is suspected
CRP test - if pneumonia suspected
Spirometry + chest X-ray - if chronic cough and uncertain cause

Question 8

When might someone with a cough require emergency admission?

Answer 8

Suspected PE or pneumothorax
Clinical features of foreign body aspiration (when a foreign body is inhaled into lungs)
Resp rate > 30 breaths per min
Tachycardia > 130 bpm
Systolic BP < 90 mmHg
O2 sat < 92% or central cyanosis (if no hx of chronic hypoxia)
Peak expiratory flow rate < 33% of predicted
Altered level of consciousness
Use of accessory muscles of respiration - esp if becoming exhausted

Question 9

When should you refer someone with a cough to a respiratory consultant?

Answer 9

When diagnosis is uncertain

When pt is unresponsive to treatment trials

Question 10

What general advice can you give to someone with acute cough/ upper resp tract infection?

Answer 10

• self-limiting usually persists for 3-4 weeks
• paracetamol/ ibuprofen - be careful of other conditions/ meds
• some pts may want to try honey, pelargonium or OTC meds with the expectorant guaifenesin (chesty) or cough suppressants (dry)
• seek medical advice if symptoms worsen rapidly/ significantly or if they do not improve in 3-4 weeks or if they become systemically unwell
• refer to smoking cessation services if appropriate

Question 11

What meds should you NOT offer someone with an acute cough?

Answer 11

• oral/ inhaled bronchodilator (salbutamol) or oral/ inhaled corticosteroid (beclometasone) - unless they have underlying airway disease i.e. asthma/COPD
• mucolytic (acetylcysteine or carbocisteine)
• antibiotics - unless systemically very unwell or at higher risk of complications - give advice about why Abx not given

Question 12

What antibiotics can be given to someone with an acute cough who is systemically very unwell?

Answer 12

Give immediate Abx - doxycycline 200mg on day 1, then 100mg OD for 4 days - AVOID IN PREGNANCY
if unsuitable, alternatives incl:
- amoxicillin 500mg TDS for 5 days
- clarithromycin 250-500mg BD for 5 days
- erythromycin 250-500mg QDS or 500mg-1g BD for 5 days
If pt considered higher risk, may give back up ABC in case they get an exacerbation
Also think about SEs esp. diarrhoea and nausea

Question 13

How would you manage a pt with sub-acute cough (i.e. post-infectious) if they do not need emergency admission?

Answer 13

• explain cough often self-limiting - usually no longer than 8/52 - if longer, pt should contact GP for assessment
  consider:
• trial of inhaled ipratropium (Atrovent - SAMA - bronchodilator)
• inhaled corticosteroid if QoL affected and cough persists despite ipratropium
• oral prednisolone 30-40mg OD for short, finite period - for severe outbursts of post-infectious cough where other common causes have been ruled out
• if other treatments fail, centrally acting antitussives (cough suppressants - codeine or dextromethorphan)

Question 14

How would you manage a pt who has chronic cough induced by ACEI?

Answer 14

• Stop ACEI and prescribe alternative usually ARBs (losartan)
• Cough resolves in 1/12 for most pts, occasionally can persist for several months

Question 15

How would you manage a pt with eosinophilic bronchitis?

Answer 15

• inhaled corticosteroid - first line
• if symptoms do not improve - increase dose of ICS - consider other possible diagnoses - consider leukotriene inhibitor i.e. montelukast

Question 16

How would you manage a pt with upper airway cough syndrome i.e. post nasal drip?

Answer 16

• antihistamine (chlorphenamine) + decongestant (pseudoephedrine)
• advice: avoid allergic/ environmental triggers if possible - symptoms should improve after 1-2 weeks of starting treatment - make several weeks/ few months before completely resolved
• if pt also has sinusitis - also offer intranasal corticosteroid (mometasone) or Abx
• if rhinitis - also offer intranasal corticosteroids (mometasone) or intranasal antihistamines (azelastine) or intranasal sodium cromoglicate

Question 17

What is rhinitis?

Answer 17

Irritation/ inflammation of the mucous membrane inside the nose
I.e. allergic rhinitis - caused by allergens such as pollen - aka hay fever

Question 18

What is post nasal drip?

Answer 18

• Aka upper airway cough syndrome
• Occurs when excessive mucus is produced by the nasal mucosa - this mucus can accumulate in the back of the nose and eventually drops into the throat
• can be caused by rhinitis, sinusitis, GORD, swallowing disorder - other causes: allergy, cold, flu, SEs

Question 19

What is eosinophilic bronchitis?

Answer 19

• type of airway inflammation
• due to excessive mast cell recruitment and activation in the superficial airways as opposed to the smooth muscles of the airways as seen in asthma
• often causes chronic cough
• lung function tests usually normal
• ICS often effective treatment