Causes of chronic cough
A. adult and children
1. Pertussis (whooping cough)
2. Asthma
2. Active/passive smoker
3. GORD
4. OSA
5. TB
B. Adults
1. ACEIs
2. post nasal drip / chronic sinusitis
3. COPD
4. chronic bronchitis
5. lung cancer
6. Bronchiectasis
7. Sarcoidosis
8. interstitial lung disease
C. Children
1. post-viral cough
2. habitual / Psychogenic cough
3. cystic fibrosisHistory of chronic cough (8)
- exposure contact with pertussis/contact with animals
- Pertussis immunisation
- history of asthma
- occupational/environmental exposure
- drug history
- smoking history
- sweating/fever/ weight loss
- recent travel
Pertussis investigation
< 4 weeks –> NPS for pertussis PCR and culture
> 4 weeks –> Pertussis serology
bronchiectasis - Why ATSI (5)
Living in overcrowded house
Lack of access to antibiotics for infection
Poor compliance with antibiotic treatment
Low immunisation rate
High rate of exposure to smoke
Bronchiectasis- C/F and Ix
cough with ++++ sputum
> 2 consecutive years
HRCT
- bronchial wall thickening
- diatled bronchiols = lack of tapering = Signet (ring) sign
Bronchiectasis- management (7)
- Early recognition and treatment of exacerbation with antibiotic
- Routine immunisation (influenza/pneumonia)
- avoid exposure to patient of respiratory infection
- Pulmonary rehabilitation for mucus clearance by chest physiotherapist
- Regular exercise 30 min per day
- Annual follow up
- Smoking cessation if smoker
DDx of acute cough in adult (7)
- asthma
- viral URTI
- pertussis
- acute bronchitis
- atypical pneumonia / Mycoplasma/Leoginella/ Chlamydia
- post nasal drip/acute rhino-sinusitis.
- Psittacosis (working with animals/Pets)
DDx of acute cough in children (6)
- asthma
- Upper RTI
- pertussis
- croup
- foreign body inhalation
- pneumonia / atypical
most common causes of atypical pneumonia
dy cough >5 days, Headache, Bilateral chest finding
- mycoplasma (most common)
- legionella (confusion/diarrhea/pneumonia)
- Chlamydia
- Psittacosis (Pet shop /birds)
- Q fever (Farm/animals)
DDX chronic cough in adults
Asthma Smoking / passive smoker GORD OSA Pertussis / check pertussis immunisation history TB COPD Chronic sinusitis Chronic bronchitis ACEIs induce asthma Lung cancer Bronchiectasis Sarcoidosis Interstitial lung disease
DDx chronic cough in children
Asthma Smoking / passive smoker GORD OSA Pertussis / check pertussis immunisation history TB Post viral cough Habitual / psychogenic cough Cystic fibrosis
interstitial lung disease - sarcoidosis
Bilateral hilar LAP masses
No clubbing of fingers
Treatment
- Self limiting
- If SOB: Prednisolone 50mg Po daily for 4 weeks
Lung cavitation DDx (6)
- Bronchogenic Ca / Pancost tumor
- TB (tuberculosis)
- Fungal infection/pneumonia
- Lung abscess
- Sarcoidosis
- Lymphoma
Risk factors for pneumonia (9)
- Age > 65
- Smoking history
- Alcohol consumption
- malnutrition
- Lack of pneumococcal /influenza vaccination
- Viral URTI
- Living in overcrowded environment
- Undiagnosed medical condition - COPD/lung cancer
- Recurrent aspiration
Pneumonia - assessment
SMART-COP
SPO2<90
Multiple lobe pneumonia
Albumin < 35
RR
< 50y → > 25
> 50y → > 30
Tachycardia > 125
Confusion
O2
< 50y → SPO2 < 93%
> 50y → SPO2 < 90%
Ph < 7.35Pneumonia - treatment
A. LOW severity CAP
1. no allergy:
Amoxicillin Po 1g TDS for 7/7, if no improvement after
48 hr, add
Doxycycline PO 100mg BD 7/7
2. mild allergy
Cefuroxime PO 500mg
Clarithromycin 500g BD
3. Severe allergy
Moxifloxacin PO 400mg daily
B. moderate severity CAP
1. no allergy:
Benzylpenicillin 1.2g IV QID
\+
Doxycycline PO100mg BD
2. mild allergy
Ceftriaxone 1g IV daily
3. Severe allergy
Moxifloxacin PO 400mg daily
severe CAP
1. no allergy:
Ceftriaxone 2g IV daily
\+
Azithromycin 500mg IV daily
2. mild allergy
Moxifloxacin IV 400mg dailyPleural effusion - causes
A. Transudate - systemic
1. Heart failure 2. Liver failure 3. Renal failure 4. hypo-proteinaemia 5. Hypothyroidism 6. Ovarian tumor (R sided pleural effusion) - Meigs syndrome
B. Exudate
1. Infection: pneumonia, empyema, TB 2. Malignancy: Lung cancer, mesothelioma, metastasis 3. Connective tissue diseases: SLE 4. Lymphoma 5. Sarcoidosis
Sarcoidosis (ILD) - examination finding (8 except 1)
Erythema nodosum Polyarthralgia LAP Splenic enlargement Hepatomegaly Parotid gland swelling Heart failure Uveitis
NO Clubbing
restrictive lung disease DDX (8)
idiopathic pulmonary fibrosis sarcoidosis hypersensitivity pneumonitis coal worker pneumoconiosis lymphatic interstitial pneumonitis asbestosis obesity eosinophilic pneumonia
interstitial lung disease- Investigation
spirometry
CXray
HRCT
interstitial lung disease- C/F
dry cough
exertional dyspnea
clubbing except in sarcoidosis
interstitial lung disease- Management
Prednisolone 50mg Po daily for 4 weeks
interstitial lung disease- Examination finding
fine crepitation hypoxia on exercise pulmonary hypertension and R side heart failure - peripheral oedema - raised JVP
ILD- Dx
- Idiopathic pulmonary fibrosis - most common in elderly
- Sarcoidosis - most common in young
Multisystemic disease
non-caseating granuloma
(note: TB is a caseating granuloma) - Hypersensitive pneumonitis
- Connective tissue disease ILD
SLE / RA / Scleroderma / Mixed connective tissue
disease - Occupational ILD
a. Coal worker pneumoconiosis
b. asbestosis
c. Silicosis - obesity
