Asthma And COPD Flashcards
What is a restrictive spirometry pattern?
a reduced FVC but with a normal FEV1/FVC ratio.
FEV1 is reduced in proportion
to the FVC
What is an obstructive spirometry pattern?
normal FVC but with a reduced FEV1
FEV1/FVC ratio reduced
PERF also reduced
What is A ‘mixed obstructive and restrictive picture’?
FVC is reduced AND the FEV1/FVC ratio is reduced
How is bronchodilator reversibility done in spirometry?
Repeating spirometry testing 20-30mins after administering a dose of bronchodilator - Salbutamol 2x200mg puffs
What will spirometry results show if airway obstruction is reversible?
Improvement in FEV1/FVC ratio after bronchodilation
When should PEFR be measured?
During asthma diagnosis - monitor peak flow twice a day for 2-4wks
Long term monitoring of asthma
What is FENO?
Exhaled Nitric Oxide test
Measures Nitric Oxide levels in exhaled breath, levels are increased when there’s active airway inflammation
Levels may be affected by smoking and ICS
What are the different drug groups of inhaler?
SABA = Short Acting Beta Agonist
LABA = Long Acting Beta Agonist
SAMA = Short Acting Antimuscarinic (rarely used in asthma)
LAMA = Long Acting Antimuscarinic (rarely used in asthma)
ICS = Inhaled corticosteroids
What are some drug combinations used in inhalers?
ICS/LABA (can be used in asthma and COPD)
LABA/LAMA (mainly used in COPD)
ICS/LABA/LAMA (mainly used in COPD)
What can be offered to patients struggling with inhaler technique?
Spacers
Taught by asthma or COPD nurses correct technique
What are some asthma symptom triggers?
Exercise
Allergen or irritant exposure
Weather changes
Viral resp infections
What are the characteristic symptoms of asthma?
Cough
Wheeze
Chest tightness
Shortness of breath
Variable expiratory airflow limitation
What is a personal asthma plan?
action plan tells you:
-which medicines to take every day
-what to do if your asthma symptoms get worse
-what to do if you have an asthma attack.
What should be examined to assess the severity of the exacerbation?
Assess vital signs:
-Level of consciousness
-Temperature
-Pulse rate and rhythm
-Resp rate
-BP
-O2 sats
-Ability to complete sentences
-Use of accessory muscles and audible wheeze
Examine chest for wheeze - may become biphasic or less apparent
Check peak flow if well enough
What are the features of a life-threatening asthma?
cyanosis,
drowsy,
exhaustion,
poor respiratory effort,
confusion (may be a sign of hypoxia);
oxygen saturation on air less than 92%;
hypotension;
PEF less than 33% best or predicted; and/or ‘silent chest’.
What are some features of acute severe asthma exacerbation?
inability to complete sentences in one breath;
oxygen saturation on air less than 92%;
respiratory rate more than 25 breaths per minute;
pulse rate more than 110 beats per minute
PEF 33–50% best or predicted.
What are some features of acute severe asthma exacerbation?
inability to complete sentences in one breath;
oxygen saturation on air less than 92%;
respiratory rate more than 25 breaths per minute;
pulse rate more than 110 beats per minute
PEF 33–50% best or predicted.
What are some features of moderate asthma exacerbations?
talking in sentences
prefers sitting to lying
not agitated
no accessory muscle use
oxygen saturation on air 92% or more
PEF more than 50% best or predicted
and no features of acute severe asthma
What should be reviewed in patient history to assess whether they should be admitted to hospital for an asthma exacerbation?
Timing of onset and cause
Severity of symptoms
Anaphylaxis symptoms
Risk factors for asthma-related death
Current asthma meds
History of near-fatal asthma - MUST go to hospital
Any recent or previous exacerbations
What treatment can be given for life-threatening or acute sever asthma exacerbation while waiting for transfer to hospital?
Controlled O2 in adults, high flow in kids - aim for 94-98% sats
Nebulised salbutamol 5mg and nebulised ipatropium bromide 0.5mg via oxygen driven neb.
Can repeat salbutamol every 20-30 mins
First dose oral prednisolone 40-50mg
What treatment can be given in primary care for moderate asthma exacerbation?
Give controlled oxygen to adults and high-flow oxygen to children 94–98% sats is aim
Give salbutamol (100 micrograms) by pMDI and large-volume spacer one puff every 60 seconds - max of 10 puffs
If there is no clinical improvement, give salbutamol 5 mg via oxygen driven neb
Give a first dose of oral prednisolone
What are the signs that a patient with a moderate asthma exacerbation can be managed at home?
a good response to initial treatment and symptoms have improved
PEF is improving to more than 60–80% of best or predicted
Oxygen saturation on air is more than 94%
person is able to manage at home with appropriate support
How soon should a patient be reviewed after an acute asthma exacerbation and what should this include?
Within 2 working days of the exacerbation:
Reassess the person’s symptoms and signs to check if the exacerbation is resolving
Assess whether the person needs additional short-term oral prednisolone treatment until full recovery
Assess for and manage any modifiable risk factors and triggers for exacerbations
inhaler technique and adherence
Review and update the person’s personalised asthma action plan
Ensure the person attends for regular follow-up in primary care
What safety netting advice should be given to patients managing asthma exacerbations at home?
Continue using AIR or MART therapies as usual
Advise to ring 999 if the person is needing one puff of AIR or MART inhaler every 1–3 minutes up to 6 puffs
Advise to ring 999 if the person is needing a SABA by pMDI and large-volume spacer one dose every 30–60 seconds up to a maximum of 10 puffs
Continue oral pred - dont stop ICS
When should a COPD patient be referred for LTOT?
