Asthma and COPD

Question 1

How is asthma diagnosed in primary care?

Answer 1

> 1 or wheee, breathlessness, chest tightness, cough.

Episodic symptoms with periods of no/minimal symptoms

Diurnal variability

Audible expiratory wheeze on auscultation

Question 2

Name three risk factors for asthma

Answer 2

FHx, premature birth, PMH, obesity, occupation, exposure to inhaled particles, smoking (exposure prenatally), brought up in deprived community, beta blockers or NSAID use.

Question 3

What are triggers for asthma?

Answer 3

Cold, exercise, dust, animal hair, pollen, anxiety/stress

Question 4

A patient is already on SABA for asthma, but they still complain about chest tightness. What drug could you add to their management plan?

Answer 4

Low dose ICS

Question 5

When are peak flow readings used in asthma?

Answer 5

Used when uncertainty after initial assessment, FeNO test or objective test to detect airway obstruction

> 20% variability after 2x daily 2-4 weeks= positive result, calculate as the difference between the highest and lowert reading expressed as %

Question 6

Define COPD

Answer 6

Irreversible obstruction of airways. Comprises of conditions 1) Bronchitis (hypertrophy and hyperplasia of mucus glands in bronchi) and 2) Emphysema (enlargement of air spaces and destroyed alveolar walls)

Question 7

A patient is already on SABA, but they still complain about chest tightness. What drug could you add to their management plan?

Answer 7

Low dose ICS

Question 8

A patient is already on SABA and ICS for asthma management. They still feel short of breath and are trigged by exercise and the cold. What next pharmacological management steps could you apply?

Answer 8

Add on LTRA - montelukast. If helping, continue this and increase ICS. If not working, add on LABA - e.g. Salmetarol, high dose steroid and oral B2 agonist.

Question 9

What are signs and examination findings of COPD?

Answer 9

Barrel chest, cyanosis, use of accessory muscles, pursed lips, hyperinflation of the chest, cachexia, wheeze/crackles on auscultation, raised JVP, leg oedema, cor pulmonale, reduced chest expansion, decreased breath sounds, hyper-resonant percussion.

Question 10

What can be seen on CXR of pt with COPD

Answer 10

Flattened hemidiaphragm, more than 6 anterior ribs, hyperluceny, decreased peripheral vascular markings, bullae

Question 11

What would you nebulise in acute asthma presenting in the ED?

Answer 11

Salbutamol and Ipratropium

Question 12

What steroids would you give for acute asthma in the ED?

Answer 12

Oral prednisolone
IV hydrocortisone (severe)
IV magnesium sulphate (if severe)
IV aminophylline (if severe and nebulisers and not causing enough bronchodilation

Question 13

What are the RF for COPD?

Answer 13

Smoking and second hand smoking 
Air pollution
Occupational 
hx of recurrent childhood infections 
Asthma

Question 14

What is cor pulmonale?

Answer 14

Right heart failure secondary to lung disease. Due to pulmonary hypertension as a consequence of hypoxia

Question 15

When would you suspect cor pulmonle

Answer 15

Lung condition
Peripheral oedema.
Raised jugular venous pressure.
Systolic parasternal heave.
A loud pulmonary second heart sound (over the second left intercostal space).
Hepatomegaly.
Other causes of peripheral oedema should be considered.

Question 16

What symptoms in end stage COPD would you look at optimising in palliative care?

Answer 16

Breathlessness, cough, secretions, pain, insomnia, depression, anxiety.

Question 17

What are the symptoms of a pt with COPD?

Answer 17

Breathlessness, wheeze, sputum production, chronic cough, persistent LRTI.

Question 18

What are signs and examination findings of COPD?

Answer 18

• Barrel chest,
• cyanosis,
• use of accessory muscles,
• pursed lips,
• hyperinflation of the chest,
• cachexia,
• wheeze/crackles on auscultation,
• raised JVP,
• leg oedema,
• cor pulmonale,
• reduced chest expansion,
• decreased breath sounds,
• hyper-resonant percussion.

