6 - Asthma and COPD Flashcards

1
Q

What is the pathophysiology of asthma?

A

- Chronic reversible airway obstruction that responds to bronchodilators

- Increased airway responsiveness and narrowing to stimuli

- Airway narrowing: bronchial muscle contraction, mucosal swelling due to mast cells and basophils releasing mediators, increased mucus production

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2
Q

What are the signs and symptoms of asthma?

A

Symptoms: Intermittent dyspnea, wheeze, nocturnal cough, sputum

Signs: tachypnea, audible wheeze, hyperinflated chest

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3
Q

What are some differentials for a wheeze apart from asthma>

A
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4
Q

If a patient presents with asthmatic like symptoms, what are some questions you need to ask in the history?

A

- Triggers: e.g cold air, exercise, pets, smoking, NSAIDs

- Diurnal variation: worse at night?

- Exercise tolerance

- Disturbed sleep?

- Other atopic diseases?

- Job?

- Days per week off school or work?

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5
Q

When is asthma classified as mild, moderate, severe, life threatening and near fatal?

A
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6
Q

What does PEF depend on?

A
  • Age
  • Gender
  • Height
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7
Q

What is the emergency management for acute asthma?

A

- Aim for sats of 94-98% with oxygen. If <92% ABG needed

- 5mg Salbutamol NEB and repeat after 15 minutes

- 40mg oral prednisolone or IV hydrocortisone

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8
Q

How do you initially diagnose asthma?

A
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9
Q

What investigations should you do if a patient is having an acute episode of asthma?

A

- PEF

  • Sputum culture and ?Blood culture
  • FBV, U+Es, CRP

- ABG

  • CXR to exclude infection or pneumonthorax
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10
Q

What investigations can you do for a patient with chronic asthma?

A

- PEF monitoring (diurnal variation with >20% variability on >3days in 2 weeks)

- CXR may have hyperinflation

- Spirometry (obstructive pattern, ratio<70% with bronchodilator reversibility)

- Skin prick test to identify allergens

- Metacholine or Histamine challenge

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11
Q

What is the criteria that needs to be fulfilled for a safe discharge after an asthma exacerbation?

A
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12
Q

What factor means a patient with asthma will be responsive to steroids?

A

Eosinophillia

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13
Q

Apart from asthma, what are some diseases that cause eosinophilia?

A
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14
Q

What are some common asthma triggers?

A
  • Smoking
  • URTI
  • Pollen
  • Pets
  • Exercise
  • Cold air
  • Aspirin and beta blockers
  • Stress
  • Occupational exposures
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15
Q

What is the general management of asthma in a primary care setting?

A
  • Avoid triggers
  • Stop smoking
  • PEF monitoring
  • Self management plan for emergencies
  • BTS pharmacological management
  • Treat correct inhaler technique
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16
Q

What is the pharmocological management of asthma using the BTS guidelines?

A

Start at step most appropriate to severity, moving up or down. Can move down after >3months of control

1st: SABA reliever when needed

2nd: Add low dose ICS

3rd: Add LABA with the ICS or LTRA or oral theophylline

4th: Increase ICS

5th: Add regular oral prednisolone with specialist input

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17
Q

What signifies poor asthma control?

A
  • 3 or more days a week with symptoms
  • 2 or more days a week with use of a rescue SABA inhaler
  • 1 or more nights a week with awakening due to asthma

Need to check inhaler technique, inhaler adherance, smoking and self management plan

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18
Q

How do beta-agnonists help asthmatics and what are the side effects of these?

A

Relax bronchial smooth muscle within minutes by increasing cAMP

SE: tachyarrhythmias, hypokalaemia, tremor, paradoxical bronchospasm

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19
Q

How do inhaled corticosteroids help asthma and what are the side effects of these?

A

Act over days to decrease bronchial mucosal inflammation

Used inhaled to minimise systemic effects

SE: usual steroid side effects, oral thrush so rinse mouth adter use

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20
Q

How does aminophylline help asthmatics and what are some side effects of this?

A

Metabolised to theophylline. Inhibits phosphodiesterase so decreases bronchoconstriction.

Used as prophylaxis at night

SE: arrhythmias, GI upsets, seizures

Monitoring: theophylline levels, ECG monitoring

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21
Q

How do LTRA help asthmatics?

A

Block the effects of leukotrienes by antagonising the CystLT1 receptor

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22
Q

What is the definiton of COPD and what are the causes of it?

A

Progressive airflow obstruction that is not reversible

Chronic bronchitis + Emphysema

Causes: smoking, alpha antitrypsin deficiency, industrial exposure e.g soot

23
Q

What is the definiton of chronic bronchitis and emphysema?

A

Chronic Bronchitis: Cough and sputum production on most days for 3 months in 2 successive years

Emphysema: Enlarged air spaces with destruction of alveolar walls and loss of elasticity. Visualised on CT and diagnosed histologically

24
Q

What is the pathophysiology of COPD?

A
  • Mucous gland hyperplasia
  • Loss of cilia function
  • Emphysema
  • Chronic inflammation and fibrosis of small airways
25
Q

What are the signs and symptoms of COPD?

A

Symptoms: cough, sputum, dyspnea, wheeze

Signs: barrel chest, use of accessory muscles, hyperinflation, decreased chest expansion, hyperresonant

26
Q

What are some complications of COPD?

A
  • Pneumothorax due to ruptured bullae
  • Polycythemia
  • Acute exacerbations
  • Cor pulmonale
  • Lung carcinoma
27
Q

What investigations can you do if you suspect COPD and what will the results be?

