Tag Archives: respiratory

Medical Research Council Dyspnoea Scale

  • Grade 1 – not troubled by breathlessness except during strenuous exercise
  • Grade 2 – short of breath when hurrying or walking up a slight hill
  • Grade 3 – walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace
  • Grade 4 – stops for breath after walking about 100m or after a few minutes on the level
  • Grade 5 – too breathless to leave the house, or breathless when dressing or undressing

Pulmonary Tuberculosis

TB is airborne and caused by mycobacterium africanum, mycobacterium bovis, and mycobacterium tuberculosis often collectively termed M. tuberculosis complex. TB can affect any part of the body, when it affects several sites it is referred to as military tuberculosis. If it affects organs excluding the lungs it is referred to as extra-pulmonary TB. Generally though, most TB is pulmonary, and it is pulmonary TB that is transmitted, although close contact is required for long periods. It is transmitted by infected droplets in coughs, sneezes, breathing, or even talking. TB can be transmitted from animals to humans; cattle are particularly prone (in this case it can be transmitted also through contaminated meat or milk). In this case it is possible to spread extra-pulmonary TB.

Pulmonary TB occurs when the bacillus is inhaled into the alveoli, this is the primary focus of the infection, and will develop into a granuloma. During the primary stage of the infection, the bacteria may be transported to the lymph nodes. Generally in healthy people the infection will be killed off with no treatment, however, in some patients, particularly those who are immunocompromised, the bacteria will not be completely eradicated, and may lie in a dormant state, which may later become infectious. While dormant, TB cannot be spread, and the patient will be asymptomatic. If the disease is active, and the lungs are involved, this is then infectious. The active disease is more prevalent in those who are immunocompromised due to HIV infection, the ageing process, or immunosuppressant therapy. Those with diabetes or who are pregnany or have co-existing diseases are also likely to be infected.

Symptoms can differ with the site of the TB; pain from bone TB, haematuria and dysuria with renal TB, and with TB meningitis headaches, nausea, vomiting, and lymph node swelling. It is always important to consider whether pulmonary TB is also present (due to its contagion ability) when any of these symptoms occur. Pulmonary TB may present with weight loss, night sweats and/or fever, cough, haemoptysis, shortness of breath, malaise or lethargy.

Treatment of TB is comprehensive and therefore requires commitment from the patient. Several drugs may be required, and the medication schedule may last for at least six months. Patients should be made aware that drugs may have serious side effects, but that continuation of the treatment schedule is vital.

IV Antibiotics for Cystic Fibrosis

Due to the use of IV antibiotics to treat exacerbations, those with cystic fibrosis now have a life expectancy of about 50 years, which has increased from 10 years about 40 years ago.

Pseudomonas aeriginosa is the most prevalent bacterium which has been associated with decline in lung function amongst people with CF. this is usually responsive to antibiotic treatment, but the organism can develop a resistance to it. Multi-resistant P aeriginosa has been connected with severe lung disease, a decline in FEV1 and also end-stage lung disease.

CF patient who have multi-resistant P aeruginosa will require more frequent trips to hospital, and longer courses of antibiotics. This is not the only organism known to be resistant to a variety of antibiotics, there are also stenotrophomonas, maltophilia, achromobacter xyloxidans, and burkholderia cepacia complex, although these are less common than pseudomonas aeruginosa.

Generally CF patients in exacerbation will be given a combination of antibiotics, this will be determined by culture results of secretions. A combination is given to reduce the risk of the organism becoming resistant. Other factors to consider are how the patient has responded to treatment previously, allergies, antibiotic sensitivity and the type of organism as well as local policy.

Generally patients are given a two week course of antibiotics, although the course may be as short as 10 days, or as long as three weeks. Naturally a shorter course includes the risk of not completely clearing the infection, increasing the chance that the organism could become resistant to the antibiotics and allowing the infection to cause lung damage. There is no general consensus of length of IV course or in fact a uniform and comprehensive policy. Each trust has its own policy which is determined by current research, experience and knowledge as well as cost implications.

