Asthma & COPD Flashcards
GO REVISE:
- Sem 3 Resp: asthma & COPD
- Sem 4: CPT
- Yr3 Medicine block: asthma & COPD
State some risk factors for asthma
- Personal or family history of atopic disease
- Respiratory infections in infancy
- Exposure (including prenatally) to tobacco smoke
- Premature birth and associated low birth weight
- Obesity
- Social deprivation
- Exposure to inhaled particulates
- Workplace exposures (includingn flour dust and isocynates from paint)
**NOTE: male sex increased risk of pre-pubertal asthma, female sex increased risk of persistence of asthma from childhood to adulthood
Discuss how asthma is diagnosed in primary care
There is no single diagnostic test to confirmd diagnosis therefore must take a thorough history and use clinical judgement to determine the probability of an asthma diagnosis based on a combination of the following:
- Presence of >1 variable symptom of wheeze, cough, breathlessness and chest tightness (usuallyd dinural, triggers)
- Personal or family history of other atopic conditions
- Results from tests e.g. serial PEFR, spirometry & reversibility, FENO
What clinical findings may make you suspect asthma?
- Widespread expiratory polyphonic wheeze
- Tachypnoea
- Low oxygen saturations
- Tachycardia
- Signs of atopy
State some investigations which may be done to diagnose asthma
Who do we offer these investigations to?
- Serial PEFR
- Spriometry & bronchodilator reversibility
- FENO (exhaled nitric oxide test)
Who do we offer to?
- Offer FeNO testing to everyone 17yrs and older. Consider in children 5-16yrs if diagnostic uncertainty after initial assessment and they have either normal or obstructive spirometry with negative BDR
- Offer spirometry to everyone over 5yrs. Offer bronchodilator reversibility to everyone 17yrs and older and consider it in those aged 5-16yrs if have obstructive spirometry
- Variable peak flow can support asthma diagnosis if there is diagnostic uncertainty after initial assessment, a FeNO test and/or spirometry. Generally use other tests first (check if this is same in children)
Describe how serial PEFR measurement is used to diagnose asthma
- Measure PEFR 3 times in the morning and 3 times in evening; at each sitting record the highest of the 3 scores
- Reccord in peak flow diary for 2-4 weeks
Patients should do it at the same time each day and must not take their asthma medication prior to peak flow as this will alter results.
Describe how spirometry is used to diagose asthma
Discuss how bronchodilator reversibility is used to diangose asthma
Spirometry
- Use spirometry to measure FEV1 and FVC; then calculate FEV1:FVC ratio
- If FEV1:FVC ratio = 70% then suggests obstructive pattern. HOWEVER, normal result in asymptomati person doesn’t rule out asthma
Bronchodilator Reversibility
- Repeat spirometry after bronchodilators are given and observe for improvement of FEV1 (in children & adults) and a increase in volume (adults only)
Describe how exhaled nitric oxide test (FENO) is used to diagnose asthma
- Nitric oxide (NO) is found in the atmosphere, and is higher in areas with air pollution. It is also produced in the body, especially if there is inflammation. A higher level of nitric oxide measured in your breath may be a sign of asthma.
- Fractional exhaled nitric oxide test measures how much nitric oxide is in your breath
- You breathe into a plastic mouthpiece or a cardboard tube attached to a handheld monitor. The monitor shows the reading on its screen.
- You will breathe in deeply, with your mouth open, and then breathe out little by little until your lungs are empty. The breath out will normally take 10 seconds in adults (6 seconds in children). Some devices will make a sound to help keep the flow at the right level throughout the test.
- You may have to do the same measurement up to 3 times
- The results will be in parts per billion (ppb) of nitric oxide in your breath
FeNO test is affected by what two things?
- Smoking
- ICS
NICCE suggests that:
- Approx 1 in 5 people with negative FeNO have asthma
- Approx 1 in 5 with positive FeNO will not have asthma
For adults aged =/18yrs, discuss what results- of following investigations- would support diagnosis of asthma:
- Serial PEFR
- Spirometry & bronchodilator reversibility
- Exhaled nitric oxide testing
Serial PEFR
- >20% variability = positive result
Spirometry & bronchodilator reversibility
- FEV1:FVC ratio <70% (however, normal spirometry in asymptomatic individual doesn’t rule out asthma. NOTE: spirometry may be affected by ICS)
- Improvement in FEV1 of 12% or more together with an increase in volume of at least 200mL in response to B2 agonist or ICS= positive result. Improvement of >400mL highly suggestive of asthma.
