18 - Asthma and COPD Flashcards
What are the four different patterns on a spirometry?
Spirometry is breathing out as quickly as possible after the maxiumum inspiratory level
- Normal: normal FEV1, FVC, FEV1/FVC ratio
- Restrictive: reduced FVC, normal FEV1/FVC ratio
- Obstructive: normal FVC, reduced FEV1, reduced FEV1/FVC ratio <70% PEFR also reduced
- Mixed: FVC reduced and FEV1/FVC ratio reduced
What are some tests used in the diagnosis/investigations of asthma?
- Patterns of breathing (e.g VC, ERV, see image)
- Spirometry with obstructive pattern and reversibility
- Serial PEFR measurement (BD for 2-4 weeks then regularly when diagnosed. Variability of 20% is positive test)
- Exhaled Nitric Oxide Test (FENO) (positive over 35ppb in children, over 40ppb in adults)
- Direct Bronchial Challenge Test with histamine or methacholine (done in specialist care when normal spirometry or obstructive spirometry with no reversibility. Positive if PC20 of 8mg/ml or less)
(google if need a reminder^^)
How is reversibility in spirometry tested for?
Repeat spirometry 20-30 minutes after salbutamol 2 puffs into a large volume spacer
If reversibility there will be an improvement in FEV1/FVC ratio by at least 12%
How does the exhaled nitric oxide test work to help support a diagnosis of asthma?
If produced in the body it is a sign of inflammation, higher levels in breath can indicate asthma
Can be falsely raised if smoker, using ICS or if eating nitrate rich food an hour before test (e.g green leafy veg, beetroot, alcohol, caffeine)
>40ppb likely to have asthma but 1 in 5 with negative result will have asthma and 1 in 5 with positive result won’t have asthma
How would you explain to a patient how to perform a peak flow test in an OSCE?
Normal is between 400 to 700 but depends on gender, height and age.
Variation up to 20% can indicate ashtma. Will be variation in night and day
What are the different types of inhalers in terms of administration and what is the correct inhaler technique for each one?
Rememeber to take off cap and check inside for any foreign objects, shake before use, if using for first time do two puffs out or twist bottom till hear a click, stand or sit uprright, tilt head back, exhale
- Pressured MDIs: exhale, wrap lips around device, press device and breathe in slowly then hold breath for 10 seconds
- MDI with Spacer: same technique as first but put inhaler in spacer or if child allow them to breathe normally and just take 6 breaths in the spacer with no need to hold breath
- DPIs: exhale, put device in mouth and inhale fast and deeply. hold breath for 10 seconds
- SMIS: new type of inhaler that works by soft mist. slow moving mist, breathe in slowly then hold breathe for 10 seconds
What are some inhaler combinations that are used?
- ICS/LABA (asthma and COPD, purple)
- LABA/LAMA (COPD)
- ICS/LABA/LAA (COPD)
How many times should inhalers be used in a day?
ICS - one puff twice daily
SABA - PRN (2 puffs 3-4 times a day with 4 puffs (8mg) being max single dose)
If using steroid inhaler rinse mouth with water or mouthwash after use to prevent oral thrush
What is the pathophysiology behind asthma?
- Chronic intermittent respiratory condition associated with airway inflammation and hyperresponsiveness
- There are bronchospasms, bronchial oedema and airway obstruction
- Can be airway remodelling
What are some symptoms that should make you suspect asthma?
- Widespread expiratory wheeze (sometimes only heard on auscultation)
- Dry cough
- Breathlessness
- Chest tightness
- Personal/Family history of atopy
- Triggers that make the symptoms worse (e.g cold air, exercise, allergen exposure, occur after taking NSAIDs or beta blockers, worse in evening and early morning)
What are some risk factors for asthma?
- Personal or family history of atopy
- Respiratory infections in infancy
- Exposure to tobacco smoke (even prenatally)
- Premature birth and low birth weight
- Obesity
- Social deprivation (e.g fungal spores and smoking)
- Workplace exposures (e.g flour dust)
How is asthma diagnosed?
