Treatment of respiratory opd cases with clinical features and inveetigations and treatment with dosage and brand name
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Respiratory OPD Cases: Clinical Features, Investigations & Treatment
Below are the most common respiratory conditions seen in outpatient practice, presented in a practical clinical format.
1. BRONCHIAL ASTHMA
Clinical Features
- Symptoms: Recurrent episodes of wheezing, breathlessness, chest tightness, cough (especially nocturnal)
- Triggers: Allergens (dust, pollen, animal dander), cold air, exercise, viral URTIs, NSAIDs, stress, smoke
- Signs: Bilateral expiratory wheeze, prolonged expiration, use of accessory muscles in severe attacks
- Note: "Not all wheezing is asthma, and not all asthma has wheezing" - Textbook of Family Medicine 9e
Investigations
| Test | Finding in Asthma |
|---|---|
| Spirometry (gold standard) | FEV1/FVC <70%, reversibility >12% (>200 mL) after bronchodilator |
| Peak Expiratory Flow Rate (PEFR) | Reduced; diurnal variation >20% |
| Chest X-ray | Hyperinflation in severe/chronic cases; usually normal |
| CBC | Eosinophilia (especially in allergic asthma) |
| Serum IgE | Elevated in atopic asthma |
| Skin prick test / RAST | Identify allergens |
| ABG (severe attacks) | Hypoxia; initially hypocapnia, late hypercapnia = danger sign |
Asthma Severity Classification (for initiating therapy):
Treatment (Stepwise Approach - Adults)
Step 1 - Intermittent Asthma (symptoms ≤2 days/week):
| Drug | Dose | Brand Name (India) |
|---|---|---|
| Salbutamol (Albuterol) inhaler (SABA - reliever) | 100-200 mcg (1-2 puffs) PRN | Asthalin, Ventorlin |
| Levosalbutamol inhaler | 50-100 mcg PRN | Levolin |
Step 2 - Mild Persistent (symptoms >2 days/week but not daily):
| Drug | Dose | Brand Name |
|---|---|---|
| Budesonide inhaler (ICS) | 200-400 mcg/day | Budecort, Pulmicort |
| Beclomethasone dipropionate (ICS) | 200-400 mcg/day | Beclate, Becotide |
| Montelukast (LTRA - alternative) | 10 mg OD at night (adults); 5 mg OD (child 6-14 yr) | Montair, Montek |
| + SABA as needed | As above | Asthalin |
Step 3 - Moderate Persistent (daily symptoms):
| Drug | Dose | Brand Name |
|---|---|---|
| Budesonide + Formoterol (ICS+LABA combo) | 200/6 mcg, 1-2 puffs BD | Symbicort, Foracort |
| Fluticasone + Salmeterol | 250/25 mcg, 1 puff BD | Seretide, Foxair, Combitide |
| Montelukast (add-on) | 10 mg OD | Montair |
Step 4 - Severe Persistent (continual symptoms throughout day):
| Drug | Dose | Brand Name |
|---|---|---|
| High-dose ICS+LABA | Budesonide/Formoterol 400/12 mcg, 2 puffs BD | Foracort 400, Symbicort |
| Theophylline SR (add-on) | 200-400 mg BD | Deriphyllin, Theo-Asthalin |
| Prednisolone (oral, for exacerbations) | 40-60 mg/day x 5-7 days | Omnacortil, Wysolone |
| Ipratropium bromide (anticholinergic, add-on) | 20-40 mcg (2-4 puffs) 3-4x/day | Ipravent, Atrovent |
2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Clinical Features
- Symptoms: Chronic progressive dyspnea, chronic productive cough, sputum (especially morning), decreased exercise tolerance
- History: Long-term smoker (>10 pack-years), biomass fuel exposure
