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Question 1

Acute Bronchitis - Definition & Presentations

Answer 1

A self limiting lower respiratory tract infection, causing inflammation of the bronchial airways

No clear definition, but key factors:
- <21 days
- cough is the predominant symptom
- w/ at least one other lower respiratory tract symptom: sputum production, wheezing, chest pain
- There is no other explanation for these symptoms (i.e. asthma)

Presentations:
- cough < 30 days
- sputum, wheezing, chest pain
- no Hx of chronic respiratory illness
-fever
-rhonchi (gurgling/bubbling sounds on auscultation)

Question 2

Acute Bronchitis - Aetiology & Risk Factors

Answer 2

Most common cause: Viral Lower resp. tract Infection

Common viruses = same as upper tract. infections:
- Coronavirus
- Rhinovirus
- Adenovirus

Infection causes inflammation of the bronchus, leading to mucus production and oedema of the bronchus –> This leads to a productive cough (Hallmark of Lower Resp. tract infection)

Risk factors: Smoking, Viral infection

Question 3

Acute Bronchitis - Epidemiology

Answer 3

One of the most common conditions seen in clinical practice

Once of the most common Adult outpatient diagnoses

Highest in Autumn and Winter

Question 4

Acute Bronchitis - Differentials

Answer 4

1) COVID-19 –> check if in contact with other COVID patients

2) Pneumonia –> Higher fever, more ill overall, rales on auscultation (clicking/crackling noises)

3) Allergic Rhinitis –> often have postnasal drip (mucus accumulation in the back of the throat causing cough. Acute rhinitis should be evident on nasal examination

4) Asthma –> bilateral wheezing, bronchospasm is recurrent and progressive (chronic instead of acute)

5) Lung cancer –> Symptoms persist >30 days, haemoptysis, weight loss, anorexia

6) Upper Resp. conditions –> Hard to tell, can be indistinguishable

Question 5

Acute Bronchitis - Investigations

Answer 5

Generally diagnosed clinically. Tests only really done to exclude other diagnoses like asthma or pneumonia

Test to consider:
- Pulmonary function test –> to exclude Asthma

• CXR –> to exclude Pneumonia
• CRP

Question 6

Acute Bronchitis - Management

Answer 6

1st line: Observe
consider:
- Antipyretic –> paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
- Short-acting beta-agonist bronchodilator –> salbutamol: 100-200 micrograms (1-2 puffs) inhaled every 4-6 hours when required; 2.5 mg nebulised every 4-6 hours when required

If ongoing cough of >4 weeks, evaluate for other causes and consider short-acting beta-agonist bronchodilator

Question 7

Acute Bronchitis - Prognosis & Complications

Answer 7

Most recover within 6 weeks of their initial symptoms.

Infection usually clears in several days, while repair of the bronchial wall may take several weeks, leading to a prolonged cough

Recurrence of acute bronchitis is common in Viral infection seasons, especially in smokers

Complications:
- Chronic cough = low chance
–> some can cough for up to 6 months post bronchitis syndrome.
–> Treat w/ Salbutamol (short-acting beta-agonist bronchodilators) until cough resolves

• Pneumonia = low chance
  –> consider in the elderly

Question 8

Asthma in Adults - Definition & Presentations

Answer 8

Asthma is a chronic inflammatory airway disease characterised by reversible, intermittent airway obstruction and hyper-reactivity

Presentations:
- Expiratory Wheeze
- Dyspnoea (SOB)
- Cough

• Chest tightness
• Diurnal variability of symptoms (worse in the morning or night)
• Episodic symptoms

Question 9

Asthma in Adults - Aetiology & Risk Factors

Answer 9

Asthma is a complex disease with underlying multi-gene association interacting with environmental exposure

Patients’ genetic make-up may predispose them to airway hyper-responsiveness when exposed to environmental triggers. Those triggers can include viral infections such as rhinovirus, respiratory syncytial virus (RSV), human metapneumovirus, and influenza virus.

Air pollutants and other allergens can trigger it

Smoking is shown to increase levels of neutrophils, which can make people more susceptible to Asthma

Infection with RSV or human rhinovirus in early life increases the likelihood of developing asthma in those with a genetic predisposition

Risk Factors:
- FHx
- Allergens/irritants
- Atopic disease Hx (i/e/ eczema. allergic rhinitis, etc..)
- Smoking/Vaping
- Resp. viral infection in early life
- Nasal Polyposis

Question 10

Asthma in Adults - Epidemiology

Answer 10

The prevalence of asthma worldwide is variable

Countries with the lowest prevalence in adults include China and Vietnam, whereas Australia and Sweden have the highest prevalence

Question 11

Asthma in Adults - Differentials

Answer 11

1) COPD
–> Hx of smoking
–> Dyspnoea occurs w/ or w/out wheezing and coughing
–> May see barrel chest, hyper-resonance to percussion and distant breathing sounds

2) Chronic Rhinosinusitis –> May present w/ nocturnal cough & SOB from post-nasal discharge

