Asthma and COPD

Question 1

risk factors asthma

Answer 1

Male sex for pre-pubertal asthma and female sex for persistence of asthma from childhood to adulthood
atopic
premature birth
obesity
tobacco exposure

Question 2

asthma diagnosis primary care

Question 3

asthma management

Answer 3

up to date vaccinations
Asthma UK
avoid triggers
smoking cessation
weight loss
1. SABA + ICS
2. LRTA
3. LABA
4. MART regime, then increase ICS to mod
5. increase ICS to high or theophylline

Question 4

severity of asthma exacerbation

Answer 4

Moderate – PEFR more than 50–75% best or predicted (at least 50% best or predicted in children) and normal speech, with no features of acute severe or life-threatening asthma.
Acute severe – PEFR 33–50% best or predicted, (less than 50% best or predicted in children) or respiratory rate of at least 25/min in people over the age of 12 years, 30/min in children between the ages of 5 and 12 years, and 40/min in children between 2 and 5 years old, or pulse rate of at least 110/min in people over the age of 12 years, 125/min in children between the ages of 5 and 12 years, and 140/min in children between 2 and 5 years old, 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, or hypotension, or cyanosis, or poor respiratory effort, or silent chest, or confusion.

Question 5

copd pathophysiology

Answer 5

treatable but nor curable and largely preventable
persistent resp symptoms and airflow obstruction
results from chronic inflammation caused by exposure to noxious particles or gases usually tobacco or occupational exposure

Question 6

COPD diagnosis

Answer 6

chronic bronchitis - cough and sputum for 3 months in 2 consecutive years
emphysema - radiologically on CXR/CT….permanent enlargement of airspaces distal to terminal bronchiole, + destruction of the walls
spirometry COAD, COLD

Question 7

COPD management

Answer 7

Smoking cessation treatment and support (where applicable).
Pneumococcal and influenza vaccination.
Pulmonary rehabilitation (where applicable).
Treatment for associated comorbidities (such as anxiety and depression)
a short-acting bronchodilator (SABA), or short-acting muscarinic antagonist (SAMA) for use as needed (to relieve breathlessness and improve exercise tolerance) should be offered.
If symptoms are not controlled, long-acting bronchodilators (LABAs), long-acting muscarinic antagonists (LAMAs), or inhaled corticosteroids (ICSs), and add on therapies may be considered in a stepwise approach — choice of treatment depends on the specific clinical situation.
ICSs should be prescribed in combination with a long-acting bronchodilator and are associated with an increased risk of pneumonia

Question 8

treatment exacerbations COOD

Answer 8

Advising the person to increase the dose or frequency of short-acting bronchodilators.
Considering the need for oral corticosteroids and an antibiotic.
Advising the person when to seek medical help and reassessing them if symptoms worsen rapidly or significantly at any time.

Question 9

palliative approach end stage COPD

Answer 9

advanced care planning
opiates
oxygen
therapy
supportive tx for breathlesness - benzodiazepines, opiates, oxygen

Question 10

mixed obstructive and restrictive picture

Answer 10

FVC reduced and FEV1/FVC ratio is reduced
restrictive - reduced FVC
obstructive - reduced FEV1/FVC

Question 11

FENO test

Answer 11

newer test
levels increased when more airway inflammation

Question 12

struggling with inhlaer technique

Answer 12

spacer

Question 13

asthma pathophysiology

Answer 13

chronic respiratory condition - airway inflammation and hyper responsiveness
disease is heterogeneous - different underlying disease processes and variety in severity, clinical course and response to tx

Question 14

asthma sx

Answer 14

cough
expiratory polyphonic wheeze (with multiple pitches and tones heard over different areas of the lung when the person breathes out)
atopic hx
chest tightness
SOB
variable expiratory airflow limitation
vary over time and intensity

Question 15

asthma triggers

Answer 15

exercise
allergen or irritant exposure
changes in weather
viral URTI
In children, symptoms may also be triggered by emotion and laughter.
In adults, symptoms may be triggered by use of non-steroidal anti-inflammatory drugs and beta-blockers.

Question 16

asthma prognosis

Answer 16

may resolve spontaneously or in response to meds
absent for weeks or months at a time

Question 17

occupational asthma

Answer 17

Occupational asthma may be suggested by adult-onset asthma, where symptoms improve when not at work

Question 18

peak expiratory flow asthma

Answer 18

A value of more than 20% variability after monitoring at least twice daily for 2-4 weeks is regarded as a positive result:

Question 19

red flag signs - alternative diagnosis asthma

Answer 19

In adults:
Prominent systemic features (such as myalgia, fever, and weight loss).
Unexpected clinical findings (such as crackles, finger clubbing, cyanosis, evidence of cardiac disease, monophonic wheeze, or stridor).
Persistent, non-variable breathlessness.
Chronic sputum production.
Unexplained restrictive spirometry.
Chest X-ray shadowing.
Marked blood eosinophilia.
In children:
Failure to thrive.
Unexplained clinical findings (such as focal signs, abnormal voice or cry, dysphagia, and/or inspiratory stridor).
Symptoms that are present from birth.
Excessive vomiting or posseting.
Evidence of severe upper respiratory tract infection.
Persistent wet or productive cough.
A family history of unusual chest disease.
Nasal polyps.

