24/11/2013

Disclaimer
Countdown to Finals Birmingham is a series of lectures,
examination teaching sessions and online case seminars. It
Cough is delivered by foundation year one doctors from Queen
Elizabeth Hospital Birmingham and its purpose is to prepare
Lucy Nell Chris Jones students for work as FY1 doctors. We do not represent the
University of Birmingham nor University Hospitals
Military FY1 (RAF) Academic FY1
Birmingham NHS Foundation Trust. The views expressed in
these lectures are therefore those of the presenter only.

@C2FBirmingham Count Down to Finals Birmingham

Differential diagnosis Lecture content

Cough

• Productive cough: Pneumonia

Dry Productive Haemoptysis

• Haemoptysis: Tuberculosis
Lung cancer
Interstitial Lung
Sarcoidosis Bronchitis Pneumonia Tuberculosis Lung cancer
disease

• Dry cough: Bronchitis

Idiopathic
pulmonary Pneumoconiosis Small cell Non small cell Mesothelioma
Sarcoidosis
fibrosis
Interstitial lung disease

Coal worker’s Extrinsic allergic

Asbestosis
pneumoconiosis alveolitis

Pneumonia Pneumonia

• Overview • Overview

• Aetiology • Aetiology

• Community acquired pneumonia • Community acquired pneumonia

• Hospital acquired pneumonia • Hospital acquired pneumonia

• Aspiration pneumonia • Aspiration pneumonia

• Management • Management

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Overview Pneumonia
• Lower respiratory tract • Overview
infection
• Aetiology
• Inflammation of lung
parenchyma • Community acquired pneumonia

• Cough, purulent sputum • Hospital acquired pneumonia

and fever • Aspiration pneumonia
– Radiological changes -
consolidation • Management

Aetiology Aetiology
Haemophilus Neisseria
influenzae Gram meningitidis
positive
cocci
Gram
Streptococcus negative
pneumoniae cocci
Typical

Moraxella
Gram catarrhalis
negative
rods

Klebsiella
Pseudomonas
pneumoniae
aeruginosa

Aetiology Aetiology
• Atypicals • Atypicals

– Legionella pneumophila – Chlamydia psittaci

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Aetiology Aetiology
• Atypicals • Atypicals

– Mycoplasma pneumoniae – Coxiella burnetii

Dry
cough

Aetiology Pneumonia
• Atypicals
• Overview

• Aetiology
– Pneumocystis (carinii) jirovecci
• Community acquired pneumonia

• Hospital acquired pneumonia

• Aspiration pneumonia

• Management

Community Acquired Pneumonia Severity

• Symptoms and signs consistent with acute • CURB – 65
LRTI.
• New focal chest signs – examination – C – confusion
• Systemic features – fever, sweating, rigors – U – urea >7 mmol
• No other explanation – R – respiration rate > 30
• Hospital setting – B – blood pressure – systolic <90, diastolic <60
– New radiological changes (shadowing) – 65 – age >65
http://www.brit-
thoracic.org.uk/Portals/0/Guidelines/Pneumonia/CAPQuickRefGuide-
web.pdf

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Severity Pneumonia
• Score • Overview
– 0-1 = low risk – treat at home with oral antibiotics
• Aetiology

– 2 = moderate risk – short-stay hospital treatment • Community acquired pneumonia

or hospital supervised outpatient treatment
• Hospital acquired pneumonia

• Aspiration pneumonia
– 3-5 = high risk – immediate admission – senior
review. Consider HDU or ITU. • Management

Hospital Acquired Pneumonia Ventilator Associated Pneumonia

• Occurs >48hrs post admission • Most common healthcare associated infection
• No signs of incubation during admission in intensive care.
• Early onset (0-4 days of admission) • Mirco-aspiration of oropharyngeal secretions
– Similar causative organisms to CAP
– Good prognosis
• Late onset
– Pseudomona aeruginosa, MRSA
– Other gram –ve bacteria
– Poorer prognosis

Pneumonia Aspiration Pneumonia

• Overview
• Risk factors?

• Aetiology
• Causative organisms – usually aerobic gram
• Community acquired pneumonia negatives.
• Hospital acquired pneumonia

• Aspiration pneumonia • Location?