A

- FBC: increased PCV

- CXR: hyperinflation with flat diaphragm, large pulmonary arteries

- CT: bronchial wall thickening, scarring, air space enlargement

- ECG: right ventricle hypertrophy

- ABG: low O2 and hypercapnia

- Spirometry: obstructive pattern (FEV1/FVC <70%)

28
Q

What healthcare professionals are involved in the MDT team for COPD patients?

A
29
Q

The severity of COPD needs to be known for therapy and prognosis. How is the severity of COPD assessed?

A

BODE index

  • Looks at BMI, airflow obstruction, dyspnea and exercise capacity
  • Predicts severity and number of exacerbations

GOLD

  • Mild, moderate, severe and very severe based on post bronchodilator FEV1% oredicted
30
Q

How is chronic COPD managed in general ?

A
  • Confirm diagnosis with spirometry
  • Smoking cessation
  • Pulmonary rehabilitation
  • Pharmacology
  • Diet and weight loss if high BMI
  • Pneumococcal and flu vaccine
  • Depression screening
  • LTOT if appropriate
  • Lung volume reduction if appropriate
31
Q

What is the inhaled pharmacological treatment for COPD?

A

1st: offer all patients SABA or SAMA

2nd: if non-asthmatic features LABA/LAMA, if asthmatic features LABA/ICS. If giving LAMA stop SAMA. Continue SABA

3rd: Triple therapy of LABA/LAMA/ICS. Use if 1 severe exacerbation (hospitalisation) or 2 moderate exacerbations (abx/steroids needed) in a year

32
Q

Apart from LABA, LAMA, SABA and ICS, what can be offered to COPD patients?

A

Prophylactic abx: Can give azithromycin to non-smokers on all treatments with 4 or more exacerbations a year. Do sputum culture and sensitivity, LFTs and ECG (long QT) before starting. Review every 3-6 months

Roflumilast: phosphodiesterase type-4 inhibitor, used in addition to bronchodilator therapy with chronic bronchitis

Mucolytics: patients with chronic cough and sputum

Modified release theophylline: only if cannot use inhaled therapy

LTOT: see future flashcard

33
Q

What patients with COPD qualify for long term oxygen therapy and why is this offered?

A
  • Given if pO2 consistently below 7.3kPa or below 8kPa with Cor Pulmonale. Do 2 separate ABGs
  • Must be non-smokers and not be a CO2 retainer. Also used for terminally ill patients

- Give continuous pO2 for at least 16hours a day for 3 year survival improvement of 50% as long term hypoxia can cause renal and cardiac damage

34
Q

What is pulmonary rehabilitation used for in COPD patients?

A

Many COPD patients avoid physical activity because of breathlessness.

6-12 week programme to increase exercise and break cycle.

Mix of supervised exercise, unsupervised home exercise, nutritional advice and disease education

35
Q

What COPD patients are offered lung volume reduction surgery?

A

Need CT to see if candidate:

  • Recurrent pneumothoraces
  • Isolated bullous disease

Can also be offered endobronchial valve and transplant

36
Q

What are the goals of pulmonary rehabilatation for COPD patients?

A
  • Alleviate symptoms
  • Improve exercise tolerance
  • Restore functional capabilities
  • Peer support
  • Disease education
37
Q

How is a COPD exacerbation managed?

A
  • Salbutamol and Iptratropium Bromide NEB
  • Controlled oxygen therapy
  • PO prednisolone
  • Abx if evidence of infection
  • IV aminophylline if nebulisers didn’t work
  • Consider physiotherapy and NIPPV
38
Q

What interventions improve prognosis/mortality for patients with COPD?

A
  • Smoking cessation
  • Lung reduction surgery
  • LTOT
39
Q

What are some drugs that can cause a cough?

A
  • ACEi
  • Beta blockers
  • NSAIDs/Aspirin
  • Methotrexate (pulmonary fibrosis)
40
Q

What are some common causes of dry cough?

A
41
Q

What is an idiopathic cough and when can this diagnosis be made?

A

Cough lasting >3 weeks in association with normal clinical exam, normal CXR and high resolution CT scan, normal lung function tests, negative methacholine inhalation test, normal PEF, normal sputum differential eosinophil count (<2%), and no GORD

42
Q

What features may help differentiation a case of CAP from TB?

A

COME BACK TO

43
Q

What are some differentials for acute asthma?

A
  • Acute bronchitis
  • Pneumonia
  • Foreign body
  • PE
44
Q

What is controlled oxygen?

A
  • Avoiding unneccessary over oxygenation
  • ABG if sats<92%
45
Q

What is included in an asthma self-management plan?

A
  • What to do normally
  • What to do if it gets worse
  • When to seek help
46
Q

How does oral prednisolone vary for a COPD and an Asthma exacerbation?

A

COPD 30mg

Asthma 40mg

47
Q

What is included in the COPD care bundle?

A
48
Q

When should you do an ABG in asthma?

A

Only when sats fall below 92%!!!!

49
Q

When should you use IV salbutamol in acute asthma?

A
  • Airway obstruction so cannot use nebuliser
  • Tracheostomy making nebuliser difficult
50
Q

Why is the half life of salbutamol important?

A

Peak onset of action 40 minutes after administration so do not need to give back to back if no response initially!

Can put them into acidosis

51
Q

How should a primary pneumothorax be treated?

A
52
Q

How should a secondary pneumothorax be treated?

A
53
Q

How is an iatrogenic pneumothorax treated?

A
54
Q

What discharge advice should you give a patient after a pneumothorax?

A