Exhaled nitric oxide testing
- =/> 40pbm (NOTE: resutls can be affected by treatment with ICS)
For children aged 5-17yrs, discuss what results- of following investigations- would support diagnosis of asthma:
- Serial PEFR
- Spirometry & bronchodilator reversibility
- Exhaled nitric oxide testing
Serial PEFR
- >20% variability= positive result
Spirometry & bronchodilator reversibility
- FEV1:FVC ratio = 70%
- Improvement of 12% or more in FEV1 after bronchodilator therapy
Exhaled nitric oxide testing
- >35pbm = positive result
For children under age of 5yrs, or those who are unable to perform some or all of the objective tests, how should you diagnose asthma?
- NICE reccomends using clinical judgement based on any positive test result and noted signs & symptoms to determine likelihood of asthma. When a child reaches 5rs carry out objectivee tests
- If the person cannot perform a particular test, attempt to perform at least two other objective tests
State some specialist tests that may be used to diagnose asthma (not including serial PEFR, spirometry or FENO)
Bronchial challenge test; offer when there is diagnosti uncertainty after other tests.
- Test measures how sensitive the airways in your lungs are
- Called an airway provocation test. It involves breathing in gradually increasing doses of a medication that can irritates the airways and cause them to get narrower. People with sensitive lungs will be affected by a much lower dose of this medication than people with healthy lungs. The test is done carefully to make sure it is safe.
- Provacation agent given as an aerosol mist or a dry powder. This starts at a very low dose and then builds up slowly. Between each dose your breathing will be tested again, to see if there are any significant changes.If a significant change occurs, the test will be stopped. You will be given medication to return breathing to normal.
- Provacation agents:
- methacholine
- histamine
- mannitol
What are the aims of asthma management?
Aim is control disease; complete control is defined as:
- No daytime symptoms
- No night-time waking due to asthma
- No need for rescue medication
- No limitations on acitivity including exercise
- Normal lung function (FEV1 and/or PEF >80% predicted or best) *NOTE: can’t use lung function tests to reliably guide asthma management in children <5yrs
- Minimal side effets from medications
Discuss the non-pharmacological management of asthma
- Avoid triggers e.g. smoke, NSAIDs, beta blockers, allergies
- Weight loss & smoking cessation if appropriate
- Ensure up to date on all vaccinations (including all childhood and annual influenza vaccination)
- Self management education & personalised asthma management
- Educate on inhaler use & technique
- Signpost to sources of information & support e.g. asthma UK, BLF
- Assess for presence of anxiety & depression (more common in people with asthma)
Discuss the pharmalogical management** of asthma in **adults; ensure to discuss idea of step up and step down therapy
- SABA to all people with symptomatic asthma to be used PRN
- Add lose dose ICS
- Add either LABA (BTS) or LTRA (NICE)
- Add LABA or LTRA (dependent on which added above) or increase ICS to medium dose
- Add additional therapy (e.g. LAMA or theophylline) or increase ICS to high dose. Specialist may also reccomend continous or frequent use of orla steroids
What is MART?
- Maintenance & reliever therapy
- Single inhaler containing ICS and fast acting LABA
- Used for both daily maintenace and relief of symptoms as required
Discuss the pharmalogical management of asthma in children (5-16yrs); ensure to discuss idea of step up and step down therapy
- SABA
- Paediatric low dose ICS
- Add LTRA
- Consider stopping LTRA and offer LABA
- Consider swapping ICS & LABA to MART
- Increase to moderate dose ICS
- Specialist referal for high dose ICS & potential additional therapies
What follow up should a newly diagnosed asthmatic receive?
CHECK
- Follow up 4-8 weeks after commencing treatment??
People with asthma should be routinely followed up with an ‘asthma review’ at least annually; discuss what an asthma review should include
- Monitor asthma via peak flow or spirometry
- Observe & give advice on inhaler tehcnique
- Check have up-to-date asthma managemtn plan
- Adherence to treatment
- Symptom control (use specified questionnaires- see later FC)
- Assess risk of future asthma attacks
- Monitor those who are on long term steroid tablets (e.g. >3 months or those who require >3/4 courses per year) for complications: BP, HbA1c, cholesterol, bone mineral density, vision
- Smoking status
- If any medication adjusted need further follow up in 4-8 weeks
What is a personalised asthma action plan?
It tells you, and anyone with you:
- which medicines you take every day to prevent symptoms and cut your risk of an asthma attack
- what to do if your asthma symptoms are getting worse
- the emergency action to take if you’re having an asthma attack and when to call 999.
You fill it in with your GP or asthma nurse, so it’s personal to you and your asthma. Then take it along to all your asthma appointments, including any out of hours appointments or A&E, so your doctor or asthma nurse can help you keep it up to date.
What questionnaires can be we use to assess asthma control (4)- think about if certain ones can only be used in children or adults
Children
- Childhood asthma control test
- Asthma control questionaire
NOTE: also explcitly ask about how often use blue reliever inhaler & ask child about symptoms- don’t just rely on parent
Adults
- The Royal College of Physicians 3 Questions
- Asthma control test
- Asthma control questionnaire
Discuss what questions, and what answers, are on the asthma control questionnaire
During the past 4 weeks:
- How much of the time did your asthma stop you from getting as much done at work, school or home?