Pleurisy

Pleurisy (also referred to as pleuritis) is the inflammation of the pleural layers surrounding the lungs. Pain is caused when there is friction between the layers. Pleurisy is a symptom of an underlying condition, not a condition in itself.

There are two layers of epithelium, the visceral pleura encases the lungs, and the parietal pleura covers the mediastrinum and chest wall. The two pleuras meet at the hilum. The pleural space between the pleuras contains lubricating fluid which helps prevent friction occurring between the two layers. The visceral pleura has an autonomic nerve supply which gives no pain sensation, whereas the parietal pleura has sensory nerve endings supplied by the phrenic nerve and therefore can experience pain.

Accumulation of pleural fluid suggests and increase of fluid production that exceeds the ability of the lymphatic system to remove it, or an obstruction in the pleural space.

Pleurisy is often caused by viral infections, but when a patient presents with pleurisy it is important first to rule out any life-threatening conditions such as MI and PE first. Although pleurisy is generally a symptom of an underlying condition, sometimes pleurisy is idiopathic.

Patients present with pain, particularly on breathing, as the pleura surfaces become inflamed and cause friction, this pleural rub can sometimes be heard as a scratching sound on inspiration. A key feature of pleurisy is that the pain is sharp and is exacerbated on coughing, sneezing or taking a deep breath.

Other symptoms of pleurisy include fever, chills, rigors, shallow breathing, shortness of breath, productive cough, diminished breath sounds.

By determining how acute the pleurisy is the underlying cause is easier to discover; acute (minutes-hours), sub-acute (hours-days) chronic (days to weeks) or recurrent. Chest x-rays are normal diagnostic tests; not only will they show a pneumothorax but also will detect if there is pleural effusion. D-dimer tests are normal practice to rule out PE, ECG to detect MI and also a sputum sample should be sent for analysis.

A full history should be taken; previous chest pain, respiratory problems, long haul travel (immobility), how long the pain has been present, what the pain is like, what triggers it, what relieves it, accompanying symptoms, shortness of breath, syncope, cough, wheezing, past medical history. Observation should be taken; respiratory rate/quality, BP, pulse, temperature (ECG is also useful). The Early Warning System should be used if in an acute setting.

Pleurisy is generally treated initially with NSAIDs (use with caution in those with asthma, as with those with gastric ulcers,, patients over 65 and those on aspirin, anti-coagulants, corticosteroids or SSRIs). Indomethacin given 50-100mg daily can improve lung function and relieve pleuritic pain in chronic cases. If NSAIDs are unsuitable, or not tolerated narcotic analgesia can be given but caution is essential as it can cause respiratory depression. It must also be considered that pleurisy is a symptom of an underlying condition requires prompt diagnosis and treatment.

Nebuliser Therapy

Most respiratory conditions are treated with an inhaled drug. This enables the drug to effectively target the receptors in the lungs.

Although the nebulising unit of air compressor, mask, chanmber and tubing is commonly referred to as the nebuliser, it’s actually the small contraption attached to the mask which contains the fluid which is the nebuliser. It is this that transforms the liquid drug into fine aerosol. In many cases, inhalers employed with spacers and the proper technique are as effective, or more effective as nebulisers. This may be because of the inefficiency of the method with around 12% of the drug actually reaching the target receptors. This depends on the patients’ breathing rate and depth, the health and age of the patients’ lungs, the volume of the drug being administered and the type of nebuliser chamber. The nebuliser chamber, its components, and air flow rate, determine the size of droplets produced. If the droplet size is too small, the drug will end up in the peripheries of the lungs which decreases the efficacy of the drug. Overfilling the chamber will also affect efficacy as well as prolonging the time taken to administer; this should be 5-10 minutes. Once the nebuliser has finished there is likely to be a small residue of the drug in the chamber.

