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.

Cautionary Measures for β2-Adrenergic Agonist Treatment

β2-adrenergic agonist treatment may lead to potentially serious hypokalaemia, especially in severe asthma cases. This effect can be intensified by theophylline, corticosteroids, diuretics, and hypoxia. Therefore, it is crucial to monitor plasma-potassium concentration in severe asthma patients. People with diabetes should also exercise caution when using β2 agonists, particularly when given intravenously, as it may increase the risk of ketoacidosis. These cautionary measures are necessary to ensure the safe and effective use of β2-adrenergic agonist treatment.

If a patient has a known allergy to a sulfa drug like co-trimoxazole, they should avoid taking sulfasalazine.

Sulfasalazine: A DMARD for Inflammatory Arthritis and Bowel Disease

Sulfasalazine is a type of disease modifying anti-rheumatic drug (DMARD) that is commonly used to manage inflammatory arthritis, particularly rheumatoid arthritis, as well as inflammatory bowel disease. This medication is a prodrug for 5-ASA, which works by reducing neutrophil chemotaxis and suppressing the proliferation of lymphocytes and pro-inflammatory cytokines.

However, caution should be taken when using sulfasalazine in patients with G6PD deficiency or those who are allergic to aspirin or sulphonamides due to the risk of cross-sensitivity. Adverse effects of sulfasalazine may include oligospermia, Stevens-Johnson syndrome, pneumonitis/lung fibrosis, myelosuppression, Heinz body anaemia, megaloblastic anaemia, and the potential to color tears and stain contact lenses.

Despite these potential side effects, sulfasalazine is considered safe to use during pregnancy and breastfeeding, making it a viable option for women who require treatment for inflammatory arthritis or bowel disease.

Pink skin and mucosae are indicative of carbon monoxide poisoning.

Carbon monoxide poisoning occurs when carbon monoxide binds to haemoglobin and myoglobin, leading to tissue hypoxia. Symptoms include headache, nausea, vomiting, vertigo, confusion, and in severe cases, pink skin and mucosae, hyperpyrexia, arrhythmias, extrapyramidal features, coma, and death. Diagnosis is made through measuring carboxyhaemoglobin levels in arterial or venous blood gas. Treatment involves administering 100% high-flow oxygen via a non-rebreather mask for at least six hours, with hyperbaric oxygen therapy considered for more severe cases.

Diagnosis and Treatment of Asthma in Adults

In adults, the diagnosis of asthma can be challenging, especially when there is diagnostic uncertainty or when both asthma and chronic obstructive pulmonary disease (COPD) are present. The British Thoracic Society recommends a 6-8 week treatment trial of inhaled beclomethasone (or equivalent) twice daily for patients with significant airflow obstruction. However, in patients with suspected inhaled corticosteroid resistance, a two-week treatment trial of oral prednisolone 30 mg daily is preferred.

To help identify asthma, clinicians should assess FEV1 (or PEF) and/or symptoms before and after 400mcg inhaled salbutamol. A >400ml improvement in FEV1 to either b2 agonists or corticosteroid treatment strongly suggests underlying asthma. Serial peak flow measurements showing 20% or greater diurnal or day-to-day variability can also be used to help diagnose asthma.

NICE NG115 further clarifies that a large response to bronchodilators or oral prednisolone (over 400 ml) can also help identify asthma. Clinically significant COPD is not present if the FEV1 and FEV1/FVC ratio return to normal with drug therapy. In cases of diagnostic uncertainty, a combination of these findings can be used to help diagnose asthma and guide treatment decisions.

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.

For this patient with pre-existing asthma, an immediate or delayed antibiotic prescription should be considered due to the higher risk of complications. The first-line antibiotic for acute bronchitis is oral doxycycline, unless the patient is pregnant or a child. As this patient has normal observations and no focal respiratory signs, same-day admission is not necessary, and treatment can be provided in the community without intravenous antibiotics or oxygen.

Reassuring the patient and prescribing carbocisteine is not recommended as mucolytics are not effective for managing acute cough caused by acute bronchitis. Administering IM amoxicillin is also not appropriate as doxycycline is the recommended first-choice antibiotic for this condition, and IM is an invasive route that is unnecessary for this patient who can swallow.

Understanding Acute Bronchitis

Acute bronchitis is a chest infection that is typically self-limiting and caused by inflammation of the trachea and major bronchi. This results in swollen airways and the production of sputum. The condition usually resolves within three weeks, but some patients may experience a cough for longer. Viral infections are the leading cause of acute bronchitis, with most cases occurring in the autumn or winter.

