Managing Chronic Asthma in Adults

When managing chronic asthma in adults, it is important to consider the patient’s current treatment plan and symptoms. In this scenario, the patient is already taking a combination inhaler and is experiencing suboptimal control of her asthma. It is important to note that this is not an acute attack and the children’s guidelines do not apply. Antibiotics are not recommended as the symptoms are not consistent with an infective exacerbation. Increasing the usage of salbutamol is also not recommended as the patient needs better overall control of her symptoms. Instead, the dose of the inhaled corticosteroid should be increased, which is in line with the next step in the treatment of asthma in adults according to the British Thoracic Society guidelines. It is important for healthcare professionals to be familiar with both SIGN and NICE guidance and be able to compare and contrast their advice.

Referral to a respiratory specialist is recommended for patients who are suspected to have occupational asthma.

Occupational Asthma: Causes and Symptoms

Occupational asthma is a type of asthma that is caused by exposure to certain chemicals in the workplace. Patients may experience worsening asthma symptoms while at work or notice an improvement in symptoms when away from work. The most common cause of occupational asthma is exposure to isocyanates, which are found in spray painting and foam moulding using adhesives. Other chemicals associated with occupational asthma include platinum salts, soldering flux resin, glutaraldehyde, flour, epoxy resins, and proteolytic enzymes.

To diagnose occupational asthma, it is recommended to measure peak expiratory flow at work and away from work. If there is a significant difference in peak expiratory flow, referral to a respiratory specialist is necessary. Treatment may include avoiding exposure to the triggering chemicals and using medications to manage asthma symptoms. It is important for employers to provide a safe working environment and for employees to report any concerns about potential exposure to harmful chemicals.

Urgent Referral for Chest X-Ray in Patients with Chronic Respiratory Problems

Unexplained changes in existing symptoms in patients with underlying chronic respiratory problems should prompt an urgent referral for chest x-ray. According to NICE guidelines on the recognition and referral of suspected cancer, an urgent chest x-ray should be offered to assess for lung cancer in people aged 40 and over with specific unexplained symptoms or risk factors.

In patients with known COPD, the recent onset of finger clubbing should not be automatically assumed to be due to the pre-existing lung disease. Finger clubbing can occur in various types of lung cancer and mesothelioma, and it is less common in COPD alone. Therefore, an urgent referral for chest x-ray is necessary to assess for possible underlying malignancy. Early detection and treatment can significantly improve the prognosis and quality of life for patients with lung cancer.

Methotrexate can lead to pulmonary fibrosis, while there is no evidence to suggest that terbinafine, paracetamol, montelukast, and tramadol have this side effect. The onset of pulmonary fibrosis due to low-dose methotrexate use can occur within weeks to months.

Methotrexate is an antimetabolite that hinders the activity of dihydrofolate reductase, an enzyme that is crucial for the synthesis of purines and pyrimidines. It is a significant drug that can effectively control diseases, but its side-effects can be life-threatening. Therefore, careful prescribing and close monitoring are essential. Methotrexate is commonly used to treat inflammatory arthritis, especially rheumatoid arthritis, psoriasis, and acute lymphoblastic leukaemia. However, it can cause adverse effects such as mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis.

Women should avoid pregnancy for at least six months after stopping methotrexate treatment, and men using methotrexate should use effective contraception for at least six months after treatment. Prescribing methotrexate requires familiarity with guidelines relating to its use. It is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose. The starting dose of methotrexate is 7.5 mg weekly, and only one strength of methotrexate tablet should be prescribed.

It is important to avoid prescribing trimethoprim or co-trimoxazole concurrently as it increases the risk of marrow aplasia. High-dose aspirin also increases the risk of methotrexate toxicity due to reduced excretion. In case of methotrexate toxicity, the treatment of choice is folinic acid. Overall, methotrexate is a potent drug that requires careful prescribing and monitoring to ensure its effectiveness and safety.

