Asthma & COPD

Question 1

What is COPD?

Answer 1

Chronic Obstructive Pulmonary Disease (COPD)

Characterised by:

• Chronic Bronchitis
• Emphysema

Question 2

What is the biggest cause of COPD?

Answer 2

Smoking

Question 3

What are the main clinical features of COPD?

Answer 3

• Exertional dysponoea
• Cough
• Sputum production
• Wheeze

Symptoms are typically ‘fixed’ whilst the disease is progressive and relentless

Greater than a 20 pack per year smoking history is very common in patients

Question 4

What are the main aims of COPD treatment?

Answer 4

Reduce breathlessness

Reduce exacerbation frequency

Question 5

What impact does COPD have on daily activities?

Answer 5

Usually significant

Question 6

What are the main risk factors for pneumonia in COPD?

Answer 6

Low BMI
Current smoking
Previous pneumonia

Question 7

What are some of the main risks with long term ICS therapy?

Answer 7

Adrenal suppression
Increased risk of tuberculosis
Increased risk of type 2 diabetes

Question 8

What are the main characteristics of an acute COPD exacerbation?

Answer 8

Increased SOB
Worsening cough
Increased sputum production
Change in sputum colour

Question 9

What are the main measures to prevent COPD exacerbations?

Answer 9

Flu vaccine (& pneumonococcal)

Optimise inhaler therapy

Education

Emergency antibiotics/steroids at home

• increased cough/sputum production
• change in sputum colour
• increased breathelessness

Question 10

What is ‘SIMPLE’ for asthma management in community phramacy?

Answer 10

Stop smoking
Inhaler technique
Monitoring
Pharmacotherapy
Lifestyle
Education

Question 11

How is asthma diagnosed?

Answer 11

Structured clinical history

Spirometry
- FEV1/FVC ratio less than 70% is a positive test

Bronchodilator reversibility test is FEV1/FVC is lower than 70%.
- An improvement in FEV1 of 12% or more, together with an increase in volume of 200mL is a positive test.

Question 12

Asthma pathophysiology and treatment effects.

Answer 12

Look at separate sheet!

Question 13

What test can be used to look at asthma control?

Answer 13

Asthma Control Test (ACT)
- Questionnaire

Or even just ask how long they need to use their blue inhaler

Question 14

What is ‘difficult asthma’ for adults?

Answer 14

Asthma with symptoms despite treatment at steps 4 or 5 plus 1 of the following:

An event of acute severe asthma which is life threatening within the last 10 years

Requirement for maintenance oral steroids for at least 6 months at a dose over 7.5mg/day (or a dose equivalent calculated over 12 months)

2 hospitalisations within the last 12 months in patients taking and adherent to high dose inhaled steroids (dose higher than 1000mcg)

Fixed airway obstruction, with a post bronchodilator FEV less than 70%

Question 15

What is the aim of Asthma therapy?

Answer 15

No daytime symptoms

No night time wakening

No need for rescue medication

No exacerbations

No limitations to QoL

Normal lung function (higher than 80%)

Minimal side effects from medicines

Question 16

What are the main challenges of difficult to treat asthma?

Answer 16

Symptoms despite maximum treatment

High rates of alternative or co-existent diagnosis

High rate of psychological co-morbidities

Poor adherence to treatment

Need specialist assessment

Question 17

What is ‘ACOS’?

Answer 17

Asthma and COPD Overlap Syndrome

- A condition that shares features of both asthma and COPD.

Question 18

What are the important clinical aspects (in terms of history) that should be covered in patients with difficult asthma?

Answer 18

Smoking history
Family history of respiratory disorders
Past and present occupation
Potential aggravating medical conditions
Drugs
Adherence to treatment
Psychosocial circumstances

Question 19

What are the main factors that can aggravate asthma?

Answer 19

Psychological e.g. depression

Upper airway disease

GORD (gastro-oesophageal reflux disease)

Adverse drug effects (e.g. NSAIDs, B-Blockers)

Allergy

Occupational factors

Cigarette smoking

Obesity

Non-adherence to medication

Co-existing conditions

• Dysfunctional breathing
• Bronchiectasis
• Severe COPD
• Vocal cord dysfunction

Question 20

How can you identify non-adherence in asthma patients?

Answer 20

Surrogate measures

• Dispensing records
• Emergency supplies

Assess airway inflammation

• Sputum eosinophil count (raised more than 2%)
• Exhaled FeNO concentrations (raised more than 25% ppb at 50ml per second)

Question 21

What pharmacological options are available to manage difficult to treat asthma?

Answer 21

Omalizumab
- Anti-IgE

Etanercept
- Tumour necrosis factor alpha

Others

• Ciclosporin
• Methotrexate
• Gold
• Terbutaline (monitor heart rate!)

Question 22

How does Omalizumab work in difficult to treat asthma?

Answer 22

It is a recombinant humanised mouse monoclonal antibody that is anti-IgE

Question 23

What are Cushing’s Symptoms?

Answer 23

Weight gain and fat deposits

• Slim arms/legs compared to torso
• ‘buffalo hump’
• ‘moon face’

Skin changes

• Thin skin, easily bruised
• Reddish-purple stretch marks
• Spots on upper body
• Oedema (swollen ankles)
• Excessive sweating
• Prolonged wound healing

Bones and muscles

• Backache
• Bone pain
• Fracturing
• Curved spine

Others:

• Depression
• Hypertension
• Hyperglycaemia
• Excessive hair
• Loss of libido
• Infertility in men
• Irregular periods in women

Question 24

What are the main treatment considerations for cushing’s symptoms?

Answer 24

Osteoporosis

Depression

Hypertension/CV Risk

Pain