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

Mycoplasma Infection and Treatment

The history of epidemic pneumonia, slow onset of symptoms, and erythema multiforme suggest the possibility of mycoplasma infection. In mycoplasma, the appearance on CXR is often worse than clinical examination, and the presence of cold agglutins or rising mycoplasma serology can confirm the diagnosis. Treatment with clarithromycin or erythromycin for 7-14 days is recommended, with doxycycline as an alternative and quinolones as an option.

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.

Understanding Pulmonary Function Tests

Pulmonary function tests are a useful tool in determining whether a respiratory disease is obstructive or restrictive. These tests measure various aspects of lung function, such as forced expiratory volume in one second (FEV1) and forced vital capacity (FVC). By analyzing the results of these tests, doctors can diagnose and monitor conditions such as asthma, COPD, pulmonary fibrosis, and neuromuscular disorders.

In obstructive lung diseases, such as asthma and COPD, the FEV1 is significantly reduced, while the FVC may be reduced or normal. The FEV1% (FEV1/FVC) is also reduced. On the other hand, in restrictive lung diseases, such as pulmonary fibrosis and asbestosis, the FEV1 is reduced, but the FVC is significantly reduced. The FEV1% (FEV1/FVC) may be normal or increased.

It is important to note that there are many conditions that can affect lung function, and pulmonary function tests are just one tool in diagnosing and managing respiratory diseases. However, understanding the results of these tests can provide valuable information for both patients and healthcare providers.

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.

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

Sjogren’s Syndrome: A Multi-System Diagnosis

This patient’s chest symptoms, along with systemic symptoms and dry eyes and mouth, suggest a possible multi-system diagnosis. Sjogren’s syndrome is a condition that should be considered, especially if the patient is a woman in her 5th or 6th decade. Men and younger people can also be affected.

Sjogren’s syndrome is characterized by various symptoms, including pulmonary fibrosis, sicca symptoms (dry eyes and mouth), Raynaud’s phenomenon, and arthralgia. Anti-Ro and anti-La antibodies are useful diagnostic tools in identifying this condition.

It is important to recognize the potential for a multi-system diagnosis in patients presenting with a combination of symptoms. In this case, Sjogren’s syndrome should be considered and appropriate testing should be performed to confirm the diagnosis.

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.

Common Pediatric Respiratory Issues and Diagnostic Considerations

Abnormal cry and stridor are indicative of potential laryngeal issues in children. When assessing for asthma, it is important to note that it is predominantly extrinsic in nature. During acute asthma episodes, relying on peak expiratory flow rate (PEFR) may be unreliable due to poor technique. It is important to consider alternative diagnoses when a child presents with failure to thrive and clubbing, as these symptoms may suggest underlying health issues beyond respiratory concerns. By keeping these diagnostic considerations in mind, healthcare providers can more effectively identify and treat common pediatric respiratory issues.

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.

Understanding Tachycardia and Bradycardia in Acute Asthma

Tachycardia is a common symptom in acute asthma, but severe attacks may also lead to episodes of bradycardia. A peak flow measurement of only 30% of predicted indicates severe airway obstruction and requires immediate admission and aggressive treatment. While oximetry is useful for assessing oxygenation, it cannot provide information on CO2 retention or acid-base status. Therefore, high-flow oxygen should always be administered in the management of acute asthma.

Understanding the symptoms and measurements associated with acute asthma is crucial for effective management. Tachycardia and bradycardia are two possible heart rate changes that may occur during an asthma attack. Additionally, a peak flow measurement of 30% or less of predicted indicates severe airway obstruction and requires prompt medical attention. While oximetry is useful for assessing oxygenation, it cannot provide a complete picture of the patient’s respiratory status. Therefore, high-flow oxygen should always be given to patients with acute asthma.

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.

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.

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.

Therapies for Smoking Cessation

There are various therapies available for smoking cessation, including newer drugs that have been specifically developed for this purpose. One such drug is Varenicline, which is a non-nicotine drug that acts as a partial agonist of the alpha-4 beta-2 nicotinic receptor.

Nicotine is a stimulant that releases dopamine in the brain, leading to addictive effects of smoking. However, nicotine replacement therapy can help replace these effects and reduce addiction to cigarette smoking. Bupropion (Zyban) is another drug that reduces the neuronal uptake of dopamine, serotonin, and norepinephrine.