NICE Recommendations for Prescribing Inhaled Corticosteroids in Asthma Patients

NICE advises prescribing an inhaled corticosteroid in patients with asthma who use an inhaled SABA three times a week or more, experience asthma symptoms three times a week or more, or are woken up by asthma symptoms once a week or more. Additionally, NICE recommends considering an ICS if the patient has had an asthma attack requiring oral corticosteroids in the past two years. These recommendations aim to improve asthma control and reduce the risk of exacerbations. By following these guidelines, healthcare professionals can ensure that their patients receive appropriate treatment for their asthma symptoms.

Management of COPD with Persistent Breathlessness

Patients with COPD who experience persistent breathlessness despite regular SABA use require additional inhaled treatment to improve symptom control and prevent exacerbations. Spirometry results confirming an obstructive picture, frequent exacerbations, and an FEV1 of less than 50% are useful in determining the next step in management.

The two options for add-on inhaled treatment are a LABA+ICS combination inhaler or a LAMA. The choice depends on the presence of asthmatic features, such as a previous diagnosis of asthma or atopy, a higher eosinophil count, substantial variation on FEV1 over time, or a substantial diurnal variation in peak flow. If asthmatic features are present, a LABA & ICS combination inhaler is preferred.

Adding a regular ICS on its own has no role in the COPD treatment ladder, while a regular SAMA can be used instead of a SABA but is not an option for add-in treatment. Adding a LABA may improve symptoms, but the combination of ICS/LABA is more beneficial for patients with a history of frequent exacerbations.

In addition to inhaled treatment, it may be necessary to issue an emergency supply of antibiotics and oral steroids for patients with persistent breathlessness and frequent exacerbations. For more information on managing stable COPD, refer to the NICE Visual Summary guide and NICE NG115 guidelines.

Overall, the management of COPD with persistent breathlessness requires a tailored approach based on individual patient characteristics and the presence of asthmatic features.

Unilateral Wheeze and Poor Asthma Control

All the symptoms of asthma are present, but a peak flow of less than 300 indicates poor control. However, a unilateral wheeze may indicate a foreign body or tumor, especially in children. Therefore, further investigation is necessary to determine the cause of the wheeze.

BTS Guidance on Low Dose ICS and LABA Treatment

According to the 2016 BTS guidance, if a patient taking a low dose ICS doesn’t respond to the addition of a LABA, the LABA should be discontinued. Instead, healthcare providers should consider increasing the dose of ICS. It is important to note that options suggesting only an increase in ICS dose without stopping the LABA are incorrect.

This guidance emphasizes the importance of individualized treatment plans for patients with respiratory conditions. By carefully monitoring patient response to medication and adjusting treatment as needed, healthcare providers can help improve patient outcomes and quality of life. Proper medication management can also help reduce the risk of adverse effects and complications associated with respiratory conditions.

Superior Vena Caval Obstruction (SVCO)

Superior Vena Caval Obstruction (SVCO) is a condition where there is a blockage of blood flow in the superior vena cava. This can be caused by external compression or thrombosis within the vein. The most common cause of SVCO is malignancy, particularly lung cancer and lymphoma. Benign causes include intrathoracic goitre and granulomatous conditions such as sarcoidosis.

The typical features of SVCO include facial and upper body oedema, facial plethora, venous distention, and increased shortness of breath. Other symptoms may include dizziness, syncope, and headache due to pressure effect. This gentleman is an ex-smoker and has a persistent productive cough that has not responded to repeated antibiotic use, which is suspicious of an underlying lung malignancy.

Prompt recognition of SVCO on clinical grounds is crucial, and immediate referral for specialist assessment is necessary. If there is any stridor or laryngeal oedema, SVCO becomes a medical emergency.

If a person with COPD has two measurements of pO2 below 7.3 kPa, they should receive LTOT.

