48. Cough/sputum/wheeze/sneezing Flashcards
what are the atopic conditions
asthma, eczema, hay fever and food allergies
presentation asthma
Episodic
Diurnal variability
Typical symptoms are:
Shortness of breath
Chest tightness
Dry cough
Wheeze
o/e asthma
normal when well
widespread “polyphonic” expiratory wheeze
what is key about the wheeze suggetsing asthma
WIDESPREAD
and polyphonic
differentials for localised monophonic wheeze
inhaled foreign body, tumour or a thick sticky mucus plug obstructing an airway
A chest x-ray is the next step.
triggers asthma
Infection
Nighttime or early morning
Exercise
Animals
Cold, damp or dusty air
Strong emotions
common drugs that can exacerbate/trigger asthma
beta blockers
nsaids
tests for making an asthma diagnosis
- Spirometry with bronchodilator reversibility
- Fractional exhaled nitric oxide (FeNO)
Where there is diagnostic uncertainty after initial investigations, the next step is testing the peak flow variability.
results of spirometry with reversibility testing that suggest asthma
reversibility = greater than 12% increase in FEV1 on reversibility testing supports a diagnosis of asthma.
what does FeNO test involve
The test involves a steady exhale for around 10 seconds into a device that measures FeNO.
what may impact the result of FeNO
Smoking can lower the FeNO, making the results unreliable.
FeNO positive result?
a level above 40 ppb is a positive test result
what is peak flow varibaility? what is a positive result
Peak flow variability is measured by keeping a peak flow diary with readings at least twice daily over 2 to 4 weeks.
NICE says a peak flow variability of more than 20% is a positive test result, supporting a diagnosis.
aim of treatment asthma
complete control of symptoms and normal lung function
No daytime symptoms.
No night-time waking due to asthma.
No need for rescue medication.
No asthma attacks.
No limitations on activity including exercise.
principles of asthma management
Start at the most appropriate step for the severity of the symptoms
Review at regular intervals based on severity (e.g., 4-8 weeks after adjusting treatment)
Add additional treatments as required to control symptoms completely
Aim to achieve no symptoms or exacerbations on the lowest dose and number of treatments
Always check inhaler technique and adherence when reviewing medications
what are the steps of asthma management in adults
- SABA
- ICS
- LTRA (e.g., montelukast)
- LABA +/- LTRA
- MART inc low dose ICS
- MART inc moderate dose ICS
- Consider high-dose inhaled corticosteroid or additional drugs (e.g., LAMA or theophylline)
- Specialist management (e.g., oral corticosteroids)
when should you prescribe ICS for adults asthma
- using SABA 3/7
- symptoms 3/7
- woken at night 1/7
if on SABA and ICS asthma, what should you do?
add Leukotriene receptor antagonist (e.g., montelukast)
what is COPD
Long-term, progressive condition involving airway obstruction, chronic bronchitis and emphysema. It is almost always the result of smoking and is largely preventable
what is chronic bronchitis
Chronic bronchitis refers to long-term symptoms of a cough and sputum production due to inflammation in the bronchi.
what is emphysema
damage and dilatation of the alveolar sacs and alveoli, decreasing the surface area for gas exchange.
presentation copd
A typical presentation of COPD is a long-term smoker with persistent symptoms of:
Shortness of breath
Cough
Sputum production
Wheeze
Recurrent respiratory infections, particularly in winter
what does copd not cause
clubbing
haemoptysis
chest pain
These symptoms should be investigated for a different cause, such as lung cancer, pulmonary fibrosis or heart failure.
what are the grades of the mrc dyspnoea scale
Grade 1: Breathless on strenuous exercise
Grade 2: Breathless on walking uphill
Grade 3: Breathlessness that slows walking on the flat
Grade 4: Breathlessness stops them from walking more than 100 meters on the flat
Grade 5: Unable to leave the house due to breathlessness