- No single diagnostic test, mixture of their signs and symptoms along with respiratory tests mentioned earlier
- If under 5 and cannot perform all objective tests use clinical judgement. When reach 5 carry out tests
- If cannot perform one test need to perform at least 2 other objective tests
What is the order that objective asthma tests should be carried out in?
Children: spirometry with BDR, then FeNO if uncertainty, then peak flow variability for 2-4 weeks
Adults: - FeNO (Fractional Exhaled Nitric Oxide) Test: A FeNO level of 40 parts per billion (ppb) or more is considered positive.
- Spirometry with Reversibility: Perform spirometry to measure FEV1 (forced expiratory volume in 1 second) and FVC (forced vital capacity). A bronchodilator reversibility (BDR) test should be conducted if spirometry indicates obstruction (FEV1/FVC ratio less than 70%). An increase in FEV1 of 12% and 200 ml is considered significant.
- Peak Expiratory Flow (PEF) Variability: Measure PEF twice daily for 2-4 weeks to assess variability. 20%
What are some red flag signs that would make you suspect an alternative diagnosis to asthma?
What is the aim of asthma management?
Control, this is acheieved when:
- No daytime symptoms.
- No night-time waking due to asthma
- No need for rescue medication
- No asthma attacks
- No limitations on activity including exercise.
- Normal lung function (FEV1 and/or PEF > 80% predicted or best)
- Minimal side-effects from medication.
Apart from prescribing pharmacological managements, what management is carried out in primary care for newly diagnosed asthmatics?
- Assess persons baseline asthma status e.g with questionnaires or lung function tests
- Provide self-management education and a personalised asthma action plan
- Provide sources of info e.g Asthma UK and British Lung Foundation
- Provide advice on weight loss, smoking cessation and breathing exercises
- Ensure the person has their own peak flow meter
- Tell patient to avoid any triggers
- Prescribe inhalers and review in 4-8 weeks
What is a personalised asthma action plan?
Everyone with asthma should have one.
Tells patient:
- what medicines to take every day to prevent symptoms
- what to do if asthma symptoms getting worse
- what to do in an emergency if having an asthma attack
How should a person with asthma be followed up?
Annual review:
- Check peak flow or spirometry
- Check inhaler technique
- Check symptoms including control with RCP 3 questions(see image)
- Calculate future risk of asthma attacks
- People on long-term steroid tablets e.g over 3 months or more than 3-4 course in a year, should check cholesterol, HbA1c, vision check, BP
- If any medication follow up in 4-8 weeks
When should you consider giving oral macrolides to prevent exacerbations in asthma?
- People aged 50–70 who have ongoing symptoms, despite high-dose inhaled steroids, who have suffered one exacerbation requiring oral steroids in the previous year
- Used to try to reduce exacerbation frequency
- Treatment with azithromycin 500 mg three times per week, should be considered for a minimum of 6–12 months
What are the Royal College of Physicians 3 Questions used in asthma reviews?
Answering no to all three questions suggest asthma control
What is the pharmacological therapy for asthma in adults?
- Start point depending on severity of asthma but most start on SABA PRN for short lived infrequent wheeze
- Step up and step down depending on control checking inhaler technique at every appointment
- See image for details
What is a MART regime in asthma control?
- Maintenance and reliever therapy
- LABA and ICS in one inhaler
- Only available when LABA is fast acting such as formoterol
What are some examples of drugs in the following categories?
- SABA
- LABA
- SAMA
- LAMA
- ICS
SABA: salbutamol, terbutaline sulfate
LABA: salmeterol, formoterol
SAMA: ipratropium bromide
LAMA: tiotropium
ICS: beclomethasone, budesonide, fluticasone
What is the pharmacological therapy for asthma in children?
- Step up and down
- LTRA trial for 4-8 weeks if ICS and reliever not controlling
- If LTRA not controlling stop LTRA and start ICS/LABA
- Consider decreasing maintenance therapy once a person’s asthma has been controlled with their current maintenance therapy for at least 3 months
What are the 4 steps of asthma self management?