- Signs: Barrel chest, hyperresonant percussion, reduced breath sounds, expiratory wheeze, prolonged expiration, "pink puffer" (emphysema) or "blue bloater" (chronic bronchitis)
- Comorbidities: Cardiovascular disease, depression, anxiety, muscle wasting, anemia
Investigations
| Test | Finding |
|---|---|
| Spirometry (post-bronchodilator) | FEV1/FVC <0.70 (fixed obstruction, not fully reversible) |
| FEV1 % predicted | Grades severity: Mild >80%, Moderate 50-79%, Severe 30-49%, Very severe <30% |
| Chest X-ray | Hyperinflation, flattened diaphragm, increased AP diameter, bullae |
| HRCT chest | Emphysematous changes, air trapping |
| CBC | Polycythemia (secondary), eosinophils guide ICS use |
| ABG | Hypoxemia, hypercapnia in advanced disease |
| ECG | Cor pulmonale (P pulmonale, right axis deviation) |
| 6-Minute Walk Test | Functional capacity assessment |
Treatment (GOLD 2024 Guidelines)
Bronchodilators - First line:
| Drug | Dose | Brand Name |
|---|---|---|
| Salbutamol (SABA) | 100-200 mcg, 2-4x/day | Asthalin, Ventolin |
| Ipratropium bromide (SAMA) | 20-40 mcg (2-4 puffs) 3-4x/day | Ipravent, Atrovent |
| Tiotropium (LAMA - once daily) | 18 mcg (1 capsule) OD via Handihaler | Tiova, Spiriva |
| Indacaterol (LABA - once daily) | 150-300 mcg OD | Onbrez |
| Glycopyrronium (LAMA) | 50 mcg OD | Seebri |
Combination bronchodilators (LABA+LAMA):
| Drug | Dose | Brand Name |
|---|---|---|
| Indacaterol+Glycopyrronium | 110/50 mcg OD | Ultibro |
| Tiotropium+Olodaterol | 2.5/2.5 mcg, 2 puffs OD | Stiolto |
| Formoterol+Ipratropium | 12/200 mcg BD | Duolin |
Add ICS only if: Blood eosinophils ≥300 cells/mcL, or history of frequent exacerbations, or concurrent asthma:
| Drug | Dose | Brand Name |
|---|---|---|
| Budesonide+Formoterol | 320/9 mcg BD | Foracort 400 |
| Fluticasone+Salmeterol | 500/50 mcg BD | Seretide 500 |
COPD Exacerbation management:
| Drug | Dose | Brand Name |
|---|---|---|
| Prednisolone | 40 mg/day x 5 days | Omnacortil |
| Antibiotics (if purulent sputum): Amoxicillin-Clavulanate | 625 mg TDS x 5-7 days | Augmentin, Moxclav |
| OR Azithromycin | 500 mg OD x 3-5 days | Zithromax, Azithral |
| OR Levofloxacin (severe) | 750 mg OD x 5-7 days | Levoday, Tavanic |
| Roflumilast (PDE4 inhibitor, severe COPD with chronic bronchitis) | 500 mcg OD | Daxas |
3. UPPER RESPIRATORY TRACT INFECTION (URTI)
Clinical Features
- Rhinorrhea, nasal congestion, sneezing, mild sore throat, low-grade fever
- Mild cough, malaise; usually self-limiting in 7-10 days
- Mostly viral (rhinovirus, coronavirus, influenza)
Investigations
- Usually clinical diagnosis; no investigations needed for mild URTI
- Throat swab culture (if streptococcal pharyngitis suspected)
- Rapid Strep test (RADT)
- CBC (to differentiate viral vs bacterial)
Treatment
| Drug | Dose | Brand Name |
|---|---|---|
| Paracetamol (fever/pain) | 500-1000 mg TDS | Calpol, Crocin, Dolo |
| Cetirizine (antihistamine for rhinorrhea) | 10 mg OD at night | Cetcip, Zyrtec |
| Loratadine | 10 mg OD | Lorfast, Clarityn |
| Oxymetazoline nasal spray (decongestant, max 5 days) | 1-2 sprays/nostril BD | Otrivin, Nasivion |
| Dextromethorphan (for dry cough) | 15-30 mg TDS | Cofsils DM, Alex |
