Respiratory Diseases

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A summary of diagnosis and treatment of common respiratory diseases

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RESPIRATORY DIAGNOSIS : 

RESPIRATORY DIAGNOSIS DR. S. ASWINI KUMAR. MD. Professor of Medicine, Govt Medical College Hospital, Thiruvananthapuram, Kerala, S. India, draswinikumars@gmail.com 1

List of Respiratory Diagnosis being discussed : 

List of Respiratory Diagnosis being discussed Acute Rhinitis Allergic Rhinitis Acute Sinusitis Acute Pharyngitis Acute Tonsillitis Acute Laryngitis Acute Bronchitis Chronic Bronchitis COPD Emphysema Bronchial Asthma Lobar Pneumonia Bronchopneumonia Interstitial Pneumonia Acute Viral Pleurisy Pleural Effusion - Synpneumonic Pleural Effusion – Tuberculous Pneumothorax – Spontaneous Hydro/hemo-pneumothorax Tuberculosis – Cavity Upper Lobe Tuberculosis – Fibrosis Upper Tuberculosis - Miliary Suppurative – Bronchiectasis Suppurative – Lung Abscess Suppurative – Empyema Pulmonary Collapse Pulmonary Embolism Bronchogenic Carcinoma Interstitial Lung Disease 2

Upper Respiratory Infection - Acute Rhinitis : 

Upper Respiratory Infection - Acute Rhinitis Running nose Sneezing Nasal block Low grade fever Headaches Dry cough O/E Nasal Congestion Common cold Viral etiology Diagnosis is clinical Lasts for 7 days if untreated Lasts for 1 week if treated Cough may linger for 2 weeks Symptomatic treatment Steam inhalation - Conzo Antipyretics - Acetaminophen Antihistamines - CPM Nasal decongestant - PPA No antibiotics required 3

Upper Respiratory Affection - Allergic Rhinitis : 

Upper Respiratory Affection - Allergic Rhinitis Running nose Sneezing Nasal block No fever No headaches Dry cough – post nasal drip O/E Nasal drip and congestion Exposure to allergens Dust, dander, pollen, cotton Sensitized immune system Antibodies to allergens Production of histamine Diagnosis - again clinical Symptomatic treatment Steam inhalation - Karvol Antipyretics – Not required Antihistamines - CPM Non-sedative - Cetrizine Nasal sprays - Flohale 4

Upper Respiratory Infection - Acute Sinusitis : 

Upper Respiratory Infection - Acute Sinusitis Purulent nasal discharge Sneezing Nasal block Low grade fever Headaches Dry cough – post nasal drip O/E Sinus tenderness Secondary bacterial infection Bifrontal head or facial pain Early morning stooping - Nasal discharge – not must X-Ray PNS - Haziness CT Scan PNS – Tumor if any Antibiotics needed Cap Amoxiclav 375mg TID Anti-inflammatory drugs Antipyretics - Acetaminophen Antihistamines - CPM Steam inhalation mandatory 5

Upper Respiratory Infection - Acute pharyngitis : 

Upper Respiratory Infection - Acute pharyngitis Low grade fever Throat irritation Throat pain Painful swallowing Phlegm from throat Dry cough & Headaches O/E Red congested pharynx Common URTI Viral etiology Sec. bacterial infection Primary streptococcal Recurrent sore throat Indication or penicillin Sips of hot liquids, Lozenges Viral - Warm saline gargles Bacterial - Amoxycillin 500 TID Antipyretics - Acetaminophen Antiinflammatory - Diclofenac B complex tablets 1 OD 6

Upper Respiratory Infection - Acute Tonsillitis : 

Upper Respiratory Infection - Acute Tonsillitis Low grade fever Throat irritation Throat pain Painful swallowing Dry cough and headaches Sputum from throat O/E Tonsils enlarged & red Bacterial infection Streptococcal etiology Enlarged tender cervical LNs Throat swab confirmatory Chronic recurrent tonsilitis Indication for surgery Cap Amoxicillin 500mg TID or Tab Roxithromycin 150mg BID Diclofenac 50mg BID Acetaminophen 500mg TID B complex tablets 1 OD Betadine throat gargles 7

Upper Respiratory Infection - Acute Laryngitis : 

