Asthma and COPD

Question 1

What are the risk factors for a patient developing asthma?

Answer 1

Personal or family history of atopy
Low birth weight
Maternal smoking around child

Question 2

What are the symptoms and signs of asthma?

Answer 2

Cough (worse at night), SOB, chest tightness, wheeze

Expiratory wheeze on auscultation
reduced PEFR

Question 3

What are the spirometry results in asthma?

Answer 3

FEV is reduced
FVC is normal
FEV/FVC <70%

Question 4

Outline the asthma management in adults

Answer 4

1) SABA
2) SABA + ICS (if >3 symptoms in a week or night time waking)
3) SABA + ICS + LTRA
4) SABA + ICS + LABA +/ LTRA
5) SABA +/ LTRA +/ MART
6) SABA +/ LTRA + MART
7) SABA +/ LTRA with either high ICS, LAMA or theophylline

Question 5

What is MART? Give some examples.

Answer 5

Maintenance and Reliever therapy
Combination of ICS and LABA

Examples are:
Fostair (beclometasone and salmeterol)
Seretide (fluticasone and salmeterol)

Question 6

What are the doses for low, moderate and high dose ICS?

Answer 6

Low: <400micrograms budesonide
Moderate: 400-800micrograms budesonide
High: >800 micrograms budesonide

Question 7

What is the diagnostic testing for >17 year olds with a suspicion of asthma?

Answer 7

Spirometry with a bronchodilator reversibility test
FeNO test

In spirometry, will see a FEV/FVC ratio <70%

Question 8

What are the moderate, severe, and life threatening features of asthma?

What is the management of an asthma attack?

Answer 8

Moderate: PEFR 50-75%, RR <25/min, Pulse <110

Severe: PEFR 33-50%, RR >25/min, Pulse >110

Life threatening: PEFR <33%, O2 sats <92%, silent chest, cyanosis, dysrhythmia, hypotension, exhaustion, confusion

Management: OSHIT ME
assess severity
immediate management: O2, salbutamol nebs, ipratropium and hydrocortisone
reassess every 15min, if PEFR still <75%, repeat salbutamol and add ipratropium if not already done, add MgSO4

Question 9

What are some differentials for asthma?

Answer 9

COPD
URTI
Bronchiecstasis

Question 10

How do SABA’s work and what are the side effects?

Answer 10

Relaxes the airways
Termed the ‘reliever’ or ‘blue inhaler’ by patients
An example is salbutamol

SE: tremor, hypokalaemia, tachycardia, dizziness, anxiety

Question 11

How do ICS work and what are the side effects? Give examples too.

Answer 11

Stop airway inflammation
Taken every day, regardless of whether the patient has symptoms
‘The preventer’
Exampes are fluticasone or or beclometasone

SE: Oral candidiasis and stunted growth in children

Question 12

How do LABA’s work? Give examples

Answer 12

Reduce inflammation and dilate airways
An example is salmeterol and formoterol
Taken every day regardless of symptoms
Long acting

Question 13

How do LTRA’s work and give an example?

Answer 13

Reduce inflammation and dilate airways
Oral medication
An example is montelukast

Question 14

What are the features of COPD and what investigations are needed for those with suspected COPD?

Answer 14

Cough, dyspnoea, wheeze

Investigations:
Post bronchodilator spirometry (shows FEV/FVC <70%)
CXR
FBC (exclude secondary polycythaemia)

Question 15

What are the categories of COPD?

Answer 15

FEV1:
Stage 1: >80%
Stage 2: 50-79% 
Stage 3: 30-49%
Stage 4: <30%

Question 16

What is the pharmacological management of COPD?

Answer 16

1) SAMA + SABA
2) If no asthmatic/steroid responsiveness features present: LAMA + LABA
If asthmatic/steroid responsiveness features present: ICS + LAMA + LABA

If all not tolerated, use theophylline (the dose should be reduced if macrolide or fluoroquinolone ABx are co-prescribed)

Mucolytic should be considered in those with a productive cough

Question 17

What is the non pharmacological management of COPD?

Answer 17

Smoking cessation
Long term oxygen therapy if they fit the criteria
Annual influenza vaccination
One off pneumococcal vaccination

Question 18

Which COPD patients should you offer LTOT to?

Answer 18

Patients who receive supplementary oxygen >15hours a day.
FEV <30%
Secondary polycythaemia
Peripheral oedema
Raised JVP
Cyanosis

Measure 2 ABGs within 3 weeks and if a pO2 is 7.3-8 then offer LTOT

Question 19

What are the most common organisms that cause infective exacerbations of COPD?

Answer 19

1) H influenzae

S pneumoniae

Question 20

What is the management for acute exacerbations of COPD?

Answer 20

Increased frequency of bronchodilator use
Prednisolone 30mg daily for 7-14 days
Antibiotics (if 2 of: increased sputum production, increased purulence of sputum, increased SOB)

If ABx are given: doxycycline PO 200mg STAT then 100mg daily .
second line is amoxicillin

Question 21

How does ipratropium work?

Answer 21

Shorting acting inhaled bronchodilator (SAMA). Tiotropium is the long acting version.
Relaxes bronchial smooth muscle

Blocks muscarinic Ach receptors

Question 22

What drug class is theophylline and how does it work?

Answer 22

Non-specific inhibitor of phosphodiesterase, causes an increase in cAMP
Can be given orally or IV

Question 23

What is the O2 management of COPD patients?

Answer 23

Prior to blood gases:

Venturi mask 28% at 4L/min, aim for O2 sats of 88-92%

Question 24

What medications can be used to aid with smoking cessation?

Answer 24

Bupropion

Varenicline