Oxygen 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.
What non-pharmacological treatments can be offered to COPD patients?
Explain modifiable risk factors and suggestions how to improve - healthy diet, physical activity etc
Smoking cessation support
Annual pneumococcal and influenza vaccine
Pulmonary rehabilitation if indicated
Develop personalised self-management plan with patient
What inhaled therapies can be offered to COPD patients?
Bronchodilator - SABA or LAMA
LABA+LAMA
Consider ICS if eosinophils greater than 300 cells per microlitre
What is pulmonary rehabilitation and when should it be offered to COPD patients?
It’s a tailored MDT care plan - optimises physical and psychological conditions through exercise training, education and nutritional, psychological and behavioural interventions
Refer if:
-MRC scale 3 or more
-Recent hospital admission for exacerbation
-Functionally disabled by COPD
When should a COPD patient NOT be referred for pulmonary rehabilitation?
Unable to walk
Have unstable angina
Had recent MI
What advice should be given to people using oxygen?
Don’t smoke as their risk or fire or explosion
When should you not offer short-burst oxygen therapy for breathlessness?
people with COPD who have mild or no hypoxaemia at rest
What’s the initial management for all COPD patients?
-SABA or SAMA as required to relieve breathlessness
Ensure non-drug options have been optimised before stepping up
What are the step up treatment options for COPD patients with NO asthmatic features/steroid responsiveness?
Offer LABA and LAMA in pts continuing to be breathless or having exacerbations
-Discontinue SAMA id LAMA given
When should ICS treatment be considered in COPD patients with NO asthmatic features/steroid responsiveness?
patients on a LAMA and LABA who have a severe exacerbation (requiring hospitalisation) or at least two moderate exacerbations (requiring systemic corticosteroids and/or antibacterial treatment) within a year,
consider the addition of an inhaled corticosteroid (ICS)—triple therapy.
Must review annually
When should ICS be trialled for 3 months in COPD patients with NO asthmatic features/steroid response?
patients on a LAMA and LABA whose day-to-day symptoms continue to adversely impact their quality of life
consider trialling the addition of an ICS for 3 months
If symptoms have improved, continue triple therapy and review at least annually.
If no improvement, step back down to a LAMA and LABA combination
What is the recommended step up treatment for COPD patients WITH asthmatic features/steroid responsiveness?
Consider LABA and ICS in pts continuing to be breathless or having exacerbations
Must review ICS annually
When would you consider adding a LAMA to COPD patients WITH asthmatic features/steroid responsiveness?
patients on a LABA and ICS who have a severe exacerbation (requiring hospitalisation) or at least two moderate exacerbations (requiring systemic corticosteroids and/or antibacterial treatment) within a year, or who continue to have day-to-day symptoms adversely impacting their quality of life
Add LAMA
Discontinue SAMA
What prophylactic antibiotics can be considered to reduce COPD exacerbations?
Azithromycin
Risk factors must be optimised and have had all treatment options available
What must be monitored before offering prophylactic antibiotics to COPD patients?
-CT of thorax
-Baseline ECG
-Sputum culture and sensitivity
-LFTs
How often should COPD patients on prophylactic Abx be monitored?
Review after first 3 months
Then at least 6 monthly
What are some features suggestive of an acute COPD exacerbation?
Worsening breathlessness.
Increased sputum volume and purulence.
Cough.
Wheeze.
Fever without an obvious source.
Upper respiratory tract infection in the past 5 days.
Increased respiratory rate or heart rate
increase 20% above baseline.
What are some features suggestive of a severe COPD exacerbation?
Marked breathlessness and tachypnoea.
Pursed-lip breathing and/or use of accessory muscles at rest.
New-onset cyanosis or peripheral oedema.
Acute confusion or drowsiness.
Marked reduction in activities of daily living
What clinical assessment must be done if a patient is presenting to primary care with a suspected COPD exacerbation?
Check vital signs (including temperature, oxygen saturation [using pulse oximetry], blood pressure, and heart rate).
Assess for confusion or impaired consciousness.
Examine the chest.
Check ability to cope at home
What treatment can be given to COPD patients waiting for hospital transfer?
Give oxygen (if available) while awaiting emergency transfer to hospital and monitor response with pulse oximetry - if sats less than 90%
Otherwise, initially give patients with COPD oxygen via a Venturi 24% mask at 2-3 l/min or Venturi 28% mask at a flow rate of 4 l/min or nasal cannula at a flow rate of 1-2 l/min (if a 24% mask is not available).
What treatments should be started in COPD patients having exacerbation but don’t need hospital admission?
Increase dose or frequency of SABA - don’t exceed max dose
Nebs may be appropriate it pt likely to become fatigued
Offer 30 mg oral prednisolone once daily for 5 days
Consider the need for osteoporosis prophylaxis for people requiring frequent courses of oral corticosteroids (3–4 courses per year
Consider the need for an antibiotic:
-Amoxicillin
-Doxycycline
-Clarithromycin
What follow up should be arranged for COPD patients after having an exacerbation?
Follow up when clinically stable
Reassess COPD symptoms
Send sputum for culture and sensitivity testing if symptoms not improved after abx
Optimise managements
Assess inhaler technique
Consider referral to resp specialist
Offer rescue pack of oral steroids and abx
How should a patient with end stage COPD be managed?
Advanced care plan
Optimise treatment for symptoms
Consider specialist admission to hospice
What are some drugs that can be given for breathlessness in end stage COPD?
Opioids
Benzodiazepines
TCAs
LTOT
