Asthma, COPD (a1antitrypsin), Bronchiectasis Flashcards
Risk factors for asthma
- Atopy - asthma/eczema/hay fever
- allergens, air pollution, smoking
- isocyanates
- exercise
- cold weather
Asthma
- presentation of asthma
- presentation of acute attack
Early onset
Cough - worse at night/in cold/exercise
Variable SOB,
Wheeze, chest tightness
Often triggered by resp infection
-worsening SOB, cough, wheeze not responding to SABA
Asthma
-diagnosis and investigations
Adults
1st line - FeNO
-eosinophils above reference range
-FeNO 50+
2nd line - BDR with spiro
-FEV1 increase 12%+ or 200ml+
3rd line - BD peak flow for 2weeks
-PEF variability 20%+
4th line - bronchial challenge test
5-16
1st line - FeNO
-FeNo 35+
2nd line - BDR with spiro
-FEV1 increase 12%
3rd line - BD peak flow for 2weeks
-PEF variability 20%+
4th line - skin prick testing to house dust mite OR total IgE and eosinophils
U5 - difficult to perform tests
ICS treatment with regular review
Still symptomatic at 5 => investigate
Refer to paeds resp if
-hospital admissions with wheeze in 12 months
Asthma
-possible meds used
-MOA
-SE
-aim of treatment
-when to step up and down
Salbutamol
- B agonist => SM relax
- SE => tremor
ICS
-stops airways narrowing
-SE => oral thrush, child growth stunted
LRTA
-stop airway narrowing
-SE => GI upset, headache
Aim of treatment
-no daytime symptoms
-no exacerbations
Any need to use reliever 3x a week
Night symptoms
Moderate asthma attack
-classification
-management
PER - 50-75%
Normal speech
RR < 25
HR < 110
ADMIT - night, past near fatal, on PO CS, pregnant
15 NRM and downtitrated to 94-98%
-PRIORITISE OXYGEN!
SABA - O2 neb/metered dose
PO prednisolone - 50mg 5 days
Add SAMA if no change
Continue with normal meds
If no change/T2RF => escalate to ITU (intubate, ventilate)
Severe asthma attack
-classification
-management
PER - 33-50%
Incomplete sentences
RR 25+
HR 110+
ADMIT if unresponsive to normal treatment
15 NRM - downtitrated to 94-98%
SABA - O2 neb/metered dose
PO prednisolone - 50mg 5 days
If no change - add SAMA, then IV MgSO34
Continue with normal meds
If no change/T2RF => escalate to ITU
-prep for intubation, ventilation
Life threatening asthma attack
-classification
-management
ANY OF THE FOLLOWING
PER - U33%
Silent chest, cyanosis, weak breathing
HR U110
BP - hypotensive
pCO2 - normal
SaO2 - U92% => ABG
Exhausted, confusion
ADMIT
15 NRM - downtitrated to 94-98%
SABA - O2 neb/metered dose
PO prednisolone - 50mg 5 days
If no change - add SAMA, them IV MgSO4
Continue with normal meds
If no change/T2RF => escalate to ITU
-prep for intubation, ventilation
Discharge criteria after asthma attack
Stable on discharge meds for 12-24hs without nebs or O2
Inhaler technique checked
PEF 75%+
Review at GP
-inhaler technique
-smoking cessation
-annual flu vaccine
-do they have an asthma emergency plan?