Upper Respiratory Infection - Acute Laryngitis Hoarseness of voice Reduction or loss of voice Low grade fever, throat pain Dry hawking cough Attempts to speak cause pain Unaccostomed overuse voice Stridor in children (croup) Often complicates coryza Talking/teaching profession Diagnosis is clinical Direct visualization - No Indirect laryngoscopy Vocal cord inflammed Warm saline gargles Steam inhalation of value Tab Diclofenac 50mg BID Tab Acetaminophen 500 TID Cap B complex forte 1 OD Complete voice rest 8

Lower Respiratory Infection - Acute Bronchitis : 

Lower Respiratory Infection - Acute Bronchitis Low grade fever Dry irritant cough Mucoid sputum  purulent Retrosternal discomfort Tightness of chest Breathlessness and wheeze O/E Bilateral rhonchi Often complicates coryza May supersede C/C Bronchitis Diagnosis is clinical Bilateral chest signs Neutrophil leucocytosis CXR Not necessary for  Cap Amoxycillin 500mg TID Tab Acetaminophen 500 TID Tab Deriphyllin 100mg TID Steam inhalation twice daily Cap B Complex forte OD Syp Linctus Codiene 1 tsp TID 9

COPD - Chronic Bronchitis : 

COPD - Chronic Bronchitis Chronic cough Male smoker Cough > 3 months For > 2 consecutive years Mucoid sputum most of times Turning purulent at times Breathlessness at rest Male smoker Obese and cyanosed “Blue blotters” Acute exacerbations Bilateral pitting edema Suggestive of cor-pulmonale STOP Smoking Short acting B2 agonists Long acting B2 agonists Anticholinergic drugs Xanthine derivatives Inhaled corticosteroids by MDI 10

COPD - Emphysema : 

COPD - Emphysema Chronic dyspnoea > cough Male smoker may be Always symptomatic Frequent exacerbations Breathlessness at rest Mucoid sputum O/E Chest emphysematous Lean habitus Male or female Polycythemic and dyspnoeic “Pink puffer” Chest X-Ray Elongated chest CT Chest – Dilated alveoli Initial treatment same C/c B Treat acute exacerbation Appropriate antibiotics Increased dose of drugs Short course oral steroids Nebulization with salbutamol 11

COPD – Chronic Bronchial Asthma : 

COPD – Chronic Bronchial Asthma Chronic history Childhood onset Sex irrespective Cough and wheezing Breathlessness at rest Seasonal/tidal variation Symptom free intervals Diagnosis clinical History of allergy or atopy Allergiic rhinitis or drug allergy Eczematoid dermatitis ankles Wheezing and rhonchi Response to B agonists Xanthines Beta agonists Corticosteroids Rotacap devices Metered dose inhalers Nebulization in hospital 12

LRTI - Lobar Pneumonia : 

LRTI - Lobar Pneumonia Acute onset of fever High grade continuous Chills and rigor characteristic Initial pleuritic chest pain Dry cough initially Expectorate mucoid sputum Rusty sputum/hemoptysis Dramatic presentation Febrile patient Tachycardia & Tachypnoea Unilateral localized lung signs CXR Homogenous opacity Sputum Gram stain culture Hospitalization if indicated Temp. Pulse, BP monitoring Inj. Benzyl Penicillin 10L IVQ6 Tab.Clarithromycin 500mg BID Tab Azithromycin 500mg BID Tab Levofloxacin 500mg BID 13

LRTI - Brochopneumonia : 

LRTI - Brochopneumonia Acute onset of fever High grade continuous Chills and rigor not much More dyspnoeic than lobar Initial pleuritic chest pain Expectorate mucoid sputum O/E Bilateral lung signs Dramatic presentation Febrile patient Tachycardia and Tachypnoea Bilateral difuse lung signs Viral or tuberculous etiology Stapylococcal pneumatoceles Hospitalization indicated ICU admission required Temp. Pulse, BP monitoring Inj. Amoxiclav 500mg TID Tab Levofloxacin 500mg BID Watch for complication ARDS 14

LRTI - Interstitial Pneumonia : 

LRTI - Interstitial Pneumonia Subacute onset of fever Low grade continuous No chills and rigor Initial pleuritic chest pain Dry cough initially Expectoration mucoid Rusty sputum/hemoptysis Non-dramatic presentation Afebrile patient Tachycardia & Tachypnoea Bilateral and diffuse lung signs CXR Reticulonodular shadows Viral or mycoplasma etiology Hospitalization is a must Often life threatening illness Intensive medical care Inj Methyl Prednisolone 0.5g Tab.Clarithromycin 500mg BID Tab Levofloxacin 500mg BID 15

