Asthma / COPD Flashcards
COPD - when to suspect and how to diagnose
Consider COPD in patients >35yo if:
1) Sx - SOB, cough +/- sputum
2) current or ex-smoker
Dx via SPIROMETRY; persistent / post-broncodilator FEV1/FVC ratio <0.7
FEV1 %predicted indicates severity
COPD - Sx and spirometry for mild / moderate / severe
Mild: FEV1%pred 60-80
- SOB on moderate exertion
- no-minimal impact on ADLs
- cough + sputum
Moderate: FEV1%pred 40-59
- SOB on walking
- impact on ADLs
- recurrent chest infections +/- exacerbations requiring steroids or Abx
Severe: FEV1%pred <40
- SOB on any exertion
- severe impact on ADLs
- increasing frequency and severity of exacerbations
Name 8 broad management areas for COPD
- pharmacotherapy
- pulmonary rehabilitation
- COPD action plan
- encourage self-management
- manage comorbidities
- optimise nutrition
- smoking cessation
- vaccination
Name 4 non-pharmacological management steps for COPD
- Monitor impact and functional status using COPD assessment test every 2-3 months
- Encourage regular physical activity - walking for >150mins / week (>30 mins / day x5 days)
- Smoking cessation
- Refer for pulmonary rehabilitation
5As for smoking cessation
- Ask and identify smokers at every visit
- Assess nicotine dependence and motivation to quit
- Advise about the risks of smoking and benefits of quitting
- Assist cessation by offering behavioural counselling (inc. Quitline referral) and pharmacotherapy
- Arrange follow-up within a week of the quit date and one month after
Outline the step-wise pharmacological management of COPD
- PRN SABA or SAMA
- add LAMA or LABA
- switch to LAMA + LABA combination
- add ICS
Name the drug options for COPD:
- SABA
- SAMA
- LAMA
- LABA
- ICS
SABA = short acting beta2-agonist
- salbutamOL or terbutaline
SAMA = short-acting muscarinic antagonists
- ipratropIUM
LAMA = long-acting muscarinic antagonists
- tiotropIUM, glycopyrronIUM, umeclidinIUM or aclidinIUM
LABA = long-acting beta2-agonists
- indacaTEROL, salmeTEROL or formoTEROL
ICS = inhaled corticosteroids
- fluticasONE or budesonIDE
Name at least one brand from each class of COPD inhaler
SABA = Ventolin/Asmol (salbutamOL), Bricanyl (terbutaline)
SAMA = Atrovent (ipratropIUM)
LAMA = Spiriva (tiotropIUM), Incruse (umeclidinIUM), Seebri (glycopyrronIUM)
LABA = Onbrez (indacaTEROL)
LABA/LAMA = Spiolto (tiotropIUM/olodaTEROL), Ultibro (indacaTEROL/glycopyrronIUM)
ICS/LABA = Seretide (fluticasONE/salmeTEROL), Symbicort (budesonIDE/formoTEROL), Breo (fluticasONE/vilanTEROL)
ICS/LAMA/LABA = Trelegy (fluticasONE/umeclidinIUM/vilanTEROL), Trimbow (beclometasONE/formoTEROL/glycopyrronIUM)
Outline an approach to COPD action plan for managing exacerbations
Treat any increase in baseline Sx early
1. Increase short-acting bronchodilator - eg. 4-8 puffs salbutamol every 3-4 hours
2. If Sx not improved, commence oral prednisolone 30-50mg daily for 5 days
3. If fever or change in colour/volume of sputum, add Abx (amoxicillin 500mg TDS vs. 1g BD or doxycyline 100mg daily) for 5 days
Outline the 4 steps to interpreting spirometry
- Shape of curve
- Unable to blow out quickly -> concave curve = obstruction
- Small volume curve = restrictive
- Both of above = mixed, eg. CF - FEV1/FVC ratio (>0.7 normal, <0.7 OBSTRUCTION)
- FEV1 + FVC (>80%pred normal, FVC <80%pred RESTRICTION)
- Change post-bronchodilator (FEV1 >+12% REVERSIBLE airways obstruction)
Asthma Ax - questions on history
- current Sx
- pattern of symptoms (day/night, seasonal)
- triggers (exercise, viral infections, ingested substances, allergens)
- relieving factors (SABA, other meds)
- impact on work and lifestyle
- home and work environment
- smoking history (inc. passive)
- PHx allergies inc. atopic dermatitis (eczema) or allergic rhinitis (‘hay fever’)
- FHx asthma and allergies
Asthma - DDx
poor cardiopulmonary fitness
resp - bronchiectasis, COPD, hyperventilation, inhaled foreign body, large airway stenosis, pleural effusion, pulmonary fibrosis, rhinitis/rhinosinusitis, upper airway dysfunction
CVD - CCF, pulmonary hypertension
comorbid conditions - obesity, gastro-oesophageal reflux
lung Ca
rare disorders - alpha-1 antitrypsin deficiency
Asthma - when to suspect and how to diagnose
2+ of: wheeze, SOB, chest tightness, cough
Sx are recurrent or seasonal, worse at night, associated w common triggers, rapidly relieved by SABA
Esp if PHx atopy, FHx asthma + atopy
Dx via spirometry; expiratory airflow limitation (FEV1/FVC LLN) + reversible (FEV1 ≥+12%)
If high clinical suspicion and normal spirometry, consider treatment trial for Dx
What are the 5 Qs on the asthma score test?