Symptoms of acute bronchitis include a sudden onset of cough, sore throat, runny nose, and wheezing. While most patients have a normal chest examination, some may experience a low-grade fever or wheezing. It is important to differentiate acute bronchitis from pneumonia, which may present with sputum, wheezing, and breathlessness.

Acute bronchitis is typically diagnosed based on clinical presentation, but CRP testing may be used to guide antibiotic therapy. Management of acute bronchitis includes analgesia, good fluid intake, and consideration of antibiotic therapy for patients who are systemically unwell, have pre-existing co-morbidities, or have a CRP level indicating the need for antibiotics. Doxycycline is the first-line antibiotic recommended by NICE Clinical Knowledge Summaries/BNF, but it cannot be used in children or pregnant women. Alternatives include amoxicillin.

According to the updated NICE guidelines in 2018, all individuals who are suspected to have chronic heart failure should undergo an NT-proBNP test as the initial diagnostic test, irrespective of their history of myocardial infarction.

Diagnosis of Chronic Heart Failure

Chronic heart failure is a serious condition that requires prompt diagnosis and management. In 2018, the National Institute for Health and Care Excellence (NICE) updated its guidelines on the diagnosis and management of chronic heart failure. According to the new guidelines, all patients should undergo an N-terminal pro-B-type natriuretic peptide (NT‑proBNP) blood test as the first-line investigation, regardless of whether they have previously had a myocardial infarction or not.

Interpreting the NT-proBNP test is crucial in determining the severity of the condition. If the levels are high, specialist assessment, including transthoracic echocardiography, should be arranged within two weeks. If the levels are raised, specialist assessment, including echocardiogram, should be arranged within six weeks.

BNP is a hormone produced mainly by the left ventricular myocardium in response to strain. Very high levels of BNP are associated with a poor prognosis. The table above shows the different levels of BNP and NTproBNP and their corresponding interpretations.

It is important to note that certain factors can alter the BNP level. For instance, left ventricular hypertrophy, ischaemia, tachycardia, and right ventricular overload can increase BNP levels, while diuretics, ACE inhibitors, beta-blockers, angiotensin 2 receptor blockers, and aldosterone antagonists can decrease BNP levels. Therefore, it is crucial to consider these factors when interpreting the NT-proBNP test.

Symptoms of Sleep Apnoea

Sleep apnoea is a condition characterized by hypersomnolence or excessive sleepiness. Apart from this, there are other common symptoms that may be experienced by individuals with this condition. These include apparent personality changes, witnessed apnoeas, and true nocturnal polyuria. Reduced libido is a less common symptom. Sleep apnoea may also be associated with other medical conditions such as acromegaly, myxoedema, obesity, and micrognathia/retrognathia.

If a person has obstructive sleep apnoea (OSA) and is a group 1 driver, they must inform the DVLA if they experience excessive daytime sleepiness (measured by an Epworth score of 11 or higher). However, if the OSA is mild (with an apnoea/hypopnoea index score of 5-15/hour) and doesn’t cause excessive daytime sleepiness, there is no need to notify the DVLA. For those with moderate or severe OSA, the DVLA must be informed and the individual must ensure that their symptoms are under control before driving.

Understanding Obstructive Sleep Apnoea/Hypopnoea Syndrome

Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a condition that causes interrupted breathing during sleep due to a blockage in the airway. This can lead to a range of health problems, including daytime somnolence, respiratory acidosis, and hypertension. There are several predisposing factors for OSAHS, including obesity, macroglossia, large tonsils, and Marfan’s syndrome. Partners of those with OSAHS often complain of excessive snoring and periods of apnoea.

To assess sleepiness, patients may complete the Epworth Sleepiness Scale questionnaire, and undergo the Multiple Sleep Latency Test (MSLT) to measure the time it takes to fall asleep in a dark room. Diagnostic tests for OSAHS include sleep studies (polysomnography), which measure a range of physiological factors such as EEG, respiratory airflow, thoraco-abdominal movement, snoring, and pulse oximetry.

Management of OSAHS includes weight loss and the use of continuous positive airway pressure (CPAP) as a first-line treatment for moderate or severe cases. Intra-oral devices, such as mandibular advancement, may be used if CPAP is not tolerated or for patients with mild OSAHS without daytime sleepiness. It is important to inform the DVLA if OSAHS is causing excessive daytime sleepiness. While there is limited evidence to support the use of pharmacological agents, they may be considered in certain cases.