• Management – Anatomical orientation of right main bronchus.
– Dependent upon positioning.

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Pneumonia Management
• General:
• Overview – Regular observations
• Aetiology
– Oxygen – titrated to sats (aim 94-98%)
– Regular analgaesia for any pleuritic pain.
• Community acquired pneumonia – Bloods and blood cultures
– ABG if hypoxic
• Hospital acquired pneumonia

• Aspiration pneumonia • Antimicrobials

– Dependent upon:
• Management • Aetiology
• Severity

Antimicrobials Antimicrobials
Community
• Hospital acquired
acquired
– Tazocin 4.5g IV TDS (empirical)

Mild Moderate Severe

– Ventilator associated and aspiration pneumonias

Amoxicillin 500mg- Co-amoxiclav 1.2g
If legionella strongly
• Co-amoxiclav or cefuroxime
Oral amoxicillin 1g TDS + Amoxicillin 500mg TDS IV +
500mg TDS clarithromycin
500mg BD
TDS IV clarithromycin
500mg BD IV
suspected, consider
adding levofloxacin • Local guidelines
• Chest physio

Follow-up
Lecture content
• Repeat CXR 6 weeks
– Why? • Productive cough: Pneumonia

• Haemoptysis: Tuberculosis
• Underlying malignancy. Lung cancer

• Dry cough: Bronchitis

Sarcoidosis
Interstitial lung disease

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Tuberculosis Tuberculosis

• Overview • Overview

• Pathogenesis • Pathogenesis

• Pulmonary TB • Pulmonary TB

• Extrapulmonary TB • Extrapulmonary TB

• Investigations • Investigations

• Management • Management

Overview Tuberculosis
• Mycobacterium tuberculosis • Overview
• Spread: infectious aerosol droplets
• Pathogenesis
• Typical presentation
• Pulmonary TB
– Pulmonary
• Primary • Extrapulmonary TB
• Reactivation
• Investigations
– Extrapulmonary
• Miliary tuberculosis • Management

Pathogenesis Tuberculosis
• Chronic granulomatous disease
• Overview
Mycobacterium
tuberculosis • Pathogenesis

• Pulmonary TB

• Extrapulmonary TB

• Investigations

• Management

Macrophages

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Pulmonary TB Pulmonary TB
• Primary – vague symptoms • Reactivation
– Gradual onset of symptoms

Pulmonary TB
• Granulomas within lung
– Only seen on CXR when >1-2cm
– Cavitating

Tuberculosis Extrapulmonary TB

• Overview
• Miliary
– Acute diffuse dissemination of tubercle bacilli
• Pathogenesis
– Typical lung appearance
• Pulmonary TB – Signs:
• Choroidal tubercles
• Extrapulmonary TB
• Hepatomegaly
• Investigations • Splenomegaly
• Neurological signs
• Management
• Ascites

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Miliary TB Choroidal tubercles

Tuberculosis Investigations
Pulmonary Extrapulmonary
• Overview

• Pathogenesis

• Pulmonary TB

• Extrapulmonary TB

• Investigations

• Management

Tuberculosis Management
• Notifiable disease in UK
• Overview
• Drug treatment – 6 months
• Pathogenesis – Four drug initial regimen – 2 months
• Pulmonary TB • Isoniazid (pyridoxine)
• Pyrazinamide
• Extrapulmonary TB • Rifampicin
• One other (e.g. ethambutol)
• Investigations
– Isoniazid and rifampicin – 4 months
• Management • Meningeal TB – 12 months + steroid

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ons.gov.uk

Lecture content Lung cancer

• Productive cough: Pneumonia

• Haemoptysis: Tuberculosis
Lung cancer

• Dry cough: Bronchitis

Sarcoidosis
Interstitial lung disease

ons.gov.uk

Lung cancer Lung cancer

• Development

• Suspected

• Confirmed

• Severity assessment

• Treatment

• Prognosis & palliation

Lung cancer Development of lung cancer

• Development

• Suspected

• Confirmed

• Severity assessment

• Treatment

• Prognosis & palliation €

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Risk factors Lung cancer

 Smoking • Development
 Occupational exposure: Asbestos
Silica
• Suspected
Diesel exhaust
• Confirmed
 Ionising radiation: Radon
Radiotherapy • Severity assessment
XR
Air pollution • Treatment
 Family history
• Prognosis & palliation
 COPD