- Track symptoms, any changes arrange an asthma review
- Measure peak flow
- Take preventer medicines
- Follow asthma self management plan
How do you assess the severity of an asthma exacerbation?
Moderate – PEFR more than 50–75% best or predicted and normal speech, with no features of acute severe or life-threatening asthma.
Acute severe – PEFR 33–50% best or predicted, or resp rate of at least 25, 30 aged 5 to 12, and 40 aged 2 to 5, or pulse 110, 125 in children 5-12 years, and 140 in children between 2-5, or inability to complete sentences in one breath, or accessory muscle use, or inability to feed (infants), with oxygen saturation of at least 92%.
Life-threatening – PEFR less than 33% best or predicted, or oxygen saturation of less than 92%, or altered consciousness, or exhaustion, or cardiac arrhythmia, orhypotension, or cyanosis, or poor respiratory effort, or silent chest, or confusion.
What defines uncontrolled asthma?
What would make you want to admit someone with an asthma exacerbation from primary care?
- Admit all people with life-threatening asthma
- Admit people with acute-severe that is not responding to bronchodilator treatment
- Admit with moderate if symptoms not improving or have had near fatal attack in the past or with one of the following features on the image
What should you do upon waiting for transfer to hopsital for an acute asthma exacerbation from primary care?
- Give controlled supplementary oxygen to all people with hypoxia using a face mask, Venturi mask, or nasal cannula to maintain sats between 94-98%
- Nebulised salbutamol 5mg (or 2.5mg if aged <5). Oxygen driven 6l/min
- If no nebuliser use MDI with spacer. 4 puffs then 5 tidal breaths with 2 puffs every 2 minutes up to 10 puffS. Repeat every 10-20 minutes
- If salbutamol not working consider nebulised ipratropium bromide if available
- Consider quaudruple dose of ICS at onset of attack then first dose of oral steroids prednisolone
How should you follow up someone in primary care after an acute asthma exacerbation?
- Within 48 hours of presentation or 48 hours after discharge from hospital
- Review symptoms and measure PEFR
- Consider stepping up or increasing ICS dose
- Address contributors to the exacerbation e.g allergens
- Ensure the person has a personalised asthma action plan
- Consider take home oral corticosteroids
- Advise on recognising poor asthma control
- If 2 attacks in 12 months refer to respiratory specialist
What is the pathophysiology of COPD?
- Persistant respiratory symptoms (e.g breathlessness, cough, sputum) and airflow obstruction that is not fully reversible and is progressive
- Treatable (not curable) and largely preventable lung condition
- Chronic inflammation from exposure to noxious particles and gas e.g tobacco, occupational exposures
What are some terms that COPD encompasses?
What are some risk factors for COPD?
- Tobacco smoking even passive smoke
- Occupational exposure (e.g coal, grains, silica)
- Air pollution
- Alpha-1-Antitrypsin deficiency (if COPD <40 consider)
- Maternal smoking
- Pre term birth
- Asthma
How is COPD diagnosed?
Symptoms, Examination + Spirometry
Symptoms: breathlessness (progressive and worse on exertion), chronic or recurrent cough, regular sputum production, frequent lower respiratory tract infections, wheeze
Examination: cyanosis, use of accessory muscles, hyperinflation of chest, cachexia, pursed lip breathing, wheeze or crackles on auscultation, raised JVP or peripheral oedema if cor pulmonale
Spirometry: FEV1/FVC <70% not reversible with bronchodilation
What is cor pulmonale and when should you suspect it?
Right sided heart failure secondary to lung disease, and is caused by pulmonary hypertension as a consequence of hypoxia.
Suspect if:
- Peripheral oedema
- Raised JVP
- Systolic parasternal heave
- A loud pulmonary second heart sound (over the second left intercostal space)
- Hepatomegaly
What questions should ask in a history when you suspect a patient has COPD?
- Onset, progression and variability of symptoms
- Check dyspnea with MRC scale
- Ask about cough and sputum and see if any haemoptysis
- Check if smoker or occupational hazards
- Check impact on life using CAT assessment
- Check vitals
- Measure BMI
- Listen to chest for any pulmonary oedema
What investigations should you arrange if you suspect a patient has COPD?
