Asthma + COPD Flashcards
Pathology of asthma
Bronchial muscle contraction, triggered by stimuli
Mucosal swelling caused by mast cell and basophil degranulation, releasing inflammatory mediators
Increased mucus production
Hyper-responsiveness of airways Reversible airway obstruction
S+S of asthma
Episodic - diurnal variability (worse at night or early morning)
Wheeze
Atopy
SOB
Pathway if pt is likely to have asthma
Initiate carefully monitored treatment (6 weeks inhaled corticosteroids)
FEV1 test
If good response to meds, diagnose asthma
If poor response, check technique + adherence + consider alternative diagnosis
Investigations for asthma
Spirometry with bronchodilator reversibility (improvement of FEV1 >12% or >200ml increase in volume)
Peak flow + reversibility to diagnose (using 4 puffs of salbutamol inhaler, 15 min pause)
FeNO (fractioned exhaled nitric oxide) - higher level of nitric oxide in exhaled air = asthma
Supported self management for asthma
Education on triggers
Smoking cessation
Weight loss
Breathing exercises
What is defined as ‘controlled’ asthma?
No daytime symptoms
No night time waking
No need for rescue meds
No asthma attacks
No limitations on activity
Normal lung function
Minimal side effects
Ladder for management in adults
Short acting B2 agonist (salbutamol)
+ Low dose ICS (beclametasone/ budesonide) - brown, called Clenil
Add inhaled LABA (salmeterol) - stop if no effect
Increase ICS dose (max 2g a day)
or add: +LTRA (leukotriene receptor antagonist eg Montelukast), SR theophylline, LAMA (tiotropium bromide)
+ daily steroid tablet
+ refer
Don’t give LABA without ICS
What medications can be added in specialist centres for asthma?
Omalizumab (anti IgE mAb)
Given by SC injection
Immunosuppressants = methotrexate
RF for developing fatal asthma
Previous hosp admission
Requiring >3 medications
Heavy use of B2 agonist
Adverse behavioural features eg non-adherance, mental illness, stress, drug abuse
Adult classification of severe asthma
PEF 33-50%
Resp rate >25
HR >110
Inability to complete sentences in one breath
Adult classification of life threatening/ fatal asthma
Altered consciousness, arrhythmias, hypotension, cyanosis, silent chest
PEF <33%
O2 <92%
PaO2 <8 kPa
Near fatal = Raised PaCO2
Child classification of severe asthma
Can’t complete sentences
SpO2 <92%
PEF 33-50%
HR >140 (1-5 y/o) >125 (>5 y/o)
RR >40 (1-5 y/o) >30 (>5 y/o
Child classification of life-threatening asthma
Silent chest, cyanosis, hypotension, confusion
Sp02 <92%
PEF <33%
Acute asthma management in adults
O2 Salbutamol 5mg nebs
Ipratropium bromide nebs
Hydrocortisone IV
Magnesium sulphate IV
Aminophylline/ IV salbutamol
What to give on discharge of acute asthma?
Prednisolone for 5-7 days
Weaning plan for salbutamol
What should be monitored in primary care for asthma?
Asthma control
Lung function assessed by spiromatry/ PEF
Inhaler technique
Adherence
Bronchodilator reliance
What are the 3 questions to ask (RCP) in an asthma pt?
Any difficulty sleeping?
Any symptoms during the day?
Has it interfered with activities?
S+S COPD
Exertional SOB, chronic cough, regular sputum production, frequent winter bronchitis, wheeze
RF for COPD
Smoking
Pollutants in work place
Alpha-1 antitrypsin deficiency
Investigations for COPD
CXR - hyperinflation, flat diaphragms, bullae
Spirometry
Staging of COPD
Stage 1 = <0.7 FEV1/FVC, >80% FEV1 % predicted
Stage 2 = <0.7 FEV1/FVC, 50-79% FEV1 % predicted
Stage 3 = <0.7 FEV1/FVC, 30-49% FEV1 % predicted
Stage 4 = <0.7 FEV1/FVC, <30% FEV1 % predicted
What is pulmonary rehab?
Program of exercise, education + support
SIRS criteria
RR >20
Temp high or low
HR >90
WCC <4 or >12
COPD x ray appearance
Hyperinflated Flat diaphragms Bullae
Management of COPD exacerbation
Controlled O2 - check ABG
Salbutamol nebs
Ipratropium bromide nebs - crossout LAMA
Corticosteroids - IV hydrocortisone
Antibiotics
Aminophylline
Resp support (BiPAP if rising CO2)
Ongoing management of COPD post exacerbation
Prednisolone 30mg OD for 7 days
Continue antibiotics
What medications precipitate asthma?