Long-Term Oxygen Therapy for COPD Patients

Long-term oxygen therapy (LTOT) is recommended for patients with chronic obstructive pulmonary disease (COPD) who have severe or very severe airflow obstruction, cyanosis, polycythaemia, peripheral oedema, raised jugular venous pressure, or oxygen saturations less than or equal to 92% on room air. LTOT involves breathing supplementary oxygen for at least 15 hours a day using oxygen concentrators.

To assess patients for LTOT, arterial blood gases are measured on two occasions at least three weeks apart in patients with stable COPD on optimal management. Patients with a pO2 of less than 7.3 kPa or those with a pO2 of 7.3-8 kPa and secondary polycythaemia, peripheral oedema, or pulmonary hypertension should be offered LTOT. However, LTOT should not be offered to people who continue to smoke despite being offered smoking cessation advice and treatment, and referral to specialist stop smoking services.

Before offering LTOT, a structured risk assessment should be carried out to evaluate the risks of falls from tripping over the equipment, the risks of burns and fires, and the increased risk of these for people who live in homes where someone smokes (including e-cigarettes).

Overall, LTOT is an important treatment option for COPD patients with severe or very severe airflow obstruction or other related symptoms.

According to the British Thoracic Society, if a patient experiences peripheral tingling, it is less likely that they have asthma. However, the patient’s smoking history doesn’t rule out asthma as a diagnosis, and given his age, it is highly unlikely that he has COPD.

Asthma diagnosis has been updated by NICE guidelines in 2017, which emphasizes the use of objective tests rather than subjective/clinical judgments. The guidance recommends the use of fractional exhaled nitric oxide (FeNO) test, which measures the level of nitric oxide produced by inflammatory cells, particularly eosinophils. Other established objective tests such as spirometry and peak flow variability are still important. All patients aged five and above should have objective tests to confirm the diagnosis. For patients aged 17 and above, spirometry with a bronchodilator reversibility (BDR) test and FeNO test should be performed. For children aged 5-16, spirometry with a BDR test and FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative BDR test. For patients under five years old, diagnosis should be made based on clinical judgment. The specific points about the tests include a FeNO level of >= 40 ppb for adults and >= 35 ppb for children considered positive, and a FEV1/FVC ratio less than 70% or below the lower limit of normal considered obstructive for spirometry. A positive reversibility test is indicated by an improvement in FEV1 of 12% or more and an increase in volume of 200 ml or more for adults, and an improvement in FEV1 of 12% or more for children.

Diagnostic Thresholds for Asthma Tests

FeNO tests, which measure nitric oxide levels in breath, are used to detect lung inflammation and asthma. The positive test threshold for adults is 40 ppb, while for children and young people it is 35 ppb or more. Obstructive spirometry, which measures FEV1/FVC ratio, has a positive test threshold of less than 70% for all age groups. Peak flow variability, which measures the difference between the highest and lowest peak flow readings, has a positive test threshold of over 20% for all age groups. While a peak flow variability of 50% is indicative of asthma, a threshold of 20% is used for diagnosis. It is important to note that some GP practices may not have access to FeNO testing equipment, which is a relatively new development in asthma diagnosis. Familiarizing oneself with these diagnostic thresholds is crucial in the context of NICE guidance, as the RCGP may test changes to guidance.

If a patient with COPD continues to smoke, it is not advisable to provide them with azithromycin prophylaxis. Instead, they should be offered smoking cessation. The use of high-dose inhaled corticosteroids is no longer recommended due to the increased risk of infections such as pneumonia. Long-term oral corticosteroids should only be used at low doses and on the advice of the respiratory team. Beta-carotene supplements are not recommended for the management of COPD due to limited evidence of their effectiveness.

The National Institute for Health and Care Excellence (NICE) updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. The guidelines recommend general management strategies such as smoking cessation advice, annual influenza vaccination, and one-off pneumococcal vaccination. Pulmonary rehabilitation is also recommended for patients who view themselves as functionally disabled by COPD.

