11: RESPIRATORY MEDICINE

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CHAPTER 11 RESPIRATORY MEDICINE

Upper respiratory tract infection (URTI)

Chest infection

Chronic obstructive pulmonary disease (COPD)

ASTHMA

Asthma is a common chronic disease affecting approximately 5% of adults and 15% of children (see p. 94). It is a disease characterised by increased responsiveness of the airways to a variety of stimuli. The clinical picture is one of wheezing, coughing or shortness of breath, often worse at night. The following is based on the 2005 update of the British Thoracic Society Guidelines for Asthma first published in Thorax in 2003.

CHRONIC ASTHMA

Diagnosis

Management

Advice

• Discuss the disease and the principles of treatment (especially the difference between relief bronchodilators and prophylactic anti-inflammatory treatment).

• Teach an appropriate inhaler technique.

• Discuss a self-management plan, where appropriate.

• Emphasise the need for regular review by the GP or nurse.

Management principles

• Avoid provoking factors, e.g.:

– smoking (active or passive)

– house dust mite (cover mattresses and pillows with plastic covers and minimise carpets, soft furnishings and soft toys, especially in the bedroom)

– drugs: avoid aspirin, NSAIDs and beta-blockers (including eye drops).

• Discuss stress as a common exacerbating factor.

• Encourage self-management (see p. 173).

Advocate the use of prophylactic treatment even with mild asthma (in patients who need a bronchodilator three times per week or more). The need for bronchodilators is therefore kept to a minimum.

• Select an appropriate inhaler device. (Aerosol inhalers are always more effective if used with a spacer device.) The use of dry powder, e.g. disks, capsules or breath-actuated inhalers may be useful for those who find simple aerosol inhalers difficult to use because of poor coordination.

• Assess inhaler technique regularly, especially if control is poor.

• Treatment should be step-wise (see below), and should be started on the step most appropriate to the severity of the asthma.

• Treatment should be stepped up and down as necessary, depending on the symptoms, the extent of bronchodilator use and the PEFR.

• The need for relieving bronchodilators should be kept to a minimum.

• Use short-term oral corticosteroids for severe asthmatic episodes to bring asthma under control.

Drug therapy (for older children and adults)

Summary of stepwise management of asthma in adults, 2004. Reproduced with permission from the British Thoracic Society/Scottish Intercollegiate Guidelines Network Executive Committee.

Step one.

Occasional symptoms: intermittent use of a short-acting bronchodilator to relieve symptoms, e.g. salbutamol 200 μg (two puffs of aerosol) prn.

Step two.

More frequent symptoms, e.g. if bronchodilator treatment is required three times per week or more: regular use of inhaled anti-inflammatory agents, e.g. beclometasone 100–400 μg (1–4 puffs of beclometasone 100 aerosol inhalation) bd, plus short-acting bronchodilators as required.

Step three.

Worsening symptoms or increasing requirement for bronchodilators: consider inhaled long-acting beta-agonists, e.g. salmeterol 50–100 μg (2–4 puffs of aerosol) bd.

Step four.

Worsening symptoms or an increasing requirement for bronchodilators: as above, plus a sequential therapeutic trial of one or more of the following:

• Regular use of high-dose inhaled steroids, e.g. beclometasone 500–1000 μg bd plus short-acting bronchodilators as required. A spacer should always be used.

• Sustained-release theophylline, e.g. Slo-Phyllin 250–500 mg bd.

• Inhaled sodium cromoglycate or nedocromil, e.g. Intal aerosol inhalation 2 puffs qds.

• Long-acting beta-agonist tablets, e.g. Volmax 8 mg bd.

• High-dose inhaled bronchodilators, e.g. nebulised salbutamol. (Long-term use should be supervised by a chest consultant.)

• Leukotriene receptor antagonist, e.g. montelukast 10 mg tablet od.

Step five.

If control is lost at any stage consider a short course of oral steroids, e.g. prednisolone 30–40 mg mane for 5 days, or until the peak flow has returned to at least 80% of the patient’s best ever peak flow. Oral steroids can be stopped abruptly, even after courses of up to 3 weeks, but should not be stopped if the patient is on long-term oral steroids or if the patient’s asthma is deteriorating subjectively or objectively.