Clonidine is a second-line agent due to its side effects, but it is an a2-noradrenergic agonist that suppresses sympathetic activity. Nortriptyline, a tricyclic antidepressant with mostly noradrenergic properties, is also an effective agent for smoking cessation.

Overall, there are many options available for those looking to quit smoking, and it is important to work with a healthcare provider to determine the best approach for each individual.

Most Likely Cause of Bronchospasm in a Patient with Asthma

Examiners often use terms like most likely to test a candidate’s ability to reason. In primary care, where there may be multiple causes, prioritizing treatment options is crucial. In a patient with a history of asthma experiencing bronchospasm, propranolol is the most likely cause, and its use should be avoided. While bronchospasm is reported in aspirin-sensitive patients and paradoxical bronchospasm in some patients treated with salmeterol, beta-blockers like propranolol can precipitate bronchospasm and should be avoided in patients with asthma.

According to the British National Formulary, beta-blockers should be avoided in patients with a history of asthma. However, in some cases, a cardioselective beta-blocker may be necessary for a co-existing condition like heart failure or following a myocardial infarction. In such situations, a specialist should initiate treatment with a low dose of a cardioselective beta-blocker like atenolol, bisoprolol fumarate, metoprolol tartrate, nebivolol, or acebutolol. These drugs have a lesser effect on airways resistance but are not free of this side-effect.

ACE inhibitors like ramipril are inhibitors of the metabolism of bradykinin and can cause cough. Bronchospasm is also reported as an adverse event associated with ACE inhibition, although it is very rare.

Cough Characteristics and Associated Conditions

A bovine cough, resembling the sound of cattle, is often heard in cases of recurrent laryngeal nerve palsy, which is commonly caused by lung cancer. Bronchiectasis, on the other hand, is characterized by the production of large amounts of purulent sputum. In women, chronic cough without airways disease is more common, and reflux is often the underlying cause. In cases of chronic obstructive pulmonary disease (COPD), a productive cough is typical, but it may become non-productive in the end stages of the disease. These distinct cough characteristics can provide valuable clues in diagnosing and managing various respiratory conditions.

Spirometry and Management of COPD

In spirometry, a ratio of FEV1/FVC less than 0.7 indicates the presence of chronic obstructive pulmonary disease (COPD). A diagnosis of stage 3 (severe) COPD is made when FEV1 is between 30-49% predicted. Smoking cessation is crucial in managing COPD. If a person prescribed with a short-acting beta-2 agonist (SABA) or short-acting muscarinic antagonist (SAMA) remains breathless or experiences exacerbations, a long-acting beta-2 agonist (LABA) or long-acting muscarinic antagonist (LAMA) should be offered. It is recommended to discontinue treatment with a SAMA if prescribing a LAMA. A regular LAMA is preferred over a regular SAMA four times daily. It is important to note that this approach differs from the PCRS approach, which categorizes treatment based on phenotypic groups for patients with predominant breathlessness, exacerbations, or COPD with asthma.

Initial Management for COPD

The most appropriate initial management for COPD would be a short acting beta agonist or a short acting muscarinic antagonist. According to the Guidelines in Practice summary, a LAMA+LABA combination should be offered to people with spirometrically confirmed COPD who do not have asthmatic features or steroid responsiveness and remain breathless or have exacerbations despite other treatments. LABA+ICS should be considered for those with asthmatic features or steroid responsiveness. Antitussive therapy is not recommended, but a mucolytic can be considered for those with a chronic productive cough. In this breathless patient, a short acting muscarinic antagonist is the better choice. By optimizing non-pharmacological management and relevant vaccinations, patients can improve their symptoms and quality of life.

Understanding Acute Opioid Toxicity

Acute opioid toxicity is a serious condition that can result in drowsiness, nausea, vomiting, and respiratory depression. The severity of symptoms may be exacerbated if alcohol or other sedatives are also involved. Hypotension is a common occurrence, and both tachycardia and bradycardia may be observed. Hypoventilation can lead to hypoxia-induced cardiac arrhythmias, and pinpoint pupils may be present. Sweating is more commonly associated with acute opioid withdrawal. It is important to seek medical attention immediately if you suspect acute opioid toxicity.

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.