Bronchodilator therapy is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators. The next step is determined by whether the patient has asthmatic features or features suggesting steroid responsiveness. NICE suggests several criteria to determine this, including a previous diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time, and substantial diurnal variation in peak expiratory flow.

If the patient doesn’t have asthmatic features or features suggesting steroid responsiveness, a long-acting beta2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) should be added. If the patient is already taking a short-acting muscarinic antagonist (SAMA), it should be discontinued and switched to a short-acting beta2-agonist (SABA). If the patient has asthmatic features or features suggesting steroid responsiveness, a LABA and inhaled corticosteroid (ICS) should be added. If the patient remains breathless or has exacerbations, triple therapy (LAMA + LABA + ICS) should be offered.

NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients who have optimised standard treatments and continue to have exacerbations. Mucolytics should be considered in patients with a chronic productive cough and continued if symptoms improve.

Cor pulmonale features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, and loud P2. Loop diuretics should be used for oedema, and long-term oxygen therapy should be considered. Smoking cessation, long-term oxygen therapy in eligible patients, and lung volume reduction surgery in selected patients may improve survival in patients with stable COPD. NICE doesn’t recommend the use of ACE-inhibitors, calcium channel blockers, or alpha blockers

Management of Moderate COPD

Patients with an FEV1/FVC ratio <0.70 and an FEV1 of 50-79% predicted are classified as having stage 2 moderate COPD. The initial management for such patients would be a short acting beta agonist or a short acting muscarinic antagonist. However, if symptoms persist, NICE recommends the use of a long acting beta agonist plus a long acting muscarinic antagonist. In cases where a long acting muscarinic antagonist is given, the short acting muscarinic antagonist should be stopped.

Inhaled corticosteroids alone are not recommended for moderate COPD. Instead, they should be used in combination with a long acting beta agonist as a second line treatment for patients with an FEV1 < 50%. Maintenance use of oral corticosteroid therapy in COPD is not normally recommended. Antitussive therapy is also not recommended.

The patient’s peak flow has dropped to 40% of normal, indicating a severe exacerbation of asthma. According to NICE guidelines, admission is recommended if severe attack features persist after a bronchodilator trial. As the peak flow has not improved, hospitalization is necessary.

Administering another nebulizer is not advisable as the patient requires close monitoring and may need multiple nebulizers. Increasing the inhaled steroid dose and sending the patient home is also not recommended as it may lead to adverse outcomes.

Prescribing 40 mg prednisolone for 5 to 7 days is suitable for patients who can be treated at home, but not for this patient with severe asthma requiring inpatient assessment and management.

Antibiotics are only prescribed if the patient has no severe or life-threatening asthma features and shows signs of infection. As the patient’s asthma has not improved despite initial treatment, sending them home with antibiotics is not appropriate.

Understanding Acute Asthma: Symptoms and Severity

Acute asthma is a condition that is typically observed in individuals who have a history of asthma. It is characterized by worsening dyspnea, wheezing, and coughing that doesn’t respond to salbutamol. Acute asthma attacks may be triggered by respiratory tract infections. Patients with acute severe asthma are classified into three categories: moderate, severe, or life-threatening.

Moderate acute asthma is characterized by a peak expiratory flow rate (PEFR) of 50-75% of the best or predicted value, normal speech, a respiratory rate (RR) of less than 25 breaths per minute, and a pulse rate of less than 110 beats per minute. Severe acute asthma is characterized by a PEFR of 33-50% of the best or predicted value, inability to complete sentences, an RR of more than 25 breaths per minute, and a pulse rate of more than 110 beats per minute. Life-threatening acute asthma is characterized by a PEFR of less than 33% of the best or predicted value, oxygen saturation levels of less than 92%, a silent chest, cyanosis or feeble respiratory effort, bradycardia, dysrhythmia or hypotension, and exhaustion, confusion, or coma.