Referral.

• asthma remains poorly controlled or if the diagnosis is in doubt

• asthma is thought to involve occupational factors.

Self-management plan.

Note the patient’s predicted or best-ever PEFR, and calculate the 75% and 50% levels. These levels can be marked on a PEFR chart or on the peak flow meter itself. (Remember to recalculate the predicted or best-ever peak flow as the child grows.)

If the patient has an upper respiratory tract infection, is experiencing nocturnal wheezing or a persistent cough, or has a PEFR consistently between 50 and 75% of normal:

• Double the dose of the inhaled steroid for the number of days it takes to return to normal or until the PEFR returns to the previous baseline.

• Continue on this increased dose for at least the same number of days again. Then return to the maintenance treatment. Use a bronchodilator two puffs 4-hourly, or as appropriate.

If the patient is experiencing shortness of breath with normal activities, is increasing the use of bronchodilators or has a PEFR which is <50% of normal:

• Increase the dose of the inhaled steroids, as above.

• If arrangements have been made to use oral steroids at home:

– See Step 5 (p. 173).

– The patient should contact the GP within 24 hours.

• If oral steroids are not immediately available, the patient should contact the GP that day.

If experiencing difficulty with speaking, bronchodilators are ineffective or the PEFR is <30% of normal, the patient should contact the GP urgently, go directly to hospital or call 999.

ACUTE ASTHMA

Many asthma deaths are preventable. Factors include:

• underuse of corticosteroids

• failure of the patient or relatives to appreciate the severity of illness

• failure of the doctor to assess the severity of illness by clinical measurement.

Management

Lower the threshold for admission if:

• an attack is late in the day

• the patient has had previous severe attacks

• the patient has had recent nocturnal symptoms

• social circumstances are unfavourable.

Treatment

• Treat with a nebulised bronchodilator, e.g. salbutamol 5 mg (2.5 mg in children), ideally via an oxygen-driven nebuliser. If a nebuliser is not available, use salbutamol inhaler via a spacer device, 6 puffs (given 1 at a time and inhaled separately), repeated at intervals of 10–20 minutes.

• Use oxygen 40–60%, if available.

• Give oral prednisolone 60 mg stat. For children aged <1 year, 1–2 mg/kg; aged 1–5 years, 20 mg stat; aged 5–12 years, 40 mg stat.

• Consider hydrocortisone 200 mg iv in adults.

If the response is good:

• Continue oral prednisolone 60 mg daily until recovery is full. For children aged <1 year, 1–2 mg/kg/day; aged 1–5 years, 20 mg/day; aged 5–12 years, 40 mg/day.

• Step up usual treatment including inhaled steroids.

• Arrange follow-up assessment the following day.

• Tell the patient to contact the GP again if the PEFR falls below 50% of its best.

Follow-up

• Assess the adequacy of maintenance treatment.

• Consider prescribing an emergency supply of oral prednisolone for the patient to keep at home.

UPPER RESPIRATORY TRACT INFECTION (URTI)

Upper respiratory tract infections are responsible for about 30% of all GP consultations.

Management of uncomplicated URTI

• Reassure the patient that the condition is self-limiting and not serious.

• Discourage the use of antibiotics in general. It is often useful to discuss the body’s natural immune response.

• Give advice on self-treatments such as paracetamol, soluble aspirin and fluids. Encourage a more self-sufficient approach to minor illness.

Administration

Sick notes are only needed after more than 6 days of continuous absence from work. Self-certificates, from the patient’s employer, should be used for the first week.

ACUTE COUGH

The commonest presentation in general practice is of an acute URTI. There is a cough, sore throat, a blocked or runny nose or painful cervical glands. Earache or sinus pain may accompany these.

Other symptoms suggest an alternative diagnosis:

CHRONIC COUGH

Diagnosis

Any cough lasting more than 4 weeks falls into the category of chronic cough (see below).

Consider the following:

• carcinoma of the bronchus

• gastro-oesophageal reflux disease

• chronic bronchitis and bronchiectasis

• tuberculosis

• postnasal drip due to sinusitis.