In the last 4 weeks …
1. Impact on ADLs
2. Frequency of SOB
3. Frequency of night/morning Sx
4. Frequency of reliever use
5. Subjective rating of asthma control
What aspects are needed for GOOD asthma control?
- Daytime Sx 2 or fewer days per week
- SABA use 2 or fewer days per week
- No limitation of activities
- No Sx at night or on waking
Partial control if 1-2 and Poor control if 3+ not met
Outline the step-wise pharmacological management of asthma
- SABA PRN
- low dose ICS + SABA PRN; or low dose budesonIDE-formoTEROL PRN
- low dose ICS-LABA + SABA PRN; or low dose ICS-formoTEROL preventer + reliever
- medium-high dose ICS-LABA + SABA PRN; or ICS-formoTEROL medium dose preventer + low dose reliever; consider LAMA
- Refer specialist
Name at least one brand of inhaler from each level of asthma treatment - level 1
For which pts can level 1 treatment be used?
SABA PRN
- Asmol/Ventolin (salbutamOL)
- Bricanyl (terbutaline)
Name at least one brand of inhaler from each level of asthma treatment - level 2
low dose ICS + SABA PRN
- Pulmicort (budesonIDE 200-400mcg)
- Flixotide (fluticasONE 100-200mcg)
or
budesonIDE-formoTEROL PRN
- Symbicort turbuhaler (200/6 DPI) or rapihaler (100/3 MDI)
Name at least one brand of inhaler from each level of asthma treatment - level 3
low dose ICS-formoTEROL preventer + reliever
- Symbicort (budesonIDE-formoTEROL), ICS dose <200mcg preventer <400mcg daily
- Fostair (beclametasONE-formoTEROL), ICS dose <100mcg preventer <200mcg daily)
or
low dose ICS-LABA + SABA PRN
- Seretide (fluticasONE-salmeTEROL), ICS dose <200mcg
+ above
Name at least one brand of inhaler from each level of asthma treatment - level 4
ICS-formoTEROL medium dose preventer + low dose reliever
- Symbicort (budesonIDE-formoTEROL), medium dose 250-400mcg, low dose 100-200mcg
- Fostair (beclametasONE-formoTEROL)
or
medium-high dose ICS-LABA + SABA PRN
- Breo (fluticasONE-vilanTEROL), ICS dose 100-200mcg
- Seretide (flutcasONE-salmeTEROL), ICS dose 250+mcg
+ above
When should LAMA’s be considered in asthma?
At level 4 of asthma treatment
Ie. Sx on most days, frequent waking, poor baseline lung function
Eg. Spiriva (tiotropIUM) 2.5mcg (PBS restricted)
Outline the general approach to an Asthma Action Plan
- Use 1-2 puffs of reliever if asthma Sx
- Increase steroid dose:
- start ICS preventer and continue for >2-4/52
- increase ICS-only preventer dose x4 for 7-14d
- increase ICS-LABA dose for 7-14d - Oral pred 37.5-50mg daily for 5-10d
Outline the approach to reviewing asthma treatment
Step down if good asthma control for 2-3 months -> reduce ICS dose by 25-50%
Before stepping up treatment, review adherence, exposure to triggers and inhaler technique
When is asthma vs COPD more likely
- age of onset
- pattern of Sx
- lung function
- history
- long-term disease trajectory
- chest XR
Age of onset
- asthma if <20yo, COPD if >40yo
Pattern of Sx
- asthma if variable, COPD if persistent
Lung function
- asthma if variable / reversible, COPD if persistent
History
- asthma if PHx asthma, COPD if PHx COPD/chronic bronchitis/emphysema
- asthma if FHx asthma/allergies
- COPD if smoke exposure
Long-term disease trajectory
- asthma if seasonal or yearly
- COPD if progressive over years
- asthma if response to treatment lasts weeks, COPD if response to treatment is limited/short term
Chest XR
- asthma if normal, COPD if hyperinflation
Paeds Asthma Dx
- <12m
- 1-5yo
- >6yo
<12m - wheeze most commonly due to acute viral bronchiolitis and/or small/floppy airways
1-5yo = preschool wheeze - treatment trial -> ‘provisional’ Dx if responsive
> 6yo - spirometry vs treatment trial
Paeds Asthma Mx
- <12m
- 1-5yo
- >6yo
<12m - asthma unlikely, specialist input prior to commencing SABA or steroid
1-5yo - SABA PRN if Sx responsive + preventer if Sx in between URTIs
> 6yo - SABA PRN + regular preventer if frequent intermittent or persistent Sx, or severe flare-ups
Paeds Asthma preventer options + step-wise Mx
low dose ICS (preferred if atopy)
- Flixotide junior (fluticasONE 50-100mcg, max 200mcg)
or
montelukast (note risk of behavioural/neuropsychiatric AEs)
Step up:
1. high dose ICS (Flixotide max 500mcg) vs. combo low dose ICS + montelukast
2. If >6yo, low dose ICS-LABA combination
Inhaled corticosteroid dose categories for:
Budesonide
Fluticasone furoate
Budesonide:
- Low 200-400
- Medium 500-800
- High >800
Fluticasone furoate:
- Low 50
- Medium 100
- High 200