Pertussis: Symptoms and Complications

Pertussis, also known as whooping cough, is a respiratory condition that can manifest at any time. Patients with pertussis experience paroxysms of coughing during waking hours, but unlike many respiratory conditions, sleep is usually undisturbed. An inspiratory whoop may not be present, and complete apnoea may occur. A useful feature in the history taking is that patients typically do not experience disturbed sleep. Additionally, there is typically a lymphocytosis present.

It is important to note that asthma in the mother is not a contraindication for pertussis. However, complications can arise from the disease, such as hemiplegia and convulsions.

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.

To ensure proper drug delivery, it is important to use the correct inhaler technique. This involves removing the cap, shaking the inhaler, and taking a slow breath in while delivering the dose. After holding the breath for 10 seconds, it is recommended to wait for approximately 30 seconds before repeating the dose. In this case, the individual should have waited for the full 30 seconds before taking a second dose.

Proper Inhaler Technique for Metered-Dose Inhalers

Metered-dose inhalers are commonly used to treat respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD). However, it is important to use them correctly to ensure that the medication is delivered effectively to the lungs. Here is a step-by-step guide to proper inhaler technique:

1. Remove the cap and shake the inhaler.

2. Breathe out gently.

3. Place the mouthpiece in your mouth and begin to breathe in slowly and deeply.

4. As you start to inhale, press down on the canister to release the medication. Continue to inhale steadily and deeply.

5. Hold your breath for 10 seconds, or as long as is comfortable.

6. If a second dose is needed, wait approximately 30 seconds before repeating steps 1-5.

It is important to note that inhalers should only be used for the number of doses specified on the label. Once the inhaler is empty, a new one should be started. By following these steps, patients can ensure that they are using their inhaler correctly and receiving the full benefits of their medication.

Calculating the Wells Score for Pulmonary Embolism

To determine the likelihood of a patient having a pulmonary embolism (PE), healthcare professionals use the Wells score. This score is calculated based on several factors, including clinical examination consistent with deep vein thrombosis, pulse rate, immobilization or recent surgery, past medical history, haemoptysis, cancer, and the likelihood of an alternative diagnosis.

If the two-level Wells score is more than 4 points, hospital admission should be arranged for an immediate computed tomography pulmonary angiogram. If the score is 4 or lower, a D-dimer blood test should be arranged. A negative result may indicate an alternative diagnosis, while a positive result should be managed the same way as a two-level Wells score of more than 4.

It is important to note that HASBLED and CHADS2VASC scoring are used in the management of patients with atrial fibrillation, not pulmonary embolism. By using the Wells score, healthcare professionals can quickly and accurately determine the likelihood of a patient having a PE and provide appropriate treatment.

Referral to secondary care for consideration of prophylactic antibiotic treatment is the recommended option for COPD patients who meet certain criteria and continue to have exacerbations. NICE suggests considering prophylactic oral macrolide therapy, such as azithromycin, for individuals who have had more than three exacerbations requiring steroid therapy and at least one exacerbation requiring hospital admission in the previous year.

Referral to secondary care for consideration of nebulisers is not appropriate for this patient as they are not experiencing distressing or disabling breathlessness despite maximal therapy using inhalers.

Referral to secondary care for consideration of phosphodiesterase-4 inhibitors is not applicable for this patient as they do not have severe disease with persistent symptoms and exacerbations despite optimal inhaled and pharmacological therapy.

Starting the patient on long term corticosteroids is not recommended in primary care and requires referral to a respiratory specialist.

Starting the patient on oral mucolytic therapy is not necessary as they do not have a chronic cough productive of sputum.

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

Causes of Clubbing and Mesothelioma as a Differential Diagnosis

Clubbing can be caused by respiratory, gastroenterological, and cardiac conditions. Respiratory causes include cystic fibrosis, bronchiectasis, lung carcinoma, fibrosis, and mesothelioma. Gastroenterological causes include lymphoma, inflammatory bowel disease, and cirrhosis. Cardiac causes include cyanotic heart disease, atrial myxoma, and bacterial endocarditis.

In this case, the patient presents with clubbing and respiratory symptoms, making it difficult to determine the exact cause. However, the patient’s occupational history as a dock worker puts them at risk for mesothelioma, a type of cancer caused by exposure to asbestos. Mesothelioma is more likely than other options due to the patient’s age, clinical and chest x-ray findings of pleural thickening and effusion. It is important to consider mesothelioma as a differential diagnosis in patients with clubbing and a history of asbestos exposure.