It is important to note that a normal pCO2 in an acute asthma attack indicates exhaustion and should be classified as life-threatening. Understanding the symptoms and severity of acute asthma can help healthcare professionals provide appropriate treatment and management for patients experiencing an acute asthma attack.

Identifying the Correct Diagnosis for Breathlessness

A variety of conditions can cause breathlessness, making it difficult to arrive at a correct diagnosis. For instance, someone with shortness of breath and bibasal crepitations may be misdiagnosed with heart failure. However, a normal ECG and BNP can rule out cardiac failure.

To identify the correct diagnosis, a thorough clinical examination is necessary. In this case, the presence of finger clubbing narrows the options down to bronchiectasis, carcinoma, and pulmonary fibrosis. The additional features of cyanosis and bibasal fine crepitations strongly suggest that pulmonary fibrosis is the underlying diagnosis.

By carefully considering all the symptoms and conducting a comprehensive examination, healthcare professionals can accurately diagnose and treat patients with breathlessness.

Adding an inhaled long-acting beta-2 agonist (LABA) would not be the appropriate course of action at this time. It should only be considered as an add-on therapy if the patient’s asthma remains uncontrolled despite regular use of inhaled corticosteroids.

Similarly, adding a leukotriene receptor antagonist (LTRA) would not be recommended at this stage. It should only be considered if the patient’s asthma remains uncontrolled despite using a combination of LABA and ICS, or if low-dose ICS is insufficient.

Doubling the dose of beclomethasone dipropionate would also not be the correct approach. This would result in a medium dose of ICS, which is only recommended if the patient remains symptomatic despite a combination of low-dose ICS and LABA. Alternatively, an LTRA may be added.

Stopping beclomethasone dipropionate and relying solely on salbutamol as needed would not be advisable. Any reduction in ICS should be done gradually to minimize the risk of worsening symptoms.

Stepping Down Asthma Treatment: BTS Guidelines

The British Thoracic Society (BTS) recommends that asthma treatment should be reviewed every three months to consider stepping down treatment. However, the guidelines do not suggest a strict move from one step to another but rather advise taking into account the duration of treatment, side-effects, and patient preference. When reducing the dose of inhaled steroids, the BTS suggests doing so by 25-50% at a time.

Patients with stable asthma may only require a formal review once a year. However, if a patient has recently had an escalation of asthma treatment, they are likely to be reviewed more frequently. It is important to follow the BTS guidelines to ensure that patients receive the appropriate level of treatment for their asthma and to avoid unnecessary side-effects.

It is recommended that individuals who are suspected to have asthma undergo both FeNO testing and spirometry with reversibility.

Asthma diagnosis has been updated by NICE guidelines in 2017, which emphasizes the use of objective tests rather than subjective/clinical judgments. The guidance recommends the use of fractional exhaled nitric oxide (FeNO) test, which measures the level of nitric oxide produced by inflammatory cells, particularly eosinophils. Other established objective tests such as spirometry and peak flow variability are still important. All patients aged five and above should have objective tests to confirm the diagnosis. For patients aged 17 and above, spirometry with a bronchodilator reversibility (BDR) test and FeNO test should be performed. For children aged 5-16, spirometry with a BDR test and FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative BDR test. For patients under five years old, diagnosis should be made based on clinical judgment. The specific points about the tests include a FeNO level of >= 40 ppb for adults and >= 35 ppb for children considered positive, and a FEV1/FVC ratio less than 70% or below the lower limit of normal considered obstructive for spirometry. A positive reversibility test is indicated by an improvement in FEV1 of 12% or more and an increase in volume of 200 ml or more for adults, and an improvement in FEV1 of 12% or more for children.