Beta blockers + aspirin
Management of mild + moderate COPD
All COPD pts: SABA or SAMA (ipratropium)
If mild (>50%): LABA (salmetrol) or LAMA (tiotropium) + ICS if not working
If moderate (<50%) = LABA (salmetrol) or LAMA (tiotropium)
AND ICS
If starting LAMA, stop SAMA - causes heart block
Remember flu vaccine + pneumococcal jab annually
Obstructive vs restrictive FEV1/ FVC ratio
Obstructive <75% (due to decreased FEV1, slightly decreased FVC)
Normal 75-80%
Restrictive >80% (due to slightly decreased FEV1, decreased FVC)
SE of steroid use
Immunosuppression
Mood + behaviour changes
Adrenal suppression after stopping
Steroids increase INR
Mineralcorticosteroids increase BP
Increases blood glucose - caution in diabetics
What happens when stopping steroids?
Adrenal insufficiency if stopped suddenly after prolonged period - use 6 week reduction course
SE of salbutamol
Palpitations Tremor Hypokalaemia
What is trelegy?
Inhaler with 3 drugs ICS + LABA + LAMA
What are light blue, teal, orange, red+white, purple, green, brown, white+turquoise inhalers?
Blue - salbutamol
Teal - salmeterol
Orange - fluticasone (ICS)
Red+white - Symbicort (budesonide + formoterol)
Green - ipratropium
Brown - budesonide
Purple - fluticasone + salmeterol
White+turquoise - tiotropium
What is the centor + fever pain criteria?
Fever
Purulence
Attend rapidly
severely Inflamed tonsils
No cough
Centor: tonsillar exudate, fever, tender lymphadenopathy, absence of cough
Causative organisms for COPD exacerbations
Haemophilus influenza
Strep pneu
Moraxella catarrhalis
Rhinovirus
Investigations for acute COPD
ABG (bicarb for acute on chronic)
CXR (hyperinflation, flat diaphragms, bullae)
FBC + U+Es, CRP
ECG
Peak flow
Culture sputum +- blood
Measure theophylline baseline
Management of acute exacerbation of COPD
COSI CAA
Controlled Oxygen (88-92) through venturi - repeat ABG 30 mins after changing O2
Salbutamol 5mg
Ipratropium bromide 500mcg neb
Corticosteroids: Hydrocortisone IV/ Pred oral 30mg 7-14 days
Amoxicillin + clarithromycin/ doxycycline
Aminophylline if no response to steroids
NIV if indicated
Indications for NIV + 2 types
COPD with respiratory acidosis (BiPAP)
Type 2 failure
Pulmonary oedema (CPAP)
Severity of asthma (moderate, severe + life threatening)
Mod = 50-75% PEFR sats >92%
Severe = RR>25 HR >110 33-50% PEFR sats >92%, unable to complete sentences
Life threatening = silent chest, cyanosed, bradycardic, hypotensive, confusion, sats <92%
What is the GOLD criteria?
Uses MRC + CAT score with number of exacerbations = produces a group (A-D)
Group dictates what inhaler to use
What is the MRC scale?
For COPD pts
Grade 1-5: not troubled by SOB to too breathless to leave house
When should MDI + spacers be used?
Reduce SE
Improve amount inhaled
Increase efficiency of use
What is the Anthisonian criteria?
For acute exacerbation of COPD. 2 of: increased SOB, increased sputum volume or presence of purulent sputum)
What is brittle asthma (+ the types)?
Difficult to control form of asthma
Type 1 = prolonged wide PEF variability
Type 2 = sudden severe attacks on stable background
When do steroids need to be tapered?
If the pt has been on them for >3 weels
When is NIV + invasive ventilation used in asthma?
NIV = never, unless on ICU
Invasive = if pt has worsening hypoxia or increasing CO2, decreasing pH or they’re becoming exhausted/ confused, respiratory arrest
What abx are given to COPD pts + what needs to be checked?
Azithromycin
LFTs + QT length on ECG
Criteria for LTOT
Non-smoker
Sats <88%
pO2 <7.2
Evidence of HF or polycythaemia = pO2 <8
Check pCO2 doesn’t rise with oxygen therapy = NIV may be needed
What is the BODE index?
Scoring system for COPD survival
