Asthma + COPD Flashcards
What is asthma?
Chronic inflammatory airway disease leading to variable air way obstruction
What is the pathophysiology of asthma?
CRAB
Chronic
Reversible obstruction
Airway hypersensitivity
Bronchoconstriction
Smooth muscle in the airways is hypersensitive to stimuli leading to airway constriction and airway obstruction
How does asthma typically present?
Episodic
Typically worse at night
SOB
Chest tightness
DRY cough
Wheeze
What other conditions does asthma often present with?
What is this called?
Asthma
Hay fever
Eczema
Food allergies
Atopy
How does asthma present on examination when the patient is well?
Typically normal
Widespread polyphonic expiratory wheeze
What are some typical triggers of asthma?
Infection
Nighttime
Exercise
Animals
Cold, damp dusty air
Strong emotions
What medications can worsen asthma?
Non selective beta blockers like propranolol
NSAIDs like. Naproxen
What investigations are done for asthma?
Spirometry
Spirometry + reversibility testing
FeNO (Fractional exhaled nitric oxide)
Peak flow variability using a peak flow diary
How is spirometry and reversibility testing used to diagnose asthma?
Work out FEV1:FVC ratio
If FEV1:FVC ratio < 70% patient has obstructive pathology
Patient is then given a bronchodilator like salbutamol, if the FEV1 has an increase in 12% or more it shows the obstruction is reversible (not COPD)
What is the use of fractional exhaled nitric oxide (FeNO)?
Measures concentration of nitric oxide exhaled by the patient
Nitric oxide is a marker of airway inflammation (higher it is more airway inflammation there is)
How can a peak flow diary be used to help investigate asthma?
Readings taken twice daily for 2-4 weeks
If there is variability of more than 20% between readings it’s positive
What are the types of medications that are used to manage asthma?
Short acting Beta 2 agonists (SABA) = salbutamol
Inhaled corticosteroids (ICS) = beclometasone
Long acting Beta 2 agonists (LABA) = salmeterol
Leucotriene receptor antagonists = monteleukast
Long acting muscarinic antagonist = Tiotropium
Theophylline
What are the BTS guidelines for the long term management of asthma?
1.) salbutamol (SABA) + Beclometasone (ICS)
If not controlled
2.) salbutamol (SABA) + [ Beclometasone (ICS) + formoterol/salmeterol (LABA)]
3.) salbutamol (SABA) + [ Beclometasone (ICS) + formoterol/salmeterol (LABA)] + Monteleukast (LTRA) or Tiotropium (LAMA)
4.) specialist referral
How frequently should an asthma patient be reviewed following a change to their medications?
4-8 weeks after adjustment
What are the initial medications given to manage long term asthma?
SABA = Salbutamol
+
ICS = beclometasone
What changes to medications do you give if an asthma patient is not coping with Salbutamol (SABA) + Beclometasone (ICS)?
Add a LABA to the ICS inhaler (MART Therapy) LABA+ICS
So now on:
Salbutamol (SABA)
+
Beclometasone (ICS) + salmeterol or formoterol (LABA)
What changes to medications do you give if an asthma patient is not coping with Salbutamol (SABA) + Beclometasone (ICS) + salmeterol/formoterol (LABA)?
Increase dose of Beclometasone (ICS) and can add Monteleukast (LTRA) or Tiotropium (LAMA)
So patient on:
Salbutamol (SABA)
+
Inc beclometasone (ICS) + salmeterol/formeterol (LABA)
+
Monteleukast (LTRA) or Tiotropium (LAMA)
What changes might a specialist do to medications in an asthma patient who is not coping with Salbutamol (SABA) + increased dose Beclometasone (ICS) + salmeterol/formoterol (LABA) + Monteleukast (LTRA) or Tiotropium (LABA)?
Increase beclometasone to a higher dose or give oral corticosteroids
May also consider theophylline or biologics
What are the risk factors for developing asthma?
Fhx
Smoking
Polluted area
Atopy
What is considered uncontrolled asthma?
Any asthma exacerbation requiring oral corticosteroids
Frequent regular symptoms needing reliever 3 or more times a day
What is the non-pharmacological management of asthma?
Smoking cessation
Patient and family education to avoid triggers
Proper inhaler technique + adherence
Regular exercise
Yearly flu jab
What is an acute asthma exacerbation?
What are some signs of an acute asthma exacerbation?