History.

Some features make one diagnosis more likely than another. For example, the child with a chronic, dry, nocturnal cough is likely to have asthma, whereas the lifelong heavy smoker aged 65 years with a chronic cough and weight loss is likely to have bronchial carcinoma.

Many adults, however, fall into the category of chronic cough with no obvious associated features.

Examination.

Chest examination may give some clues, but is often normal in patients with a chronic cough.

• weight loss

• maxillary or frontal sinus tenderness

• cervical lymphadenopathy

• nasal obstruction.

Investigations.

In suspected asthma, peak flow measurements before and after exercise and also pre- and post-inhalation of salbutamol may give the diagnosis (see p. 170).

A CXR is mandatory in patients aged over 40. Be prepared to repeat this after 6 weeks if the result is normal in patients who are losing weight.

Management

Management is of the underlying condition if this can be diagnosed. Often this is not possible, in which case a step-wise, empirical approach often produces results:

• Give 2 weeks of a broad-spectrum antibiotic, e.g. amoxicillin 500 mg tds.

• If there is no response, give 2 weeks of a PPI, e.g. lansoprazole 15 mg od.

• If this fails to cure the cough, try giving 2 weeks of inhaled beclometasone 400 μg bd.

If this regimen fails to relieve the symptoms, referral to a chest physician is justified.

The chronic cough of terminal chest disease can be relieved by pholcodine linctus or morphine.

CHEST INFECTION

Coughs and colds are the commonest presenting complaints in general practice in the winter and spring months.

Management

• Is the patient unwell? If not, and there are no features in the history or examination to suggest anything other than a simple URTI with a cough, the patient can be reassured that there is nothing seriously wrong. Paracetamol 4-hourly can be advised. The condition should last no more than a week.

• Exacerbations of chronic bronchitis and infective episodes in bronchiectasis require antibiotics. The elderly commonly fall into this group. Oral amoxicillin 500 mg tds for 1 week is usually sufficient as a first-line choice, with erythromycin or tetracycline as alternatives. If this fails, co-amoxiclav 1 tds or ciprofloxacin 500 mg bd are good second-line choices.

• If pneumonia is suspected, see below.

• Steam inhalation or salbutamol via a metered-dose inhaler can help to loosen sputum.

• Consider asthma in patients with repeated episodes of cough or wheeze (see p. 170).

PNEUMONIA

Pneumonia presents either as a rapidly developing chest infection or as a consequence of a prior URTI.

Diagnosis

History.

• cough, which is usually productive

• fever (not always present in the elderly or small children)

• breathlessness

• pleuritic chest pain

• haemoptysis

• vomiting or diarrhoea in children

• falls or confusion in the elderly.

Examination.

• tachycardia

• pyrexia (not always present in the elderly or small children)

• coarse crepitations, bronchial breathing and reduced air entry on auscultation of the affected lobe

• grunting and intercostal recession, which may be found in small children. Some children may have no chest signs.

Investigations

• CXR if the diagnosis is uncertain.

• Sputum for microscopy and culture if obtainable.

• Dipstick urine for ketones if dehydration is suspected.

Ill patients should be admitted to hospital, as should all children and the immunocompromised, e.g. diabetics.

HAEMOPTYSIS

The coughing up of blood may vary from slight streaking of phlegm to massive and fatal haemorrhage. A careful history usually allows distinction from haematemesis, although blood swallowed from the upper respiratory tract may be vomited back later.

Diagnosis

Consider the following possible causes:

• URTIs: tonsillitis, sinusitis.

• LRTIs: pneumonia, bronchitis, TB.

• Malignancy: bronchus, larynx, lung secondaries.

• Infarction: pulmonary embolus.

Most cases in general practice involve minor blood-speckling of mucus, produced from the upper respiratory tract due to excessively violent coughing.

History

Shortness of breath and pleuritic chest pain suggest a pulmonary embolus. A productive cough suggests bronchitis or pneumonia. Chronic cough and weight loss raise the suspicion of a bronchial carcinoma. Known or suspected pulmonary metastases from e.g. a breast primary can present in general practice as haemoptysis.