Acute Pleurisy : 

Acute Pleurisy Acute onset fever Low grade continuous No Chills and rigor Typical pleuritic chest pain Continuing pain Dry cough initially No progressive dyspnoea Acute presentation Viral etiology – Coxackie B Bornholm’s disease Plain pleurisy, no effusion U/L pleural rub diagnostic Chest Xray may be normal OP treatment Antibiotics not needed Analgesics needed Acetaminophen high dose Splinting of the chest Watch for complications 16

Syn-pneumonic Pleural Effusion : 

Syn-pneumonic Pleural Effusion Acute onset of fever High grade continuous Chills and rigor characteristic Pleuritic chest pain Dry cough without dyspnoea Later progressive dyspnoea Evolves over few days Dramatic presentation again Febrile and toxic patient Delayed progressive dyspnea Tachycardia and tachypnoea Mediastinal shift  opposite Unilateral localized lung signs Hospitalization if indicated Temp. Pulse BP monitoring Inj. Benzyl Penicillin 10L IVQ6 Tab.Clarithromycin 500mg BID Therapeutic aspiration Chest tube drainage 17

Tuberculous Pleural Effusion : 

Tuberculous Pleural Effusion Low grade fever Evening rise of temperature Dry non-productive cough Pleuritic chest pain Slowly progressive dyspnoea Evolves over 3-4 weeks Even asymptomatic Non-dramatic presentation Febrile and ill looking patient Usually a uncontrolled diabetic History of contact with PTB Spread from underlying focus Pleural fluid study diagnostic Hospitalization if indicated Therapeutic aspiration Anti-tuberculous treatment Corticosteroid - Prednisolone Respiratory physiotherapy Watch for complications 18

Pneumothorax : 

Pneumothorax Pleuritic chest pain Acute onset dyspnoea Steadily progressive in nature Dry non-productive cough Feeling - something giving way Fever not likely to occur Even partial and asymptomatic Dramatic presentation Afebrile but acutely dyspnoeic Percussion diagnostic Immediate DD Acute LVF History of previous PTB Chest X-Ray diagnostic Hospitalization indicated Therapeutic aspiration Closed pleural aspiration Intercostal tube drain Anti-tuberculous treatment Watch for complications 19

Hydro-Pneumothorax : 

Hydro-Pneumothorax Pleuritic chest pain Subacute onset dyspnoea Steadily progressive in nature Dry non-productive cough Fever likely but low grade Rupture Pul lesion, aspiration H/o L Abscess, Br Ca, trauma Febrile not acutely dyspnoeic Horizontal upper level dullness Shifting dullness, S splash History of previous PTB CXR Horizontal upper level Pleural fluid study diagnostic Hospitalization indicated Therapeutic aspiration Intercostal tube drain Mediciser breath exercises Antibiotics needed Anti-tuberculous treatment 20

Tuberculosis – Cavity upper lobe : 

Tuberculosis – Cavity upper lobe Subacute onset Low grade fever Evening rise of temperature Dry non-productive cough Mucoid sputum - small amount Blood stained or Hemoptysis Loss of appetite and weight Low profile presentation Febrile but not acutely ill Usually a uncontrolled diabetic History of contact with PTB +ve Mx and +ve Sputum X-Ray chest with cavity AFL Hospitalization not indicated Confirmation of Diagnosis Anti-tuberculous treatment Register in RNTCP Administer Category 1 ATT Review with Sputum AFB 21

Tuberculosis - Fibrosis Upper Lobe : 

Tuberculosis - Fibrosis Upper Lobe Subacute onset Low grade fever Evening rise of temperature Dry non-productive cough Mucoid sputum - small amount Blood stained or Hemoptysis Dyspnoea if massive fibrosis Low profile presentation Febrile but not acutely Usually a uncontrolled diabetic History of contact with PTB +ve Mx and +ve Sputum X-Ray chest with cavity AFL Hospitalization indicated Therapeutic aspiration Intercostal tube drain Mediciser breath exercises Antibiotics needed Anti-tuberculous treatment 22

Tuberculosis - Miliary : 

Tuberculosis - Miliary Subacute onset Low grade fever Evening rise of temperature Dry non-productive cough Mucoid sputum - small amount Blood stained or Hemoptysis Loss of appetite and weight Low profile presentation Febrile and acutely ill looking Usually a uncontrolled diabetic History of contact with PTB -ve Mx and +ve Sputum X-Ray chest - miliary mottling Hospitalization indicated Life threatening illness Intensive medical care needed Anti-tuberculous treatment Corticosteroids Anti-tuberculous treatment 23