Nebulisers are not generally indicated for mild-moderate asthma because it has been shown that this can often lead to an overuse of bronchodilators rather than preventers.

Nebulisers are used to administer anticholinergics, corticosteroids, bronchodilators, antifungals and antibiotics as well as recombinant human deoxyribonuclease (used to increase expectoration and reduce viscosity in cystic fibrosis patients). If the nebuliser is used with antibiotics or corticosteroids a mouthpiece should be used to avoid contact with the skin and eyes.

Generally nebulisers are no more efficient than inhalers, and in fact some inhaled drugs are not available in nebuliser form, they can promote over-dependence on bronchodilators in asthmatics and also be habit-forming if the patient enjoys the cooling sensation. It is, however, helpful for patients with reduced manual dexterity or patients receiving palliative care.

Heatwave At-Risk Groups

The elderly and the very young are more at risk physiologically of suffering the effects of a heatwave. When the ambient temperature is higher than skin temperature, the body cools by sweating. This is a mechanism may be impaired in the young children and the elderly. In the elderly thermoregulation (controlled by the hypothalamus) can also be impaired.

Young children and babies tend to have core temperature which rise and fall faster during infection and dehydration.

In the elderly, cardiac and respiratory problems can be exacerbated as more blood is circulated to the skin in order to improve cooling. Increased air pollution during heatwaves can also cause problems for those with respiratory conditions.

Heatstroke occurs when the body’s core temperature remains at the increased level of 40˚C for 45 minutes or longer. Symptoms include hot, dry skin, nausea and/or vomiting, drowsiness, fatigue, nocturnal insomnia, convulsions, unconsciousness confusion.

Asthma

It is estimated that around 10% of the UK population have some degree of asthma. Frequently people do not get treatment because they feel it is something they just have to live with, not realising that effective treatment is readily available. Patient education coupled with pharmacological intervention can mean that asthma is well-controlled and has little or no impact in a person’s life.

When a patient reports respiratory problems, it’s vital to obtain a history, exploring if the patient has had any breathlessness, how serious it is (impeding ability to speak in complete sentences, for example), roughly how long the episodes last, how many there have been, and also if the patient detected any trigger for the episode; likewise the same factors should be considered for any episodes of wheezing, coughing (including products of the cough), and tightness in the chest or discomfort, and any rhinitis. Family history of respiratory problems should assessed and the patient’s occupation should also be noted to assess likelihood of occupational asthma.

Diagnosis of asthma is based on the symptoms expressed, the patient’s history, and the reversibility of the airways. The asthma may be allergic or non-allergic. If allergic sensitivity may be found to dust mites, pollen, mould or animals. Asthma can also be triggered by pollutants, smoke, climatic changes or as a response to a viral illness.

A family history of asthma, eczema or rhinitis can help towards an asthma diagnosis.

Peak flow can be checked during the consultation, however, if asthma is exercise or allergy induced it is possible that a normal result could be achieved. Giving the patient a peak flow meter to use at home and asking the patient to fill in a brief peak flow diary can help to diagnose the problem. Peak flow is a practical measure of how bad an episode is and how well medication is working. Explaining the use and technique of peak flow, also advising on inhaler technique is good practice for the initial consultation (if necessary for the patient). If there is a peak flow variability of 20% or more after using a bronchodilator, or during a week of peak flow diary recordings, this provides supporting evidence of an asthma diagnosis, differentiating it from COPD.

It may be prudent to start a patient on inhaled steroids as well as a bronchodilator; some asthma deaths have been linked to overuse of bronchodilators, also a bronchodilator alone may not be sufficient for the patient. If a person experiences a few symptoms frequently, it is unlikely that a bronchodilator alone would control the condition.

Inhaled steroids (beclometasone, fluticasone, or budesonide) are all suitable for patients with either an exacerbation of asthma over the past two years, if the patient is having interrupted sleep one or more nights per week, if the patient is experiencing symptoms three or more times a week or if the patient is using an inhaled beta 2 agonist three or more times a week. Sodium cromoglicate requires qds administration and therefore is not always practical, so it is generally not used as a first-line treatment.

