Asthma and COPD Flashcards
How is asthma diagnosed in primary care?
> 1 or wheee, breathlessness, chest tightness, cough.
Episodic symptoms with periods of no/minimal symptoms
Diurnal variability
Audible expiratory wheeze on auscultation
Name three risk factors for asthma
FHx, premature birth, PMH, obesity, occupation, exposure to inhaled particles, smoking (exposure prenatally), brought up in deprived community, beta blockers or NSAID use.
What are triggers for asthma?
Cold, exercise, dust, animal hair, pollen, anxiety/stress
A patient is already on SABA for asthma, but they still complain about chest tightness. What drug could you add to their management plan?
Low dose ICS
When are peak flow readings used in asthma?
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 %
Define COPD
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)
A patient is already on SABA, but they still complain about chest tightness. What drug could you add to their management plan?
Low dose ICS
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?
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.
What are signs and examination findings of COPD?
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.
What can be seen on CXR of pt with COPD
Flattened hemidiaphragm, more than 6 anterior ribs, hyperluceny, decreased peripheral vascular markings, bullae
What would you nebulise in acute asthma presenting in the ED?
Salbutamol and Ipratropium
What steroids would you give for acute asthma in the ED?
Oral prednisolone
IV hydrocortisone (severe)
IV magnesium sulphate (if severe)
IV aminophylline (if severe and nebulisers and not causing enough bronchodilation
What are the RF for COPD?
Smoking and second hand smoking Air pollution Occupational hx of recurrent childhood infections Asthma
What is cor pulmonale?
Right heart failure secondary to lung disease. Due to pulmonary hypertension as a consequence of hypoxia
When would you suspect cor pulmonle
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.
What symptoms in end stage COPD would you look at optimising in palliative care?
Breathlessness, cough, secretions, pain, insomnia, depression, anxiety.
What are the symptoms of a pt with COPD?
Breathlessness, wheeze, sputum production, chronic cough, persistent LRTI.
What are signs and examination findings of COPD?
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.
How do you classify COPD?
1) Mild: > 80% predicted FEV1
2) Moderate 50-79%
3) Severe 30-49%
4) Very severe <30%
What are the features of an acute COPD exacerbation?
Worsening of symptoms: increase in cough/sputum, wheeze, breathlessness, hx of recent URT infection, HR/RR 20% above baseline, Fever
How does a severe acute COPD exacerbation present?
The symptoms of a normal acute exacerbation + cyanosis/peripheral oedema (new), marked breathlessness, tachypnoea, drowsy, pursed lips, accessory muscle used at rest
How do you treat a acute COPD exacerbation?
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
What can be seen on CXR of pt with COPD
Flattened hemidiaphragm, more than 6 anterior ribs, hyperluceny, decreased peripheral vascular markings, bullae
What signs would be present in a patient who is at end stages of COPD?
More exacerbations, slow decline, frequent exacerbations, low BMI, poor lung function on spirometry, co-morbidities such as cancer or cvd.
How is end stage COPD managed?
Advanced care plan, co-ordinate with resp nurse, district nurse, palliative care team, social services.
What drugs are used for breathlessness in end stage COPD?
Opiods - oral morphine, benzodiazepine such as diazepam, oxygen therapy.
What drugs are used for a cough in end stage COPD?
simple linctus, weak opiod cough suppressant such as codeine linctus, nebuliser saline solution or mucolytic.
How are secretions in end stage COPD managed?
Use antimuscarinic such as hycosine hydrobromide.
What symptoms in end stage COPD would you look at optimising in palliative care?
Breathlessness, cough, secretions, pain, insomnia, depression, anxiety.
When would a patient be admitted to hospital for a COPD exacerbation?
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
What are the non-pharmacological treatments for COPD?
Stop smoking
Flu vaccines
Nutritional support
What are the pharmacological treatments of COPD?
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
When would surgery for COPD be indicated?
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
Name two indications for long term O2
Non smokers with 2 readings with PaO2 <7.3kPa. OR PaO2 7.2-7.8kPa with nocturnal hypoxia, polycythemia, peripheral oedema, peripheral hypertension.