Hamilton W, Peters TJ et al. Thorax 2005;60:1059-65 Hamilton W, Peters TJ et al. Thorax 2005;60:1059-65

Signs and symptoms Signs and symptoms

Weight loss
Chest pain

Thrombo-
Dyspnoea

Anorexia

cytosis
Haemoptysis Cough
Thrombocytosis
Anorexia
Weight loss
Chest pain White: PPV of symptom = 0-1%
Yellow: PPV of symptom = 1-2%
Dyspnoea Orange: PPV of symptom = 2-10%
Red: PPV of symptom = >10%

NICE CLINICAL GUIDELINE 27 NICE CLINICAL GUIDELINE 27

Signs and symptoms Signs and symptoms

Thrombocytosis
Anorexia
Weight loss
Chest pain
Haemoptysis
Dyspnoea
5 Days 2 weeks 5 Days 2 weeks
Clubbing
Hoarseness
Lymphadenopathy

2 weeks 3 weeks

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NICE CLINICAL GUIDELINE 27

Lung cancer Confirming the diagnosis

• Development
CT chest, liver, adrenals
• Suspected

• Confirmed

• Severity assessment

• Treatment

• Prognosis & palliation

NICE CLINICAL GUIDELINE 27 NICE CLINICAL GUIDELINE 27

Confirming the diagnosis Confirming the diagnosis

CT chest, liver, adrenals CT chest, liver, adrenals

PET-CT

PET-CT or EBUS-guided TBNA or EUS-guided FNA

NICE CLINICAL GUIDELINE 27 NICE CLINICAL GUIDELINE 27

Confirming the diagnosis Confirming the diagnosis

CT chest, liver, adrenals

Neck ultrasound +FNA

PET-CT or EBUS-guided TBNA or EUS-guided FNA

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NICE CLINICAL GUIDELINE 27

Confirming the diagnosis Small cell lung cancer

Classification • 20 – 30% of lung tumours

• Kulchitsky cells: Paraneoplastic syndromes Small cell

Non-small cell Small cell  ACTH/ACTH-like substance

 ADH
 Lambert-Eaton myasthenic syndrome

• Early development of metastases

Squamous Large cell Adenocarcinoma Alveolar cell
• Responds to chemotherapy

Squamous cell lung cancer Lung cancer

• Development
• 40% of lung tumours
• Suspected
• Paraneoplastic syndrome Squamous cell
• Confirmed
 PTHrP
• Severity assessment
• Commonly presents as infection
• Treatment
• Occasionally cavitates

• Local spread common – widespread mets occur late

• Prognosis & palliation

Small cell - limited Small cell - extensive

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Non-small cell – Stage 1 Non-small cell – Stage 1

Non-small cell – Stage 2 Non-small cell – Stage 2

Non-small cell – Stage 2 Non-small cell – Stage 3

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Non-small cell – Stage 4 Lung cancer

• Development

• Suspected

• Confirmed

• Severity assessment

• Treatment

• Prognosis & palliation

Treatment Lung cancer

• Optimise cardiac function and respiratory function
• Development
• Small cell lung cancer:
• Limited: Chemotherapy / Chemoradiotherapy • Suspected
• Extensive: Chemotherapy
•Prophylactic cranial irradiation / biologicals
• Confirmed
• Non-small cell:
• Stage I: Surgery • Severity assessment
• Stage I-III: RT
• Stage III-IV: CT • Treatment
• Palliation:
• Endoscopic laser therapy • Prognosis & palliation
• Endobronchial irradiation
• Transbronchial stenting

Treatment Lecture content

• Optimise cardiac function and respiratory function
• Small cell lung cancer: • Productive cough: Pneumonia
• Limited: Chemotherapy / Chemoradiotherapy
• Extensive: Chemotherapy
•Prophylactic cranial irradiation / biologicals
2-10 months • Haemoptysis: Tuberculosis

• Non-small cell: Lung cancer

• Stage I: Surgery
• Stage I-III: RT • Dry cough: Bronchitis
20% suitable for resection
• Stage III-IV: CT 5-year survival: 25-30% Sarcoidosis
• Palliation: Interstitial lung disease
• Endoscopic laser therapy
• Endobronchial irradiation
• Transbronchial stenting