Question 19

How do you classify COPD?

Answer 19

1) Mild: > 80% predicted FEV1
2) Moderate 50-79%
3) Severe 30-49%
4) Very severe <30%

Question 20

What are the features of an acute COPD exacerbation?

Answer 20

Worsening of symptoms: increase in cough/sputum, wheeze, breathlessness, hx of recent URT infection, HR/RR 20% above baseline, Fever

Question 21

How does a severe acute COPD exacerbation present?

Answer 21

The symptoms of a normal acute exacerbation + cyanosis/peripheral oedema (new), marked breathlessness, tachypnoea, drowsy, pursed lips, accessory muscle used at rest

Question 22

How do you treat a acute COPD exacerbation?

Answer 22

Short acting bronchodilator, increase dose/frequency of bronchodilator, nebuliser is helpful is pt is fatigued–> salbutamol and ipratropium

Oral corticosteroids, 30g prednisolone 1 a day for 5 days, osteoporosis people taking oral CCS 3-4 year

ABx–>
Amoxicillin 500 mg 3 x day for 5 days
OR
Doxycycline 200 mg day 1, then 100 mg for 5 day course

no imporovement for 2-3 days sputum sample for culture / susceptibility

Question 23

What can be seen on CXR of pt with COPD

Answer 23

Flattened hemidiaphragm, more than 6 anterior ribs, hyperluceny, decreased peripheral vascular markings, bullae

Question 24

What signs would be present in a patient who is at end stages of COPD?

Answer 24

More exacerbations, slow decline, frequent exacerbations, low BMI, poor lung function on spirometry, co-morbidities such as cancer or cvd.

Question 25

How is end stage COPD managed?

Answer 25

Advanced care plan, co-ordinate with resp nurse, district nurse, palliative care team, social services.

Question 26

What drugs are used for breathlessness in end stage COPD?

Answer 26

Opiods - oral morphine, benzodiazepine such as diazepam, oxygen therapy.

Question 27

What drugs are used for a cough in end stage COPD?

Answer 27

simple linctus, weak opiod cough suppressant such as codeine linctus, nebuliser saline solution or mucolytic.

Question 28

How are secretions in end stage COPD managed?

Answer 28

Use antimuscarinic such as hycosine hydrobromide.

Question 29

What symptoms in end stage COPD would you look at optimising in palliative care?

Answer 29

Breathlessness, cough, secretions, pain, insomnia, depression, anxiety.

Question 30

When would a patient be admitted to hospital for a COPD exacerbation?

Answer 30

When deteriorating and co-morbidity e.g. heart disease/diabetes
Rapid onset 
Severe breathlessness 
Can't cope 
Impaired consciousness 
Cyanosis 
O2 sats less than 90% on pulse oximetry 
new arrhythmia 
Failure to treat acute exacerbation 
on long term o2

Question 31

What are the non-pharmacological treatments for COPD?

Answer 31

Stop smoking
Flu vaccines
Nutritional support

Question 32

What are the pharmacological treatments of COPD?

Answer 32

Step 1: SABA and SAMA
Step 2: IF no asthmatic features / steroid responsiveness (asmtha / atopy/ esoisophils, diurnal variations in peak flow)
- ADD LABA and LAMA

IF YES asthmatic features or steroid responsiveness
- add LABA and ICS

Step 3: if on LABA and LAMA (still daily symptoms or >1 severe or >2 moderate exacerbation)
Try LAMA + LABA + ICS (3 month trial)- stop ICS

Step 4: specialist referral

Question 33

When would surgery for COPD be indicated?

Answer 33

Lung volume reduction for patients who have tried all medical therapy and have upper lobe predominant emphysema, FEV1<20%, PaCO2 below 7.3kPa and/or TLCO above 20% predicted

Question 34

Name two indications for long term O2

Answer 34

Non smokers with 2 readings with PaO2 <7.3kPa. OR PaO2 7.2-7.8kPa with nocturnal hypoxia, polycythemia, peripheral oedema, peripheral hypertension.