Rapid deterioration in symptoms :
-SOB
-use of accessory muscles
-Tachypnoea
-tight chest/reduced air entry
-symmetrical expiratory wheeze
What is the ABG progression with a patient with worsening asthma severity?
Initially respiratory alkalosis since TACHYPNOEA
Normal or high pCO2 or low pO2 (hypoxia) is very bad since patients becoming exhausted with poor respiratory effort leading to RESPIRATORY ACIDOSIS
What are the severity’s of an acute asthma exacerbation?
Moderate
Severe
Life-threatening
Near fatal
What is considered a moderate asthma exacerbation?
Peak flow 50-75% best or predicted
What is the classification of severe asthma exacerbation?
Any 1 of:
Peak flow 33-50% best or predicated
RR over 25
HR over 110
Unable to complete sentences
What are the features/classification of life-threatening asthma exacerbation?
Any 1 of:
Sats < 92%
PaO2 < 8kPa
Peak flow < 33%
Silent chest
Confusion
How do you classify a near fatal asthma exacerbation?
PaCO2 > 6kPa (Type 2 resp failure)
Silent chest
Will likely need ITU
How is a mild asthma exacerbation managed?
Inhaled SABA (Salbutamol)
X4 dose of inhaled corticosteroids for 2weeks
Or
Oral steroids
Abx if evidence of infection
48hr follow up
What is the management of moderate asthma exacerbation?
Nebulised salbutamol
Steroids (oral pred or IV hydrocortisone)
What is the management for a severe /life-threatening asthma exacerbation?
15L non rebreathing oxygen aiming for 94-98% sats (titrate down)
Nebulised oxygen (8L) driven salbutamol (2.5-5mg every 15mins)
Oral Prednisolone 40-50mg for 5days
IV magnesium sulphate
What side effects can salbutamol cause and needs to be monitored when treating asthma exacerbation?
Hypokalaemia
Tachycardia
Lactic acidosis
What is COPD?
Long term, progressive non reversible airway obstruction, chronic bronchitis and emphysema
What is chronic bronchitis?
Long term symptoms of a cough and sputum production due to inflammation in the bronchi
What is emphysema?
Damage and dilation of the alveolar sacs and alveoli decreasing the surface area for gas exchange
How can COPD be differentiated from. Asthma on spirometry?
COPD will have an FEV1:FVC ratio that’s less than 70% but FEV1 or FVC wont improve by 12% or more with a bronchodilator
What are the symptoms of COPD?
SOB
Cough
Sputum production
Wheeze
Recurrent respiratory tract infections
What is the scale used to score breathlessness?
MRC Dyspnoea Scale
How is the MRC dyspnoea scale graded?
Grade 1 - Grade 5
What is an MRC Dyspnoea Scale Grade 1 for breathlessness?
Breathless on strenuous exercise
What is an MRC Dyspnoea Scale Grade 2 for breathlessness?
Breathless on walking uphill
What is an MRC Dyspnoea Scale Grade 3 for breathlessness?
Breathlessness that slows the patient walking on the flat
(Walk slower than others of the same age on the flat due to breathlessness or have to stop for breath on the flat)
What is an MRC Dyspnoea Scale Grade 4 for breathlessness?
Breathlessness stops them from walking more than 100m on the flat
What is an MRC Dyspnoea Scale Grade 5 for breathlessness?
Unable to leave the house due to breathlessness
What investigations would you do if a patient is long term short of breath, sputum production, cough and you think it may be COPD?
Spirometry (FEV1:FVC ratio, TLCO)
BMI
FBC
Sputum culture
CXR
CT thorax
ECG + ECHO
Serum alpha-1 antitrypsin
What does TLCO test for?
How well oxygen and CO2 diffuse across the alveolar membrane through the lungs into the blood
What is the long term management of COPD?
Smoking cessation
Pulmonary rehabilitation
Pneumococcal and annual flu vaccine
What is the initial medical treatment for COPD?
SABA (Salbutamol) + SAMA (Ipratropium bromide)
After giving the pateitn a SABA + SAMA, there is no asthmatic or steroidal responsive features, what medications do you give for the COPD patietn?
LABA + LAMA = Anoro Ellipta inhaler
When COPD has asthmatic or steroid responsive features how is it treated?
Long acting beta agonist (salmeterol)
+
ICS (beclometasone)
=
Fostair
What is a medication that can be given to breakdown mucus?