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Bronchitis Bronchitis

• Overview • Overview

• Aetiology • Aetiology

• Symptoms and signs • Symptoms and signs

• Management • Management

Overview Bronchitis
• Inflammation of
• Overview
bronchi.
– Large and medium
sized airways • Aetiology

• Acute
• Symptoms and signs
– Viral illness
• Chronic • Management
– Type of COPD

Acute Bronchitis Bronchitis

Respiratory
Syncitiial Virus
Rhinoviruses
Parainfluenza • Overview

• Aetiology
Viruses
• Symptoms and signs
Adenoviruses
Influenza
• Management
Coronaviruses

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Symptoms and Signs Bronchitis

Unproductive Chest • Overview

cough tightness

• Aetiology

Discomfort
behind
• Symptoms and signs
sternum Wheeze

• Management

Occasional
crackles

Management Lecture content

• Usually self-limiting
– Improves spontaneously in 4-8 days • Productive cough: Pneumonia

• Haemoptysis: Tuberculosis
• Symptomatic relief Lung cancer

• Dry cough: Bronchitis

Sarcoidosis
Interstitial lung disease

Sarcoidosis Sarcoidosis

• Pathogenesis

• Epidemiology

Multisystem granulomatous disorder of unknown aetiology • Clinical features

• Investigations

• Treatment

• Prognosis

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Sarcoidosis Pathogenesis

• Pathogenesis
• Non-caseating granulomas
• Epidemiology
• Epitheloid cells, macrophages, lymphocytes
• Clinical features
Increased activation
Anergy
• Investigations • TNF-alpha, IFN-gamma, IL-12

• Treatment TH1 response

• Depressed cellmediated immunity to antigens
• Prognosis • e.g. Tuberculin, Candida albicans

J Bras Pneumol 2005;31(5)

Sarcoidosis Epidemiology

• Pathogenesis

• Epidemiology

• Clinical features

• Investigations

• Treatment

• Prognosis

Sarcoidosis Clinical features

• Pathogenesis

• Epidemiology

• Clinical features

• Investigations

• Treatment

• Prognosis

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Clinical features Lupus pernio

Organ/System Features
Skin Erythema nodosum, skin papules, lupus pernio
Eye Uveitis, conjunctivitis, keratoconjunctivitis sicca
Bone Arthralgias, bone cysts
Metabolic Hypercalcaemia
Liver Granulomatous hepatitis, hepatosplenomegaly
CNS CN palsy, hypopituitarism
Heart Arrhythmias, conduction defects, cardiomyopathy

Sarcoidosis Investigations

• Pathogenesis
• Bedside: Lung function tests
• Epidemiology
• Bloods: ACE
• Clinical features

• Investigations • Imaging: CXR

Transbronchial biopsy
• Treatment

• Prognosis

Sarcoidosis Treatment

• Pathogenesis Hilar lymphadenopathy Extrapulmonary

Infiltration Abnormal lung function
• Epidemiology

• Clinical features Persists for 6 months

No treatment
• Investigations
Prednisolone 30mg OD 6/52
Prednisolone 15mg alternate days 6-12/12
• Treatment

• Prognosis
Mortality rate: 5-10%
Remits in 2 years in 2/3

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Lecture content Interstitial lung disease

Interstitial Lung
disease
• Productive cough: Pneumonia
Bronchitis
Idiopathic
• Haemoptysis: Tuberculosis pulmonary Pneumoconiosis
fibrosis
Lung cancer

• Dry cough: Sarcoidosis

Interstitial lung disease Coal worker’s Extrinsic allergic
Asbestosis
pneumoconiosis alveolitis

Lecture content Summary

Cough

• Productive cough: Pneumonia

Bronchitis Dry Productive Haemoptysis

• Haemoptysis: Tuberculosis Interstitial Lung

Sarcoidosis Bronchitis Pneumonia Tuberculosis Lung cancer
disease
Lung cancer

• Dry cough: Sarcoidosis Idiopathic

pulmonary Pneumoconiosis Small cell Non small cell Mesothelioma
fibrosis

Interstitial lung disease

Coal worker’s Extrinsic allergic
Asbestosis
pneumoconiosis alveolitis

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