Allergic Reactions and MSG Syndrome in Chinese Cuisine

Chinese cuisine is known for its use of cashew nuts and peanut oil in many dishes, which can pose a risk for patients with peanut allergies. Anaphylactic reactions may occur with cashew nuts, while peanut oil can also trigger allergic reactions. Additionally, monosodium glutamate (MSG), a common flavor enhancer in Chinese food, can cause the MSG syndrome. Symptoms of this syndrome include sudden onset headache, heartburn, palpitations, sweating, swelling, and flushing of the face. Tingling or increased facial pressure may also be reported. While the condition is generally self-limited and resolves on its own, antihistamines may be helpful in some cases. It is important to note that the MSG syndrome is unlikely to cause shock, which is not consistent with the patient’s presentation of hypotension.

Effective Treatment for Acute Asthma

When it comes to treating acute asthma, steroid tablets and injected steroids are equally effective. A dose of oral prednisolone of 40-50 mg per day for at least five days or intravenous hydrocortisone 400 mg can be used. It is important to continue taking prednisolone until recovery, which should be a minimum of five days. Additionally, it is important to not stop inhaled corticosteroids during the prescription of oral corticosteroids. By following these key points, patients can effectively manage their acute asthma symptoms.

Asthma Assessment and Management in Primary Care

Asthma is a chronic respiratory condition that affects millions of people worldwide. In primary care, patients with acute asthma are stratified into moderate, severe, or life-threatening categories based on their symptoms. For moderate asthma, treatment involves the use of beta 2 agonists such as salbutamol, either nebulized or via a spacer. If the patient’s peak expiratory flow rate (PEFR) is between 50-75%, prednisolone 40-50 mg may also be prescribed.

For severe asthma, admission may be necessary, and oxygen should be given to hypoxemic patients to maintain a SpO2 of 94-98%. Beta 2 agonists such as salbutamol, either nebulized or via a spacer, and prednisolone 40-50 mg should also be administered. If there is no response to treatment, admission is recommended.

In life-threatening asthma cases, immediate admission should be arranged through a 999 call. Oxygen should be given to hypoxemic patients to maintain a SpO2 of 94-98%, and nebulized beta 2 agonists (e.g. Salbutamol) + ipratropium should be administered. Prednisolone 40-50 mg or IV hydrocortisone 100 mg may also be prescribed.

In summary, the management of asthma in primary care involves stratifying patients based on their symptoms and administering appropriate treatment based on their category. It is important to closely monitor patients and adjust treatment as necessary to prevent exacerbations and improve their quality of life.

Contraindications of Bupropion and Varenicline

Bupropion and Varenicline are two drugs commonly used for smoking cessation. However, they both have specific contraindications that need to be considered before prescribing them to patients.

Bupropion is contraindicated in patients with a history of eating disorders, seizures, central nervous system tumors, and acute alcohol or benzodiazepine withdrawal. Additionally, certain factors can increase the risk of seizures in patients taking Bupropion, such as the use of medications that lower the seizure threshold, diabetes, alcoholism, history of cranial trauma, and use of stimulants and anorectics.

On the other hand, Varenicline is listed as a caution rather than a contraindication in patients with a history of mental health problems. While patients with psychiatric illnesses should be closely monitored while taking Varenicline, it is not specifically contraindicated in this population.

In summary, when considering the contraindications of Bupropion and Varenicline, it is important to note that Bupropion is specifically contraindicated in patients with a history of eating disorders, while Varenicline is cautioned in patients with a history of mental health problems.

NICE Guidelines for Referral of Suspected Lung Cancer Patients

The National Institute for Health and Care Excellence (NICE) has issued guidelines for the recognition and referral of suspected lung cancer patients. According to the guidelines, patients aged 40 and over with unexplained haemoptysis should be referred urgently for an appointment within two weeks, even if their chest x-ray is normal. Additionally, patients with two or more unexplained symptoms such as cough, fatigue, shortness of breath, chest pain, weight loss, or appetite loss, or those with persistent or recurrent chest infection, finger clubbing, supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, chest signs consistent with lung cancer, or thrombocytosis should be offered an urgent chest x-ray within two weeks to assess for lung cancer. These guidelines aim to ensure timely diagnosis and treatment of lung cancer, which is crucial for improving patient outcomes.