Carbocisteine (mucolytic agent)
What is the issue with Azithromycin?
Patients need an ECG and liver function monitoring before and during treatment
When is a patient given Long-term oxygen therapy?
Severe COPD:
-chronic hypoxia < 92%
-Polycythaemia
-cyanosis
-cor pulmonale
What patients can you not give Long-term oxygen therapy to?
Smokers
What is Cor pulmonale?
Right sided heart failure due to respiratory disease leading to pulmonary hypertension leading to increased afterload for the right ventricle leading to back flow of blood through the right side of the heart to systemic veins
What are some causes of Cor pulmonale?
COPD
PE
ILD
Cystic fibrosis
Primary pulmonary hypertension
What are some symptoms of cor pulmonale?
SOB
Peripheral oedema
Breathless on exertion
Syncope
Chest pain
What are some signs of cor pulmonale?
Hypoxia
Cyanosis
Raised JVP
Peripheral oedema
Parasternal heave
Mitral regurgitation (pan systolic murmur)
Hepatomegaly
How is cor pulmonale managed?
Diuretics
Long term oxygen therapy
Treat underlying cause
What is the most common cause of a COPD exacerbation?
Infection (bacterial or viral)
What would the ABG of a patient with an acute COPD exacerbation look like?
Acidotic
Low pO2
High pCO2
Raised bicarbonate (patients bicarb is high normally due to chronic aspect of COPD but the exacerbation is too much for the bicarb to prevent the pH being acidotic)
What investigations would you do for a patient who is having a COPD exacerbation?
FBC
ABG
U+Es
Sputum culture
Blood cultures (if signs of sepsis)
ECG
CXR
What are the target saturations of a patient at risk of retaining CO2?
88-92%
What are the target saturations of a patient with COPD who you are confident do not retain CO2?
94-98%
What oxygen masks are given to patients with COPD to deliver a very specific amount of oxygen?
Venturi masks
What is the first line medical management for an acute infective exacerbation of COPD?
Regular inhalers or nebulisers (salbutamol and ipratropium bromide)
Steroids (Prednisolone 30mg OD for 5 days)
Abx
Respiraotry physiotherapy
What is the management of a severe acute exacerbation of COPD. When the initial management isn’t enough?
IV aminophylline
Non-invasive ventilation (NIV)
Intubation and ventilation (ITU)
What is NIV (Non invasive ventilation)/how does it work?
Full face mask and hood where the is Inspiratory positive airway pressure forcing air into the lungs and then expiratory positive airway pressure to keep the lungs open on exhalation
When is NIV used?
Persistent respiratory acidosis (pH < 7.35 and PaCO2 >6) despite max treatments
Potential to recover
Acceptable to patient
What is the contraindication to NIV?
Untreated pneumothorax
What investigations should be done regularly while receiving NIV?
ABGs
What are some causes of COPD?
Smoking
Air pollution
Occupational exposure
Alpha-1-antitrypsin
TB
What is necessary for a safe asthma discharge bundle (following an exacerbation)?
PEFR > 75% best
Nebulisers stopped 24hrs before discharge
Inpatient asthma nurse review for technique and adherence
5 day oral Prednisolone
2 day GP follow up
Resp clinic follow up
What is an asthma management plan?
Patient has a card which says their best peak flow result on it
It has 2 other values on it stating they should take rescue steroids if their peak flow falls below a set number
Or
Seek immediate 999 help
What are some signs of COPD?
Barrel chest
Hyper resonant chest percussion
Reduced chest expansion
Wheeze
Tripodding
Pursedlips breathing
Use of accessory muscles
Cor pulmonale signs
What is the management for acute bronchitis?
Oral doxycycline but often resolves without
What is the main blood test abnormality with acute bronchitis?
CRP
What is an alternate name for Non invasive ventilation (NIV)?
BiPAP (Bilevel Positive Airway Pressure)
What is the management of severe/life threatening asthma exacerbation if the patient doesnt respond to:
15L non rebreathing oxygen aiming for 94-98% sats (titrate down)
Nebulised oxygen (8L) driven salbutamol (2.5-5mg every 15mins)
Oral Prednisolone 40-50mg for 5days
IV magnesium sulphate
Nebulised ipratropium bromide
IV 100mg Hydrocortisone
Escalate to ITU
Consider NIV (non invasive ventilation or ventilation)