- How often have you had SOB?
- How often did asthma symptoms wake you up in night or wake you up earlier than usual?
- How often do you use your reliever inhaler?
- How would you rate your asthma control?
Score each question 0-5.
Discuss what questions are asked in The Royal College of Physicians 3 Questions
State some factors associated with increased risk of future asthma attacks in:
- Adults
- Children
If someone presents to GP with exacerbation of asthma, what is the first question you need to ask yourself?
In order to answer this question, what examinations/observations would you do?
Does this person need admitting to hospital; need to assess severity hence do:
- Full respiratory examination (starting with general inspeciton as always)
- Observations: RR, sats, HR, BP, temp
- Recrod PEFR if they are old and well enough to comply and compare to their best
- Review history: previos admissions, ITU admissions
Remind yourself of how to grade the severity of an asthma attack
**Highliht any differences for children
Mild
- PEFR >75% of best or predicted
- No features of severe asthma
Moderate
- PEFR 50-75% of best or predicted
- No features of severe asthma
Acute Severe
- PEFR 33-50% of best or predicted (or less than 50% in chidlren)
- Cannot complete sentences in 1 breath
- Resp rate >25/min (or >30 if child 5-12yrs, >40 if child 2-5yrs)
- HR >110/min (or >125 if 5-12yrs, 140 if2-5yrs)
Life-threatening
- PEFR <33% of best or predicted
- Near or fully silent chest
- Sats <92%
- ABG pO2 <8kPa
- ABG normal pCO2
- Cyanosis/hyppoxia
- Poor respiratory effort
- Exhaustion, confusion, arrhythmias
Near Fatal
- Raised pCO2
Which patients, suffering from asthma exacerbation, might you consider admiting to hospital?
What should you do whilst awaiting admission?
You have decided to admit your patient to hospital for their asthma exacerbation; what should you do whilst awaiting admission?
- Oxygen
- Salbutamol (via nebuliser for acute severe or above. Can give via pMDI for moderate. A short pause between puffs may be necessary to avoid hyperventilation with puffs given one at a time and inhaled with five tidal breaths. For an adult, give 4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs. Repeat every 10-20 minutes if clinically necessary. For a child, give a puff every 30–60 seconds, up to 10 puffs. If the response is poor, give further doses while awaiting hospital admission, and switch to a nebulizer if available).
You have decided your patient doesn’t need admitting to hospital for their asthma exacerbation; discuss:
- What treatments you will start/consider
- What follow up you will arrange
- What safety netting advice is required
Treatments
- SABA via spacer to manage acute symptoms
- Consider quadrupling ICS dose at onset of asthma attack and for up to 14 days (NOTE: not everyone suitable for this due to compliance hence offer below)
- Oral prednisolone (40-50mg for 5 days in >12yrs)
- Consider abx e.g. amoxicillin if infective exacerbation
Follow up
- Follow up in 48hrs
- Arrange referral to specialist if 2 or more exacerbations in a year
Safety netting
- Recongising when deteriorating and what to do e.g. get worse, very short of breath, fast HR etc…seek medical attention
Who are spacers given to?
Describe how to use a spacer
- Given to people who may be struggling with inhaler tehcnique
- Mutiple ways to use: can use for single breath, multiple breaths etc..
Discuss how COPD is diagnosed in primary care
Diagnosis largely based on clinical features supported by spirometry.
Documenting a pts MRC dyspnoea scale is vital to allow clinicians to monitor progression of disease; remind yourself of the MRC dyspnoea scale
If someone presents to GP with likely acute exacerbation of COPD what is the question you need to ask yourself?
What will you do to help you answer this?
Do they need admitting to hospital
Take detailed history, do examination to assess for….
Discuss how you should assess a pt with an acute exacerbation of COPD
When should you consider admitting a pt with COPD exacerbation to hospital?
When should you suspect someone has end stage COPD?
Discuss how you should manage end stage COPD (be sure to include management of breathlessness)
- Focus is on palliative care to relieve symptoms & improve quality of life
- Ensure the have an advanced care plan
- Optimise COPD symtpoms such as:
- Breathlessnes: simple measures (e.g. good ventilation, positioning), opiates, oxygen
- Cough: humidified weak air, opiate
- Secretions: positioning, glycopyrronium bromide
- Pain
- Insomnia: zopiclone
- Depression/anxiety: non-pharmacological and pharmacological e.g. SSRI
- Consider admission to hospice
- Support for family/carers
Dicuss what may be detailed in an advanced care plan/what should be discussed in when doing advanced care planning