Patients who have been diagnosed with anaphylaxis should be referred to a specialist allergy clinic for proper management. In the case of this boy, specialist input and education for his caregivers and school may be necessary. Prescribing a 300 microgram adrenaline injector is not recommended as it is the incorrect dose for his age. Instead, he should be given two 150 microgram adrenaline injectors with appropriate training provided. Referral for patch testing may not be sufficient as more rigorous follow-up is needed after anaphylaxis. Regular antihistamines may be necessary if ongoing symptoms such as urticaria are present, but this is not indicated in the question.

Anaphylaxis is a severe and potentially life-threatening allergic reaction that affects the entire body. It can be caused by various triggers, including food, drugs, and insect venom. The symptoms of anaphylaxis typically develop suddenly and progress rapidly, affecting the airway, breathing, and circulation. Swelling of the throat and tongue, hoarse voice, and stridor are common airway problems, while respiratory wheeze and dyspnea are common breathing problems. Hypotension and tachycardia are common circulation problems. Skin and mucosal changes, such as generalized pruritus and widespread erythematous or urticarial rash, are also present in around 80-90% of patients.

The most important drug in the management of anaphylaxis is intramuscular adrenaline, which should be administered as soon as possible. The recommended doses of adrenaline vary depending on the patient’s age, with the highest dose being 500 micrograms for adults and children over 12 years old. Adrenaline can be repeated every 5 minutes if necessary. If the patient’s respiratory and/or cardiovascular problems persist despite two doses of IM adrenaline, IV fluids should be given for shock, and expert help should be sought for consideration of an IV adrenaline infusion.

Following stabilisation, non-sedating oral antihistamines may be given to patients with persisting skin symptoms. Patients with a new diagnosis of anaphylaxis should be referred to a specialist allergy clinic, and an adrenaline injector should be given as an interim measure before the specialist allergy assessment. Patients should be prescribed two adrenaline auto-injectors, and training should be provided on how to use them. A risk-stratified approach to discharge should be taken, as biphasic reactions can occur in up to 20% of patients. The Resus Council UK recommends a fast-track discharge for patients who have had a good response to a single dose of adrenaline and have been given an adrenaline auto-injector and trained how to use it. Patients who require two doses of IM adrenaline or have had a previous biphasic reaction should be observed for a minimum of 6 hours after symptom resolution, while those who have had a severe reaction requiring more than two doses of IM adrenaline or have severe asthma should be observed for a minimum of 12 hours after symptom resolution. Patients who present late at night or in areas where access to emergency care may be difficult should also be observed for a minimum of 12

Importance of Thorough Respiratory Examination in Lung Cancer Diagnosis

Pleural effusion and slowly resolving consolidation may indicate lung cancer, requiring urgent referral to a respiratory physician under the two week wait criteria. However, a comprehensive examination is necessary to avoid missing an effusion. Simply auscultating the chest is insufficient. A thorough respiratory examination, including noting any deviation of the trachea, percussion note, and tactile vocal fremitus, can provide important clues and need not significantly prolong the examination time. Failure to perform a thorough examination or investigation of malignancy is a contributing factor to delay in cancer diagnosis, according to the NPSA. In this case, the patient’s smoking history and slow-to-resolve consolidation further support the need for urgent referral and detailed imaging to reveal any underlying cause.

It is important to note that a patient’s decision to continue smoking should not be a reason to deny them treatment for their asthma. As a healthcare professional, it is your responsibility to bring this to the attention of the doctor involved and discuss the situation with them. This will also give the doctor an opportunity to explain their perspective on the matter. It is not recommended to bring this up during a practice meeting as it may come across as confrontational.