| Ambroxol (mucolytic, if thick secretions) | 30 mg TDS | Mucolite, Ambrodil |
| Antibiotics only if: Secondary bacterial infection (purulent sputum, high fever, tonsillar exudate for >72 hrs) | ||
| Amoxicillin (strep pharyngitis) | 500 mg TDS x 7-10 days | Mox, Amoxil |
| Azithromycin (penicillin allergy) | 500 mg OD x 3 days | Azithral |
4. COMMUNITY-ACQUIRED PNEUMONIA (CAP)
Clinical Features
- Fever (>38°C), chills, productive cough (rusty/purulent sputum), pleuritic chest pain
- Dyspnea, tachypnea (>20 breaths/min), tachycardia
- Signs: Dullness on percussion, bronchial breath sounds, increased vocal resonance, crackles
Investigations
| Test | Finding |
|---|---|
| Chest X-ray | Lobar/segmental consolidation, air bronchograms |
| CBC | Leukocytosis (WBC >11,000), left shift |
| CRP / ESR | Elevated |
| Sputum Gram stain + Culture & Sensitivity | Identify pathogen |
| Blood culture x2 | Positive in bacteremic pneumonia |
| Procalcitonin | Elevated in bacterial pneumonia |
| Pulse oximetry / ABG | SpO2 assessment |
| Urine Legionella antigen | If Legionella suspected |
| CURB-65 score | Assess severity, guide admission |
CURB-65 Severity Score
- C = Confusion, U = Urea >7 mmol/L, R = RR ≥30/min, B = BP <90/60, Age ≥65
- Score 0-1: Treat as outpatient; Score 2: Consider hospitalization; Score ≥3: Severe - hospitalize/ICU
Treatment
Outpatient (mild CAP, CURB-65 0-1):
| Drug | Dose | Brand Name |
|---|---|---|
| Amoxicillin | 500-1000 mg TDS x 5-7 days | Mox, Cipmox |
| OR Amoxicillin-Clavulanate | 625 mg TDS x 5-7 days | Augmentin |
| + Azithromycin (for atypicals) | 500 mg OD x 5 days | Azithral, Zithromax |
| Levofloxacin (monotherapy option) | 750 mg OD x 5 days | Levoday, Tavanic |
| Moxifloxacin (respiratory fluoroquinolone) | 400 mg OD x 5 days | Moxiflox, Avelox |
Adjuncts:
| Drug | Dose | Brand Name |
|---|---|---|
| Paracetamol (fever) | 1000 mg TDS | Crocin, Dolo 650 |
| Ambroxol (mucolytic) | 75 mg SR OD or 30 mg TDS | Ambrodil SR, Mucolite |
| Vitamin C + Zinc (supportive) | OTC doses | Limcee, Zincovit |
5. ALLERGIC RHINITIS (Major driver of respiratory OPD)
Clinical Features
- Paroxysmal sneezing, profuse watery rhinorrhea, nasal congestion, nasal/palatal/eye itching
- "Allergic salute", bluish-grey turbinates on examination, post-nasal drip causing chronic cough
- Seasonal (pollens) or perennial (dust mites, pet dander)
- Often co-exists with asthma - "one airway, one disease"
Investigations
- Clinical diagnosis
- Skin prick test / Specific IgE (RAST) - identify allergen
- Nasal cytology - eosinophilia
- Nasal endoscopy if indicated
Treatment
| Drug | Dose | Brand Name |
|---|---|---|
| Intranasal Fluticasone (first-line) | 2 sprays/nostril OD | Flonase, Flixonase, Nasoflo |
| Intranasal Mometasone | 2 sprays/nostril OD | Nasonex, Momesone |
| Intranasal Budesonide | 2 sprays/nostril BD | Rhinocort |
| Cetirizine (2nd gen antihistamine) | 10 mg OD | Cetcip, Zyrtec |
| Fexofenadine | 120-180 mg OD | Allegra, Fexova |
| Loratadine | 10 mg OD | Lorfast, Clarityn |
| Montelukast (LTRA, add-on) | 10 mg OD night | Montair, Montek |
| Montelukast + Levocetirizine (combo) | 1 tab OD at night | Montair-LC, Montek-LC |
