Respiratory

• Airways: asthma (including cough-variant), COPD, bronchiectasis, cystic fibrosis.
• Malignancy: lung cancer — the one you cannot miss in a smoker with a changed cough.
• Upper airway cough syndrome (post-nasal drip) and gastro-oesophageal reflux — the two commonest causes in non-smokers with a normal CXR, alongside asthma.
• Cardiac: heart failure. Interstitial: pulmonary fibrosis. Also OSA and ACE inhibitors — always check the medication list.

Honey (2.5–10 mL) modestly reduces nocturnal cough and improves sleep in children with viral URTI — it coats pharyngeal cough receptors and dampens the cough reflex arc via the nucleus tractus solitarius.

• Occupational hypersensitivity pneumonitis from thermophilic actinomycetes in mouldy sugar cane bagasse.
• Acute form within 4–8 hours of exposure: fever, dry cough, dyspnoea — often mistaken for infection; it settles away from work and recurs on return.
• Prevention is the treatment: exposure avoidance, PPE and workplace dust control. Take an occupational history in every unexplained breathlessness.

Asymptomatic pulmonary sarcoidosis (e.g. incidental bihilar lymphadenopathy) usually needs no treatment — most cases remit spontaneously. Reserve corticosteroids for progressive or symptomatic lung disease and for significant extrapulmonary involvement: cardiac, neurological, ocular, hypercalcaemia, or renal.

• Preferred site is the 5th intercostal space, just anterior to the mid-axillary line (the “safe triangle”) — chest walls are often too thick at the classic 2nd space mid-clavicular line for the needle to reach the pleura.
• Always insert immediately above the rib below, to avoid the neurovascular bundle running under each rib.
• If the patient is stable enough, the Seldinger technique has fewer complications than blunt dissection for a small-bore drain.

• Open (“sucking”) chest wound: apply a three-sided occlusive dressing so it acts as a one-way flutter valve — air escapes on expiration but cannot be drawn in on inspiration. (A commercial vented chest seal is the modern equivalent.)
• Tracheobronchial injury: suspect with a persistent large air leak and failure of the lung to re-expand despite a functioning drain. Advance the ET tube into the unaffected main bronchus to isolate the injured side, and additional chest drains may be needed while arranging urgent thoracic surgical review and bronchoscopy.

Two or more adjacent ribs fractured in two or more places creates a free-floating segment that moves paradoxically — inward on inspiration, outward on expiration. The bigger problem is the underlying pulmonary contusion and the splinting from pain, so prioritise analgesia (including regional blocks), physiotherapy and respiratory support rather than fixating on the paradox itself.

Think of it in an obese patient with excessive daytime sleepiness and poor sleep, often with coexisting OSA — the defining feature is chronic daytime hypercapnia. Check a VBG (or ABG) for CO2 to confirm chronic respiratory failure; don't rely on sleepiness alone to make the diagnosis.

Most of ipratropium's added bronchodilator benefit in acute severe asthma/COPD occurs with the first few doses (commonly the first 3, within the first hour) — continuing regular dosing beyond that adds little further benefit, so many protocols limit ongoing ipratropium after the initial loading doses in favour of continued short-acting beta-agonist therapy.