As per the NICE 2017 guidelines, if a patient with asthma is not effectively managed with a SABA + ICS, their treatment plan should include the addition of a LTRA instead of a LABA. In this case, since the patient is already taking a short-acting beta-agonist and a low-dose inhaled corticosteroid, the recommended course of action would be to offer them an oral leukotriene receptor antagonist. This is in contrast to the previous BTS guidance which would have suggested the use of a long-acting beta-agonist in such a scenario.

The management of asthma in adults has been updated by NICE in 2017, following the 2016 British Thoracic Society (BTS) guidelines. One of the significant changes is in ‘step 3’, where patients on a SABA + ICS whose asthma is not well controlled should be offered a leukotriene receptor antagonist, not a LABA. NICE doesn’t follow the stepwise approach of the previous BTS guidelines, but to make the guidelines easier to follow, we have added our own steps. It should be noted that NICE doesn’t recommend changing treatment in patients who have well-controlled asthma simply to adhere to the latest guidance.

The steps for managing asthma in adults are as follows: for newly-diagnosed asthma, a short-acting beta agonist (SABA) is recommended. If the patient is not controlled on the previous step or has symptoms >= 3/week or night-time waking, a SABA + low-dose inhaled corticosteroid (ICS) is recommended. For step 3, a SABA + low-dose ICS + leukotriene receptor antagonist (LTRA) is recommended. Step 4 involves a SABA + low-dose ICS + long-acting beta agonist (LABA), and LTRA should be continued depending on the patient’s response. Step 5 involves a SABA +/- LTRA, and switching ICS/LABA for a maintenance and reliever therapy (MART) that includes a low-dose ICS. Step 6 involves a SABA +/- LTRA + medium-dose ICS MART, or changing back to a fixed-dose of a moderate-dose ICS and a separate LABA. Step 7 involves a SABA +/- LTRA + one of the following options: increasing ICS to high-dose (only as part of a fixed-dose regime, not as a MART), a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline), or seeking advice from a healthcare professional with expertise in asthma.

It is important to note that the definitions of what constitutes a low, moderate, or high-dose ICS have changed. For adults, <= 400 micrograms budesonide or equivalent is considered a low dose, 400 micrograms - 800 micrograms budesonide or equivalent is a moderate dose, and > 800 micrograms budes

Superior Vena Cava Obstruction (SVCO)

Superior Vena Cava Obstruction (SVCO) is a condition where there is an obstruction of blood flow in the superior vena cava. This can be caused by external venous compression due to a tumour, enlarged lymph nodes, or other enlarged mediastinal structures. 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/upper body oedema, facial plethora, venous distention, and increased shortness of breath. Impaired venous return can cause symptoms of dizziness and even result in syncopal attacks. Headache due to pressure effect is also seen.

Prompt recognition of SVCO on clinical grounds and immediate referral for specialist assessment is crucial. The presence of any stridor or laryngeal oedema makes SVCO a medical emergency. Treatment typically involves steroids and radiotherapy, with chemotherapy and stent insertion being indicated in some cases.

Post-Exposure Immunisation for Pertussis: Guidelines and Recommendations

According to The Green Book, post-exposure immunisation with pertussis-containing vaccine should be offered to all household contacts over 10 years of age who have not received a dose of pertussis-containing vaccine in the last five years and no Td-IPV vaccine in the preceding month. This is a new recommendation in guidelines published in February 2011. The rationale for this is that the duration of immunity conferred by immunisation is increased by the addition of the preschool booster, which was only introduced in October 2001.

Children born before November 1996 would have been eligible for only three primary doses of (whole cell) pertussis-containing vaccine during infancy, and immunity is likely to have waned in these individuals. Therefore, contacts over 10 may benefit from a dose of pertussis-containing vaccine. Studies have shown the safety and immunogenicity of a tetanus/low dose diphtheria/low dose acellular pertussis (Tdap) vaccine in adolescents and adults up to 65.

It is important to note that all household contacts aged 10-64 should be offered post-exposure immunisation, not just those in closest contact with the case. This includes the lodger, parents, and grandmother in the given scenario. The 6-month-old case should complete their course of primary immunisation and have the preschool booster dose as planned, while the 3- and 5-year-old contacts should complete their normal course of primary vaccination and preschool booster as planned to prolong the duration of immunity.

In summary, understanding and implementing key national guidelines for respiratory problems, such as post-exposure immunisation for pertussis, is important for healthcare providers.