Question 20

ddx asthma

Answer 20

bronchiectasis
COPD
cystic fobrisis
GORD
HF
lung cancer
PE
TB

Question 21

asthma follow up

Answer 21

follow up - People with asthma should be followed up at least annually. Closer monitoring of people with poor lung function and/or a history of an asthma attack within the last year should be considere

Question 22

asthma exacerbation management

Answer 22

target sats 94-98
increased doses of inhaled corticosteroids, and/or a short course of oral prednisolone and a short-acting beta-2 agonist. Hospital admission is necessary for people with life-threatening asthma or severe asthma which does not adequately respond to initial treatment
Offer 30 mg oral prednisolone once daily for 5 days — discuss adverse effects of prolonged therapy.
Amoxicllin 5 days

Question 23

copd referral to specialist

Answer 23

Lung cancer, cor pulmonale, or bronchiectasis is suspected.
COPD is very severe or rapidly worsening.
The person is under 40 years of age and/or there is a family history of alpha-1-antitrypsin deficiency.
There is diagnostic uncertainty.
Oxygen therapy, long-term non-invasive ventilation therapy, long-term oral corticosteroids or lung surgery is being considered

Question 24

emergency admission COPD

Answer 24

Severe breathlessness.
Inability to cope at home (or living alone).
Poor or deteriorating general condition.
Acute confusion or impaired consciousness.
Cyanosis or reduced oxygen saturation.
Worsening peripheral oedema.
A new arrhythmia.

Question 25

clinical features COPD

Answer 25

35 +…
Breathlessness — typically persistent, progressive over time, and worse on exertion.
Chronic/recurrent cough.
Regular sputum production.
Frequent lower respiratory tract infections.
Wheeze.
Other symptoms which may be present include:
Weight loss, anorexia and fatigue — common in severe COPD but other causes must be considered.
Waking at night with breathlessness.
Ankle swelling – consider cor pulmonale.
Chest pain – uncommon in COPD, consider other causes.
Haemoptysis – uncommon in COPD, consider other causes.
Reduced exercise tolerance.
Examination may be normal. or
Cyanosis.
Raised jugular venous pressure and/or peripheral oedema (may indicate cor pulmonale).
Cachexia.
Hyperinflation of the chest.
Use of accessory muscles and/or pursed lip breathing.
Wheeze and/or crackles on auscultation of the chest.

Question 26

COPD <40

Answer 26

Consider alpha-1-antitrypsin deficiency if the person is younger than 40 years of age or has a family history.

Question 27

STAGES COPD

Answer 27

Stage 1, mild — FEV1 80% of predicted value or higher.
Stage 2, moderate — FEV1 50–79% of predicted value.
Stage 3, severe — FEV1 30–49% of predicted value.
Stage 4, very severe — FEV1 less than 30% of predicted value or FEV1 less than 50% with respiratory failure.

Question 28

trigger exacerbation COPD

Answer 28

triggered by a range of factors including respiratory tract infections (most commonly rhinovirus), smoking, and environmental pollutants.

Question 29

LTOT COPD

Answer 29

xygen saturations of 92% or less breathing air.
Very severe (forced expiratory volume in 1 second [FEV1] less than 30% predicted) or severe (FEV1 30–49% predicted) airflow obstruction.
Cyanosis.
Polycythaemia.
Peripheral oedema.
Raised jugular venous pressure

Question 30

PHARM management COPD

Answer 30

If they have no asthmatic features or features suggestive of steroid responsiveness:
Offer a long-acting beta-2 agonist (LABA) plus a long-acting muscarinic antagonist (LAMA).
If the person continues to have day-to-day symptoms adversely affecting quality of life:
Consider a 3 month trial of LABA plus LAMA plus inhaled corticosteroids (ICS).
If there is no improvement at 3 months change back to LABA plus LAMA.
If symptoms have improved, continue with LAMA plus LABA plus ICS and review at least annually.
If they have asthmatic features or features suggestive of steroid responsiveness:
Consider offering LABA plus ICS.
If person continues to have day-to-day symptoms adversely affecting quality of life or has 1 severe (needing hospitalization) or 2 moderate exacerbations of COPD within a year, offer LABA plus LAMA plus ICS.