Simply changing the patient’s inhaler treatment will not address the issue of treatment being withheld. It is not acceptable to refuse to adjust their inhalers until they agree to seek smoking cessation treatment, as this can be seen as blackmail. Additionally, removing the patient from the practice list for not quitting smoking is not an appropriate course of action.

Cognitive Therapy and Breathing Exercises for Hyperventilation Syndrome

Two studies have shown that cognitive therapy and breathing exercises can effectively treat hyperventilation syndrome. This condition often leads to pleuritic chest pain without any apparent cause. During therapy sessions, specific anxiety triggers can be identified and addressed. However, for those with chronic hyperventilation syndrome, cognitive therapy and breathing exercises can provide relief and improve overall quality of life. With these treatments, patients can learn to control their breathing and reduce symptoms of hyperventilation syndrome.

Understanding Inhaled Corticosteroids: Uses, Benefits, and Side Effects

Inhaled corticosteroids are commonly used to manage reversible and irreversible airways disease. They can also help distinguish between asthma and chronic obstructive pulmonary disease (COPD) when used for 3-4 weeks. If there is clear improvement over this period, it suggests asthma. In COPD, inhaled corticosteroids can reduce exacerbations when combined with an inhaled long-acting beta2 agonist. However, it’s important to use corticosteroid inhalers regularly for maximum benefit, and improvement of symptoms usually occurs within 3-7 days.

While inhaled corticosteroids are generally safe, high doses used for prolonged periods can induce adrenal suppression. However, in children, growth restriction associated with systemic corticosteroid therapy and high dose inhaled corticosteroids doesn’t seem to occur with recommended doses. Although initial growth velocity may be reduced, there appears to be no effect on achieving normal adult height. The most common side-effects are hoarseness, throat irritation, and candidiasis of the mouth or throat. Candidiasis can be reduced by using a spacer device and rinsing the mouth with water or cleaning a child’s teeth after taking a dose. Paradoxical bronchospasm is a rare occurrence.

In summary, inhaled corticosteroids are a valuable tool in managing airways disease, but it’s important to use them as directed and be aware of potential side-effects. With proper use, they can provide significant relief and improve quality of life for those with asthma and COPD.

Management of Acute Asthma Symptoms

Several important points should be considered when managing a patient with acute asthma symptoms. Firstly, it is important to note if the patient is already taking preventative treatment for asthma. If they are, an increase in the use of their salbutamol inhaler may indicate that their symptoms are worse than usual. Secondly, recent viral infections can trigger asthma symptoms. Additionally, the absence of discoloured thick phlegm and fever makes it less likely that the patient has a bacterial infection and therefore doesn’t require antibiotic therapy.

When managing acute asthma symptoms, it is important to note that changing inhalers may not be appropriate at this stage. Oxygen therapy is not necessary if the patient’s oxygen saturations are above 94% in air. A nebuliser may not be indicated if the patient’s breathing rate is not compromised and they are clinically stable. It may be beneficial to initially try a salbutamol inhaler before ipratropium bromide. These considerations can help guide the management of acute asthma symptoms.

Supraclavicular Lymph Node Enlargement and Malignancy

The right supraclavicular lymph node drains the mid-section of the chest, oesophagus, and lungs. An enlarged and fixed node in this area can indicate malignancy, with the lungs being a common primary site. While glandular fever is a possibility, it is less common in this age group, and the patient is presenting with several alarm symptoms.

Empirically treating with antibiotics is not recommended, as there are no signs of an infected sebaceous cyst, the patient is not feverish, and there is no identified focus for infection. According to NICE guidance, patients with cervical or supraclavicular lymphadenopathy should undergo an urgent chest x-ray.

The NPSA’s thematic review of delayed cancer diagnosis found that 23% of lung cancer cases had diagnostic delays, although not all of these were directly attributable to general practitioners’ actions. Therefore, it is crucial to investigate any supraclavicular lymph node enlargement promptly to rule out malignancy and ensure timely treatment.