- CXR: exclude other causes like cancer and bronchiectasis
- FBC: look for anaemia or polycythaemia
- Spirometry
Possibly: sputum culture, ECG and serum natriuetic peptides, CT, alpha-1-antitrypsin serum
What is the MRC dyspnea scale?
How can you classify the severity of airway obstruction using the results of a spirometry?
What is Asthma-COPD overlap syndrome?
A person developing COPD may have some reversiblilty and steroid responsiveness
What are some complications of COPD?
- Exacerbations of COPD
- Cor Pulmonale
- Type 1 and Type 2 respiratory failure
- Depression and anxiety
- Pneumothorax
- Lung cancer
- Frequent chest infections e.g pneumonia
- Muscle wasting and Cachexia
What non-pharmacological management should be offerred to COPD patients?
- Explain the diagnosis, risk factors for progression and the importance of a healthy diet and physical activity. (e.g NHS and British Lung Foundation)
- Smoking cessation advice
- Offer pneumovax and flu vaccinations
- Offer pulmonary rehabilitation if indicated
- Develop personalised self-management plan
- Optimise treatment of co-morbidities
- Consider referral to physio, pulmonary rehab for breathing techniques and sputum removal
What is pulmonary rehabilitation and when should it be offered to patients with COPD?
Individually tailored, program for people with COPD with exercise training, education, and nutritional, psychological, and behavioural interventions
Refer anyone with an MRC score>3 or if they have had a recent hospitalisation from an acute exacerbation
Do not refer people who are unable to walk or those with unstable angina or those who have recently had an MI
What is long term oxygen therapy and when should you refer a patient with COPD for this?
Treats chronic hypoxemia to prevent pulmonary hypertension and therefore cor pulmonale
Cannot give if smoker
Apart from GPs and respiratory specialists, who else in on the MDT for COPD patients?
When choosing an inhaler for a COPD patient what are some things you need to consider?
What pharmacological therapy in terms of inhalers should be offered to patients with COPD?
- Initial Therapy for breathlessness: SABA or SAMA. Before stepping up from this ensure confirmed on spirometry, smoking cessation, vaccinations given and non-pharmacological measures tried
- Without asthmatic features/steroid unresponsiveness: LABA + LAMA (stop SAMA) and SABA reliever. If still having day-to-day symptoms or serious exacerbation/2 moderate exacerbations add ICS trial for 3/12. If improves review anually, if no improvement stop ICS
- With asthmatic features/steroid responsiveness: LABA + ICS and SABA reliever. If still having same as above then add LAMA for triple therapy
Apart from inhalers, what other pharmacological therapy can be offered to COPD patients which often needs specialist advice to be initiated?
- Prophylatic antibiotics: azithromycin to prevent exacerbations if non-smoker, >4 exacerbations a year or hospitalised exacerbations. Carry out sputum culture and sensitivity, CT thorax to rule out pathology, baseline ECG (QT prolongation) and LFTs first, Review after 3/12 then every 6/12
- Roflumilast: PDE4 inhibitor. For severe COPD with chronic bronchitis
- Mucolytic Treatment: if cough with sputum, only continue if improvement
- Oral Theophylline: if patient unable to use inhaled treatment
- Oxygen
When are nebulisers used in COPD treatment?
- People with distressing or disabling breathlessness despite maximal therapy using inhalers
- Need to assess patients/carers ability to use it
- If hypercapnic give nebuliser driven by air
How should you follow up a patient with COPD and what should you do at this review?
- At least once a year, if FEV1<30% predicted twice a year
- Assess severity of symptoms with MRC scale
- Exacerbation frequency and severity
- Consider alternative causes of symptoms e.g asthma, cancer
- Record smoking status and BMI
- Ensure had vaccinations
- Assess for complications (such as cor pulmonale) or comorbidities (such as obstructive sleep apnoea, lung cancer, cardiovascular disease, osteoporosis, anxiety and depression)
When should you suspect an acute exacerbation of COPD and how do you grade the severity of it?