Admission to hospital is indicated if the adult patient has a pulse higher than 100 beats/minute, unable to speak in full sentences, respiratory rate above 25 breaths/minute or peak flow is 50% below normal/predicted.

Asthma is considered life-threatening if peak flow is 33% below predicted, oxygen saturation is below 92%, cyanosis is present, patient is hypotensive, arterial partial pressure is O2<8kPa, patient is bradycardic, exhausted, hypotensive, confused, has feeble respiratory effort, has dysrrhythmia or a silent chest or, obviously, is in a coma.

Steroids are indicated in such situations; they can be given intra-muscularly or orally (IM route takes 6 hours to take effect, oral takes 8 hours) route choice is down to personal preference.

A high dose (30-40mg) of an oral steroid, prednisalone is indicated in such cases for seven days after the acute episode.

Pregnancy will not necessarily have an impact on asthma, and asthma medications have not been found to harm the mother or unborn baby. It is important for mother and baby that the asthma is well-controlled throughout the pregnancy. If it is not, the mother is at greater risk of complications such as pre-eclampsia, hypertension, hyperemesis gravidarum, premature birth, increased prenatal mortality, intrauterine haemorrhage.

To reduce acute exacerbations of asthma and hospital admissions it is important that each patient has their own personal action plan, that they have received sufficient help and advice, that their peak flow and inhaler techniques are regularly checked and that their peak flow is routinely checked in the surgery. When the patient presents, it is worthwhile to check on their inhaler use and how many episodes of waking in the night they’ve had, how often they have asthma symptoms and how this affects their everyday life.

Summary of Chest Pain Triage in Primary Care

Urgent referral to A&E is needed for patients presenting with:

  • ACS: crushing/squeezing chest pain at rest, possibly accompanied by nausea, sweating, shortness of breath or dizziness, pain radiation from left arm to jaw may be present.
  • Aortic aneurysm dissection – symptoms include sharp tearing pain, dyspnoea, syncope, a feeling of impending doom.
  • PE – includes symptoms of sharp sudden pain in a patient with a history of recent inactivity/stasis – perhaps recent long-haul travel, recent surgical procedure under general anaesthetic or hospital admission which has restricted normal level of activity, breathlessness.

Chest pain not necessarily requiring urgent transfer to A&E:

  • Angina – similar symptoms to ACS, but pain experienced on exertion and relieved at rest (possibly with a history of CVD). If the patient is unstable patient should be treated along the lines of ACS. Treat initially with GTN.
  • Chest infection/pleurisy; patient will present with pain on moving or breathing, presents as sharp central pain. Patient may also have a fever. This can be safely treated in primary care setting.
  • Pericarditis; again, symptoms as pleurisy, to be treated with NSAIDs if suitable for patient, consider outpatient ECG.
  • GORD – burning pain, retrosternal. May have a long history, possibly associated with particular foods. Not particularly urgent unless presenting with malaena or haematemesis. Patient may require gastroscopy; primary care may involve PPIs or H2 blockers.

It is vital to take a detailed history, as well as appropriate observations (BP, ECG, pulse, respiratory rate, temperature).

P – Provocation/palliation – what triggers the pain? What relieves it?

Q – Quality – what is the pain like? Stabbing, crushing, aching, dull, tearing. Also use pain scale.

R – Radiation – where does the pain begin, and where does it radiate to?

S – Site – what’s the location of the pain?

T – Timing – when did the pain start? What was the duration? How many episodes have there been? When did the episodes start? Is it getting better or worsening?

Also, record any accompanying symptoms such as dizziness, nausea/vomiting/burping, feeling of impending doom, syncope.

Symptoms suggesting ACS need urgent referral to hospital. If this is the case, the patient should be given 300mg aspirin and high-flow oxygen.