| Ipratropium nasal spray (for watery rhinorrhea) | 2 sprays/nostril BD-TDS | Ipravent nasal |
6. ACUTE BRONCHITIS
Clinical Features
- Productive cough (white/yellow sputum), low-grade fever, malaise
- Chest discomfort, mild wheeze possible
- Usually follows URTI; mostly viral
- Resolves in 2-3 weeks
Investigations
- Mostly clinical; chest X-ray to exclude pneumonia
- CBC: may show mild leukocytosis
Treatment (mostly symptomatic)
| Drug | Dose | Brand Name |
|---|---|---|
| Ambroxol (mucolytic) | 30 mg TDS or 75 mg SR OD | Ambrodil, Mucolite |
| Salbutamol inhaler (if wheeze) | 100-200 mcg PRN | Asthalin |
| Dextromethorphan (for dry irritating cough) | 15-30 mg TDS | Alex DX, Cofsils DM |
| Paracetamol (fever/malaise) | 500-1000 mg TDS | Crocin, Dolo |
| Antibiotics (only if secondary bacterial infection): Amoxicillin-Clavulanate | 625 mg TDS x 5 days | Augmentin |
7. PULMONARY TUBERCULOSIS (TB) - Important in South Asia
Clinical Features
- Chronic cough >2 weeks, hemoptysis, evening fever, drenching night sweats
- Weight loss, anorexia, fatigue
- Signs: Reduced breath sounds, crackles in upper lobes
Investigations
| Test | Finding |
|---|---|
| Sputum AFB smear x 2 | Acid-fast bacilli |
| Sputum CBNAAT/GeneXpert | Confirms MTB + rifampicin resistance in 2 hrs |
| Chest X-ray | Upper lobe infiltrates, cavitation, fibrosis, hilar lymphadenopathy |
| Mantoux test (TST) | Induration ≥10 mm (positive in non-immunocompromised) |
| IGRA (QuantiFERON) | Latent TB diagnosis |
| CBC, LFT, RFT, Blood sugar | Before starting ATT (baseline) |
Treatment (RNTCP/NTEP - India, DOTS regimen)
Intensive Phase (2 months):
| Drug | Daily Dose (by weight) | Brand Name |
|---|---|---|
| Isoniazid (H) | 5 mg/kg (max 300 mg) | Isonex, Stanozide |
| Rifampicin (R) | 10 mg/kg (max 600 mg) | Rifocin, Rimactane |
| Pyrazinamide (Z) | 25 mg/kg (max 2 g) | Pyrafat |
| Ethambutol (E) | 15 mg/kg | Combutol |
| Fixed-dose combination (FDC) used in NTEP | Weight-based FDC | Forox (H+R+Z+E) |
Continuation Phase (4 months):
| Drug | Dose | Brand Name |
|---|---|---|
| Isoniazid + Rifampicin | As above | Rifinah, Macox |
| Pyridoxine (B6 - prevents INH neuropathy) | 10-25 mg OD | Benadon |
Key Prescribing Principles for Respiratory OPD
- Inhaler technique must always be demonstrated; a good drug with poor technique = poor outcome
- Spirometry before and after bronchodilator is the standard for asthma and COPD diagnosis
- Do not over-prescribe antibiotics for viral URTIs and acute bronchitis - most resolve without them
- Allergy control + trigger avoidance are as important as medications in asthma and allergic rhinitis
- COPD is irreversible but treatable - smoking cessation remains the single most effective intervention
- CURB-65 guides pneumonia severity and treatment setting decision
- Monitor for side effects: ICS - oral candidiasis (rinse mouth after); fluoroquinolones - tendinopathy, QT prolongation; theophylline - narrow therapeutic index, check levels
Sources: Katzung's Basic and Clinical Pharmacology 16e, Textbook of Family Medicine 9e, Murray & Nadel's Textbook of Respiratory Medicine, Fishman's Pulmonary Diseases and Disorders, GOLD 2024 COPD Guidelines
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