- Increased sputum volume and purulence
- Cough
- Wheeze
- Fever without an obvious source.
- URTI in the past 5 days.
- Increased resp rate or heart rate increase 20% above baseline.
Clinical exam: check vitals, assess for confusion or drowsiness, examone chest, consider other causes e.g MI
When should you admit someone to hospital with an acute exacerbation of COPD?
- Severe breathlessness
- Inability to cope at home (or living alone).
- Poor or deteriorating general condition including significant comorbidity (such as cardiac disease or insulin-dependent diabetes).
- Rapid onset of symptoms
- Acute confusion or impaired consciousness
- Cyanosis
- Sats <90%
- Worsening peripheral oedema
- New arrhythmia
- Failure of exacerbation to respond to initial treatment
- Already receiving long-term oxygen therapy
- Changes on chest X-ray
What should you do upon waiting transfer to hospital with a patient that is having an acute exacerbation of COPD?
- Give oxygen and monitor response with pulse oximetry aiming for 88-92%
- Otherwise, initially give patients with COPD oxygen via a Venturi 24% mask at 2-3 l/min or Venturi 28% mask at a flow rate of 4 l/min or nasal cannula at a flow rate of 1-2 l/min
How should you treat a person with an acute exacerbation of COPD who does not require admission?
- Increase dose of SABAs
- If breathlessness affecting ADLs then offer 30 mg oral prednisolone once daily for 5 days
- Abx (amoxicillin or doxycycline or clarithromycin for 5 days) if purulent sputum
- If no improvement after 2-3 days of taking abx send off sputum culture and then review choice of abx
- Safety netting
How should you follow up a patient after they have had an exacerbation of COPD?
- Follow up when clinically stable (e.g 6 weeks after onset)
- Assess any residual or changed symptoms — consider the need for further investigations e.g CXR
- Optimize non-pharmacological and pharmacological management to reduce the risk of further exacerbations.
- Ensure the person knows how to use prescribed medications appropriately and assess for adverse effects.
- Consider the need for referral to a respiratory specialist and/or referral or re-referral for pulmonary rehabilitation.
- Review the person’s self-management plan
- Offer take home reliever pack with abx and oral steroids if:
- Have had an exacerbation within the last year, and remain at risk of exacerbations.
- Understand and are confident about when and how to take the medication, and are aware of associated risks and benefits.
- Know to when to seek help and when to ask for replacements once medication has been used.
What is end-stage COPD?
When people have severe and worsening decline in their symptoms, quality of life and functional level. Acute exacerbations are common and increase the risk of dying
Can use Gold Standards Framework to assess if getting to end stage as hard to diagnose when it is end stage
How should patients with end-stage COPD be managed?
- Ensure the patient has an advanced care plan including palliative care
- Coordinate care with a respiratory nurse specialist, district nurse, palliative care team, and social services
- Optimise treatment for COPD symptoms
- Consider hospice care if symptoms not controlled, if preferred place of death or if patient/family needs emotional support
What are some drug treatments that you should offer to help symptoms in end stage COPD?
Breathlessness: keep room cool, fan, window open, opiates (oral morphine), benzodiazepines (lorazepam), oxygen (if not on LTOT)
Cough: humidified room air, codeine, morphine, nebulised saline
Secretions: positioning, suctioning, antimuscarinic like hyoscine hydrobromide
Pain: opioids with antiemetics, TCAs
Consider treatment for insomnia, depression, anxiety
What information should be included in an advanced care plan?
- Check understanding of their illness and prognosis
- Concerns and preferences for future treatment and care including:
- Preferred place of care.
- When, who, and how to call for help when there is a crisis or acute exacerbation, and management options.
- Discontinuation of inappropriate interventions.
- Interventions which might be considered in an emergency, for example, anticipatory medications.
- Whether resuscitation should be attempted if they were to have a life-threatening deterioration
- Support of their family/carers.
- Needs for psychological and spiritual care.
What would indicate poor asthma control in a asthma review?