Examination

• The throat may reveal a possible source of bleeding if the tonsils are inflamed or the fauces injected.

• Chest examination may reveal pneumonia or bronchitis.

• Look for cervical and axillary lymphadenopathy in suspected carcinoma, and weigh the patient if malignancy is suspected.

Investigations

• ECG in pulmonary embolus shows S-waves in lead I and Q-waves and inverted T-waves in lead III.

• CXR to exclude e.g. TB, carcinoma and pneumonia.

Management

• Manage the underlying disease if a diagnosis is made.

• Haemoptysis can be very distressing. Diazepam orally or iv may be useful for acute distress (e.g. in terminal care).

• Refer for e.g. diagnostic bronchoscopy if the diagnosis is uncertain.

Admit all cases of haemoptysis heavier than simple streaking of mucus, unless the patient is expected to die, e.g. in palliative care at home.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

COPD is very common in general practice, accounting for 30 000 deaths a year in the UK, and is the sixth leading cause of death worldwide. It is caused mainly by smoking. It is extremely unlikely to be present in patients under 50 or those who have never smoked. The following is based on the National Institute for Health and Clinical Excellence guidelines 2004.

Diagnosis

History.

COPD should be considered in adults with persistent cough, sputum production or shortness of breath.

• cough lasting more than 1 month, or recurrent cough

• sputum colour and volume

• shortness of breath, which is worse on exertion

• smoking (number of packs smoked and number of years as a smoker)

• any occupational exposure to dust or noxious fumes

• the effect of the respiratory problems on the patient’s daily activities.

Grade breathlessness according to the MRC dyspnoea scale:

1. Only breathless with strenuous exercise.

2. Breathless when hurrying on the level or up a slight hill.

3. Walk slower than people of the same age due to breathlessness or have to stop for breath when walking on the level.

4. Stop for breath after walking 100 yards or after a few minutes on the level.

5. Too breathless to leave the house.

Examination

• Look at the chest. Hyperexpansion is common.

• Auscultate for wheeze (common) and signs of infection (also fairly common).

• Clubbing should be absent. Its presence suggests bronchiectasis or lung cancer.

• The heart should not be enlarged and the JVP should not be elevated, unless there is also coexisting heart failure.

Investigations

• CXR to help exclude e.g. malignancy and heart failure.

• Spirometry (in all cases). The characteristic feature of COPD is airway obstruction, defined as an FEV1:FVC ratio <70% and a measured FEV1 less than 80% of predicted (FEV1%).

• Reversibility testing: repeat spirometry 5 minutes after a 400 μg dose of inhaled salbutamol. An improvement in FEV1 of more than 500 ml, or normalisation of the FEV1, suggests asthma. Lesser improvements suggest bronchodilators will improve the COPD symptoms.

• PEFR. Variation in PEFR tends to be small in COPD. Serial home PEFR measurements may help to distinguish between COPD and asthma. A normal PEFR does not exclude COPD.

Referral.

Consider referral to a chest physician if the patient is:

• under 40 years of age

• a non-smoker

• considerably disabled by dyspnoea

• diagnostically difficult.

Management

Take a step-wise approach to treatment, trialling the following drugs in order. Assess the response by asking the patient what effect there has been on objective measures such as exercise tolerance, and also by improvements in spirometry (FEV1%).

Mild COPD (either mild symptoms, or FEV1 no less than 50% predicted)

• Short-acting bronchodilator inhaler, e.g. salbutamol 100 μg, two puffs qds.

• Anticholinergic bronchodilator, e.g. ipratropium bromide inhaler 20 μg, two puffs qds or tiotropium 18 μg od (especially if there is excessive mucus).

Moderate to severe COPD (FEV1 <50% predicted, or disabling symptoms)

• Steroid inhaler, e.g. beclometasone dipropionate 200–250 μg, two puffs bd.

• Long-acting beta-agonist, e.g. salmeterol inhaler 25 μg, two puffs bd.

If symptom control is poor, consider referral to a chest specialist for e.g. possible home oxygen therapy.

Related

Churchills Pocketbook of General Practice