3) Breathing Pattern Disorder –> Breathlessness w/ light-headedness and peripheral tingling. Can coexist w/ Asthma
–> Hyperventilation = most common breathing pattern disorder

4) Vocal cord dysfunction –> Throat tightness, hoarse voice/voice changes, cough and throat clearing

5) Bronchiectasis –> Increased sputum production, SOB, cough & wheezing. If severe, recurrent pulmonary infections

Question 12

Asthma in Adults - Investigations

Answer 12

1st line:
- Spirometry (FEV1/FVC ratio and BDR) –> Identify airway obstruction
- Peak expiratory flow rate (PEFR)
- CXR –> exclude other pathologies
- FBC w/ differential

consider:
- Fractional exhaled nitric oxide (FeNO) –> finds eosinophilic inflammation
- Bronchial challenge test
- Allergen testing

Question 13

Asthma in Adults - Management

Answer 13

1st line - Infrequent symptoms:
- SABA (Short-acting Beta Agonist) as needed –> salbutamol inhaled: (100 micrograms/dose inhaler) 100-200 micrograms inhaled up to four times daily
–> As little as possible

Step 1 - If SABA doesn’t work:
- Low-dose ICS (Inhaled corticosteroids) alongside SABA
–> budesonide inhaled: 200 micrograms inhaled twice daily

Step 2 - if Step 1 fails:
- Fixed -dose LABA (Long-acting Beta agonist) + low-dose ICS
(before moving on, check patients inhaler technique as this may be the problem)
–> budesonide/formoterol inhaled: dose depends on brand and formulation; consult product literature for guidance on dose

If step 2 fails, increase ICS dosage

If step 3 fails then refer to specialist

Question 14

Asthma in Children - Prognosis & Complications

Answer 14

The life expectancy of people with controlled asthma is similar to that for the general population

Asthma is a chronic disease

Complications:
- Moderate/Severe exacerbation = medium chance -> if poorly controlled or if exposed to major trigger
- Airway remodelling = medium chance –> due to persistent inflammation
- Oral candidiasis secondary to use of inhaled corticosteroids = medium chance
- Dysphonia secondary to use of inhaled corticosteroids = medium chance
- Oesophageal candidiasis secondary to use of inhaled = low chance

Question 15

Asthma in Children - Definition & Presentations

Answer 15

Asthma is a chronic respiratory disorder characterised by variable airway inflammation, airway obstruction, and airway hyper-responsiveness in Children under 12 years

Presentations:
- presence of risk factors
- wheezing episode triggers
- increased work of breathing
- features of atopic disease

Other presentations:
- age >3 years
- dry night-time cough
- dyspnoea on exertion
- expiratory wheezing

Question 16

Asthma in Children - Aetiology & Risk Factors

Answer 16

Causes = Genetic and environmental combined

• Allergens
• Viral infections = important role

Early respiratory viral infections increase chance of Asthma in later life

Three categories of wheezing illness have been described in young children:

–> Transient early wheezing (1 or more episodes of lower respiratory tract illness [LRTI] with wheezing in the first 3 years of life, but no wheezing at 6 years of age)

–> Late-onset wheezing (no history of LRTI with wheezing in the first 3 years, but wheezing at 6 years of age)

–> Persistent wheezing (1 or more episodes of LRTI with wheezing in the first 3 years of life, and wheezing at 6 years of age)

Question 17

Asthma in Children - Epidemiology

Answer 17

Paediatric asthma is the most common chronic respiratory disease in the developed world, with the highest prevalence found in English-speaking countries such as the US, the UK, and Australia

Question 18

Asthma in Children - Differentials

Answer 18

1) Bronchiolitis
–> Onset in the first 18 to 24 months
–>Associated with maternal smoking and acute illness

2) Episodic (viral) Wheezing –> Wheeze triggered only by viral infections

3) Inhaled foreign body –> sudden onset of symptoms such as cough, wheeze, or choking is suggestive

4) Recurrent aspiration
–> Hx of vomiting
–> Focal signs of pneumonitis or pneumonia may be present on examination acutely during episodes

5) Cardiac failure
–> Other features of cardiac failure are present (tachycardia, gallop rhythm, or hepatomegaly)

Question 19

Asthma in Children - Investigations

Answer 19

first line:
- Spirometry
- Response to bronchodilator on spirometry –> If Asthma, result expected to be better

consider:
- CXR
- Peak Expiratory Flow Rate
- Airway challenge tests
- Exercise challenge tests
- Sputum culture
- Skin-prick test

Question 20

Asthma in Children - Management

Answer 20

in Children 0-5 years:
first line:
-SABA as needed –> salbutamol inhaled: (100 micrograms/dose metered-dose inhaler) 100-200 micrograms (1-2 puffs) every 4-6 hours when required

• If not working, try low-dose inhaled corticosteroid
• If still not working try medium-dose

in children 6-11 years:
Similar to Adults-
First line:
-SABA as required –> salbutamol inhaled: (100 micrograms/dose metered-dose inhaler) 100-200 micrograms (1-2 puffs) every 4-6 hours when required

