Acute Cough

Department of General Practice RCSI Medical School Dublin

Acute cough

Senior Cycle 1 General Practice

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Format of module

1 Acute cough2 Format of module3 Structure of eLearning modules4 Learning outcomes5 Patient scenario6 Epidemiology 7 Aetiology8 Diagnosis9 Investigation & referral10 Prognosis11 Children: duration of cough12 Children: repeat consultations13 Children: antibiotic resolution

14 Children: antibiotic complications15 Children: antibiotic side effects16 Adults: antibiotic resolution17 Adults: antibiotic duration18 Adults: side effects19 Adults: OTC treatments20 Antibiotics21 Management strategies22 Delayed v immediate treatment23 Patient information leaflets/ weblinks24 Patient scenario revisited25 References & sources26 Post-test MCQ/ Evaluation reminder

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Structure of eLearning modules

1 Pre-test MCQ attempt to assess prior knowledge2 eLearning module + references3 Post-test MCQ to assess new learning4 Self-directed learning from resources provided5 Repeat post-test MCQ attempts6 eModule overall evaluation

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Learning outcomes

At the end of the module you should be able to:

1 Describe the clinical features of acute cough in children & adults

2 Outline the benefits & harms of common treatment options

3 Discuss how to manage a patient with acute cough

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Patient scenario

History40 year old man7 day history of mild shortness of breath and cough.Productive of purulent sputum. No relevant past history. Smokes 10 day.Works as insurance agent.

ExaminationVital signs normal. Auscultation: scattered wheeze.

ConsultationRequests antibiotic as “last doctor prescribed it for me”

What is the likely cause of his symptoms?

What is the likely duration of illness?

What treatment would you recommend?

How would you deal with his request for antibiotics?

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Epidemiology

AdultsUS: affects 5% adults 90% seek medical attentionUK: consultation rate 77.2 /1000 person years at risk

Children UK consultation rate 310/1000 person years at risk 0-4 years100/1000 person years at risk 5-15 years

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Diagnosis

AdultsDiagnosis on clinical groundsAbsence of vital sign abnormality &abnormal findings onChest auscultation “rules out”pneumonia

ChildrenPreceding coryzaSome valuei n clinical findings of fever or chest signs

Children: re-consultation probabilityPost-test probabilities-------------------------------------------------------------------------Category of interest Post-test probability(% who have sign) % (95% CI)-------------------------------------------------------------------------Neither sign (71) 6.5 (3.1 to 11.7)Chest signs only (21) 18.2 (6.9 to 35)Fever only (11) 27.8 (9.6 to 53)Both signs (3) 40.0 (5.2 to 85)

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Aetiology

Viral 50-80%InfluenzaParainfluenzaRespiratory syncitial virus (RSV)Pertussis

Bacterial 20% adults, <10% childrenTypicalStrep pneumoniaeHaemophilus influenzae

AtypicalMycoplasmaBordetella

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Investigation & referral

Diagnostic testsSputum seldom indicatedA normal CRP is of prognostic value to rule out community acquired pneumoniaChest X ray rarely indicated (unless other features suggest it)

Referral1 to 5% referred to hospital“Sick” childVulnerable adults:

• Elderly

• Co-morbidity

• Institutionalised

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Prognosis

AdultsInitial consult 7-10 days durationSubsequent duration 10-14 daysRe-consultation 15-20%

ChildrenDuration of illness similar to adultsParents expectations

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Duration of cough in pre-school children

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Therapy

AntibioticsOver the counter (OTC) preparations

SUMMARYWorldwide, it is estimated that half of all medicines are inappropriately prescribed, dispensed or sold, and that half of all patients fail to take their medicine properly.

An estimated two-thirds of global antibiotic sales occur without any prescription, and studies in Indonesia, Pakistan and India show that over 70% of patients were prescribed antibiotics.

The great majority - up to 90% - are estimated to be unnecessary.

The inappropriate use of medicines is not only widespread, it is costly and extremely harmful both to the individual and the population as a whole.

Adverse drug events rank among the top 10 causes of death in the USA and are estimated to cost that country between US$ 30 and US$ 130 billion each year.

Growing resistance to antimicrobial medicines is a particularly serious challenge in countries at all economic levels, and results largely from inappropriate prescribing and use. For the treatment of malaria, chloroquine resistance is now established in 81 of the 92 countries in which the disease is endemic.

Much greater use of evidence-based diagnostic and treatment guidelines by health professionals is needed.

More effective monitoring and regulation of medicines, and public education and information are important components of a strategy for increased rational use. WHO http://apps.who.int/medicinedocs/fr/d/Js6160e/10.html

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http://apps.who.int/medicinedocs/fr/d/Js6160e/10.html


Antibiotic: choice of drug

Typical organismsAminopenicillinTetracyclineMacrolide

Atypical organismsTetracyclineMacrolide

Penicillin sensitiveMacrolideTrimethoprim

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Adults: antibiotics resolution

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Adults: antibiotics duration

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Adults: antibiotics side effects

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Children: antibiotics resolution

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Children: antibiotics complications

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Children: antibiotics side effects

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Antibiotics

BenefitsDuration of illness (adults)Complications (children)

RisksSide effectsMedicalisationResistanceCost

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Adults- over the counter medicines

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Management strategies

Delayed prescribing

Patient Information Leaflet (PiL)

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Duration of cough: delayed v immediate antibiotic

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Patient Information Leaflet

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Patient scenario (revisited)

History40 year old man7 day history of mild shortness of breath and cough.Productive of purulent sputum. No relevant past history. Smokes 10 day.Works as insurance agent.

ExaminationVital signs normal. Auscultation: scattered wheeze.

ConsultationRequests antibiotic as “last doctor prescribed it for me”

What is the likely cause of his symptoms?

What is the likely duration of illness?

What treatment would you recommend?

How would you deal with his request for antibiotics?

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Additional resources

Cochrane Review (adults)http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000245/frame.html

Clinical Knowledge Summaries (CKS)http://cks.library.nhs.uk/chest_infections/in_summary/acute_bronchitis

Patient UKAdults http://www.patient.co.uk/pdf/pilsL520.pdf Children http://www.patient.co.uk/pdf/pilsL43.pdf

OGPL (Oxford General Practice Library) Respiratory Problems Lynch J & Simon C 1st edition (2007)

GP Notebook www.gpnotebook.co.uk

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http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000245/frame.html

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000245/frame.html

http://cks.library.nhs.uk/chest_infections/in_summary/acute_bronchitis

http://cks.library.nhs.uk/chest_infections/in_summary/acute_bronchitis

http://www.patient.co.uk/pdf/pilsL520.pdf



http://www.gpnotebook.co.uk/


Post-test MCQ & Evaluation reminder

Now, please take your Post-test MCQ

Finally, remember to complete the eModule Evaluation. Thank you.

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Acute Cough

Documents

Transcript of Acute Cough