Suppurative Lung Disease - Bronchiectasis : 

Suppurative Lung Disease - Bronchiectasis Subacute onset chronic course Low grade fever and ill health Expectoration purulent sputum Foul smelling large quantity Postural variation in quantity Blood stained or Hemoptysis Loss of appetite and weight Low profile presentation Febrile but not acutely History of measles / W cough History of contact with PTB Coarse leathery crepirations HRCT – Gold standard Hospitalization not required Steam inhalation Lung physiotherapy Postural drainage Appropriate Antibiotics needed As per culture reports obtained 24

Suppurative Lung Disease – Lung Abscess : 

Suppurative Lung Disease – Lung Abscess Acute onset High grade fever and ill health Expectoration purulent sputum Foul smelling large quantity Postural variation in quantity Blood stained or Hemoptysis Not if not communicating High profile presentation Febrile and acutely ill toxic H/o unresolved pneumonia H/o foreign body aspiration Variable physical signs CXR and CT chest diagnostic Hospitalization Steam inhalation Lung physiotherapy Postural drainage Appropriate Antibiotics needed As per culture reports obtained 25

Suppurative Lung Disease – Empyema : 

Suppurative Lung Disease – Empyema History similar to effusion But more acute onset High grade fever and ill health If communicating to bronchus Expectoration purulent sputum Foul smelling large quantity Postural variation in quantity Picture-Synpneumonic effusion Febrile and acutely ill toxic History unresolved pneumonia Diabetes, lung abscess, PTB Intercostal edema / tenderness CXR and CT chest diagnostic Hospitalization required Intercostal tube drainage Under water seal ensured Appropriate Antibiotics needed As per culture reports obtained Decortication of the pleura 26

Pulmonary Collapse - Atelectasis : 

Pulmonary Collapse - Atelectasis History insignificant May be foreign body No fever or cough Chest discomfort on side Breathlessness if severe Expectoration minimal Loss of appetite and weight High index of suspicion Foreign body aspiration Feature of lung mass Features of volume loss CXR diagnostic CT Scan mandatory Encourage Coughing Lung physiotherapy/suction Bronchoscopic aspiration Foreign body/mass removal Continuous positive pressure Mechanical ventilation 27

Pulmonary Embolism Infarction : 

Pulmonary Embolism Infarction Difficulty in breathing Pain or discomfort in chest Cough and hemoptysis Sudden collapse or death Background venous thrombus Prolonged bed rest / coma O/E Tachypnoea Tachycardia Typical clinical presentation Need - high index of suspicion S1 Q3 T3 in ECG may be clue D Dimer test only to exclude CXR and CT chest diagnostic Gold standard - Angiography Anticoagulant medication Inj. Heparin or Warfarin Thrombolyitic Therapy Inferior venacaval Filter Pulmonary Thrombectomy Prevention is better than cure 28

Bronchogenic Carcinoma : 

Bronchogenic Carcinoma Chronic dry cough Blood tinge or hemoptysis Dysphonia and dysphagia Loss of appetite and weight Collapse consolidation / mass Paraneoplastic manifestations Presentation with secondaries Subacute illness male smoker Ill looking emaciation L nodes Horners / Brachial Neuralgia CXR – Obvious mass/widening Atelectsis/consolidation/LNs CT Chest and guided biopsy SCLC respond chemotherapy Brachitherapy /radiotherapy SCLC -Cisplatin and Etoposide NSCLC respond to surgery Wedge or segment resection Lobectomy or Pneumonectomy 29

Interstitial Lung Disease : 

Interstitial Lung Disease Chronic disabling dyspnoea Low grade fever & hemoptysis Exposure to organic/inorganic Underlying Connective Tissue Current & previous medication Infection or malignancy related O/E Diffuse Parenchymal LD Prolonged disabling illness Underlying cause determined CXR – suggest not diagnostic PFT – Restrictive pattern HRCT usually diagnostic Lung biopsy to exclude cancer Different Pathological causes Different for each disease Avoid occupational exposure Corticosteroids Prednisolone Immunosuppressant drugs Hypoxemia - Supplement O2 30

Summary : 

Summary 31

Slide 32: 

Thank You 32

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