-If not working, try Low-dose inhaled corticosteroid
-If not working, try medium dose
-If not working, try medium dose w/ LABA
-If not working, see specialist

Maintaining normal physical activity levels is an important component of adequate asthma control

Children who are obese or overweight should be referred for weight reduction programmes to reduce respiratory symptoms

Question 21

Asthma in Children - Prognosis & Complications

Answer 21

The life expectancy of those with well controlled childhood asthma is equivalent to that of the general population

Asthma that presents in late childhood (7-9) usually continues to adulthood. Asthma is a chronic disease

Complications:
- Airway remodelling = medium
- Asthma exacerbation = low
- Dental caries = low –> Casualty = unknown/unproven
- Right middle lobe syndrome = low
- oropharyngeal candidiasis = low
- Adrenal suppression = low –> effects of corticosteroid therapy

Question 22

Bronchiectasis - Definition & Presentations

Answer 22

Abnormal dilation of bronchi due to the destruction of the elastic and muscular components of the bronchial wall, caused by chronic inflammation.

Chronic inflammation of bronchial wall leads to wall oedema and mucus production

Presentations:
The majority of patients will present with:
- Chronic cough
- Sputum production
- Crackles, high-pitched inspiratory squeaks and rhonchi

Can also present with:
- Fatigue
- Haemoptysis -> Red flag
- Rhinosinusitis
- Weight loss -> Red flag

Question 23

Bronchiectasis - Aetiology & Risk Factors

Answer 23

Bronchiectasis has many different causes

Adults:
- 18% = Post-infectious Resp. disease (childhood measles, influenza.., COVID, Mycobacteria or severe bacterial pneumonia, etc..)
- 15% = COPD
- 7% = Asthma
- 9% = connective tissue disorders (Rheumatoid Arthritis
- Allergy to Aspergillus fumigatus
- Immunodeficiency
- Genetic
- Up to 29% are Idiopathic (Sometimes because cause cannot be identified)

In children, the most common causes of non-cystic fibrosis bronchiectasis are: - - Infection (4% to 36%)
- Asthma (40%)
- Immunodeficiency (10% to 34%)
- Aspiration (4% to 22%)

Risk Factors:

Question 24

Bronchiectasis - Differentials

Answer 24

1) COPD
-> Diminished breath sounds, characterising COPD, are not found in bronchiectasis
-> Chest CT may be normal or show emphysema in COPD, as opposed to the characteristic abnormal results found in bronchiectasis

2) Asthma
-> Inspiratory squeaks and crackles, often present in bronchiectasis, are not present in asthma
-> Chest CT may show thickened airways but lack the enlarged or widened airway seen in bronchiectasis
-> Airflow obstruction is often reversible in asthma

3) Pneumonia
-> Patients with pneumonia describe symptoms of short duration (7 to 10 days), as opposed to years in bronchiectasis
-> Chest sounds may be similar
-> CXR Consolidation, which is seen in pneumonia, is not seen in bronchiectasis

4) Chronic sinusitis
-> The inspiratory squeaks and crackles found in bronchiectasis are uncommon in chronic sinusitis
-> CXR and chest CT are normal in chronic sinusitis

Question 25

Bronchiectasis - Investigations

Answer 25

1) Chest CT -> First line (thickened, dilated airways with or without air fluid levels; varicose constrictions along airways; cysts and/or tree-in-bud pattern)

2) CXR

To find the cause:
3) FBC -> The WBC count will aid in determining the presence of infection or exacerbation
-> High eosinophil = an underlying allergic bronchopulmonary aspergillosis is possible
4) Sputum culture -> Test for bacteria
5) Rheumatoid factor
6) Specific IgE/ skin prick test to Aspergillus fumigatus
7) serum HIV antibody
8) Sweat chloride test -> Check for cystic fibrosis
9) Pulmonary function test

Question 26

Bronchiectasis - Management

Answer 26

Initial Treatment:
1) Advise exercise and improved nutrition -> higher body mass index has been shown to correlate with a beneficial outcome in adults
2) Airway clearance therapy -> maintenance of oral hydration; percussion, breathing, or coughing strategies
3) Inhaled bronchodilator
-> Salbutamol inhaled:
-> children 4-11 years of age: 2.5 to 5 mg, up to four times daily when required
-> adults: 100-200 micrograms (1-2 puffs) up to four times daily when required

Acute exacerbation (due to underlying disease):
1) Antibiotic eradication therapy (if Pseudomonas aeruginosa is underlying cause)
-> amoxicillin: 500-875 mg orally twice daily, or 250-500 mg orally three times daily
-> Treat the cause of the exacerbation
2) Airway clearance to clear mucus, with or without bronchodilators

Ongoing:
1) antibiotic eradication therapy
2) healthy diet and exercise

Question 27

Bronchiectasis - Prognosis & Complications

Answer 27

Bronchiectasis is an irreversible condition in adults.
In children and adolescents, it may be reversible with early detection and effective treatment

Factors associated with a faster decline in lung function include more frequent severe exacerbations

Pseudomonas species in the sputum of patients with bronchiectasis indicates more extensive lung disease and more severe impairment of pulmonary function