-peak flows when they’re well
COPD
-risk factors
Smoking
a1antitrypsin deficiency - COPD presentation in young with liver signs
Occupational exposures
- cadmium
- coal
- cotton
- cement
- grain
COPD
-presentation, signs, symptoms
SOB (load capacity imbalance increases neural drive to breathe)
Wheeze
Sputum
Exercise limitation
High RR, tripod
Decreased chest expansion, barrel chested (hyperinflation)
Decreased BS
Cyanosis, asterixis
Cor pulmonale => RHF
Cachexia
Pathophysiology of COPD
Emphysema
-oxidative stress => decreased recoil, capillary beds destroyed
Bronchitis
-increased goblet cells, abnormal tissue repair => mucus hypersecretion
BOTH LEAD TO AIRWAY OBSTRUCTION
Severity of COPD
-mild
-moderate
-severe
-V severe
FEV1/FVC <0.7, no change in BD test (U12% change)
Mild - FEV1 >80
Moderate - FEV1 50-79
Severe - FEV1 30-49
V severe - FEV1 <30
COPD
-diagnosis, investigations
Clinical diagnosis
CONFIRMATION OF DIAGNOSIS - Post BD spirometry FER U70%
CXR
-hyperinflation, bullae, flat hemidiaphragm, RHF
-WANT TO EXCLUDE LUNG CANCER
FBC - polycythemia
COPD
-management (conservative, medical, prophylaxis, cor pulmonale, surgery)
Smoking cessation
Flu and pneumococcal vaccine
Pulmonary rehab - refer if MRC 3 (having to stop because of SOB, or walks slower than other people)
1st line - SABA/SAMA as required
2nd line - switch SAMA <=> SABA as required
3rd line - if no asthma/steroid response
-add LABA + LAMA to SABA as required
3rd line - if asthma/steroid responsive
-add LABA + ICS to SABA as required
-add LAMA if needed
Prophylactic azithromycin if
-3+ exacerbations needing CS
-1 exacerbation => admission
Cor pulmonale
- loop diuretics in edema
- O2 therapy
Surgery
-valves, coils, bullectomy
LTOT if
PO2 U7.3 OR
PO2 7.3-8 and
-2ndary polycythemia
-pHTN
-peripheral edema
Acute COPD exacerbation presentation
-common causative organisms
Increased SOB, cough, wheeze
Purulent sputum
Hypoxia
Haemophilus influenza, resp viruses
Management of acute exacerbations of COPD
-O2
-meds
-when to admit
Target sats
- 94-98
- 88-92 if CO2 retainer, T2RF risk
BD, spacer, nebulizers
-SABA, SAMA
Pred 5/7
ABx if evidence of infection
-Amox/clarythromycin/doxy
If T2RF => NIV (bipap)
ICU for invasive vent if
-SaO2 U88 with max O2
-v acidotic
-unable to protect airway
-haemodynamic instability
Bronchiectasis
- pathophysiology, epidemiology
- causes
More prevalent in females, older
Chronic infection/inflammation => permanent dilation of airways
- post infection - TB, measles, pertussis, pneumonia
- systemic AI
- CF
- bronchial obstruction - lung cancer, foreign body
- Kartagner syndrome (ciliary dyskinesis)
Bronchiectasis
-presentation, symptoms
Persistent purulent sputum
Persistent cough
Recurrent chest infections, frequent COPD/asthma exacerbations
SOB
Coarse crackles, wheeze
Inspiratory squeak
Clubbing
Bronchiectasis
-diagnosis, investigations
-management
DEFINITIVE DIAGNOSIS - High res CT (signet rings)
AIM TO IDENTIFY UNDERLYING CAUSE
-most common - H influenzae
- Obstructive spirometry
- Sputum culture - causative organism
- CXR (tram tracking)
- CF testing - sweat/gene test
- Gross AB deficiency testing
Physical training - inspiratory muscle training
Postural drainage
ABx for exacerbations
BD, immunisations
Surgery if localised disease
Alpha 1 antitrypsin deficiency
-pathophysiology
-presentation
-investigations
-management
Autosomal recessive/codominance
A1AT protects cells from neutrophil elastase
Lung and liver signs in young, non smokers
-Emphysema - marked in LL
-cirrhosis, hepatocellular carcinoma, cholestasis
A1AT conc
Obstructive spirometry
No smoking
Supportive
-BD
-physiotherapy
Medical - IV A1AT protein concentrate
Surgical - lung volume reduction, transplantation
COPD - long term oxygen therapy
-who is suitable
-what does it involve
PO2 U7.3kPa OR
PO2 7.3-8kPa and
-2ndary polycythemia
-peripheral edema
-pulmonary HTN
Min 15hrs/day of supplementary O2
Must not be smoking
Assess
-risk of trips, burns/fires
Asthma
-stepping down treatment
Asthma review every 3 months
No strict guidelines on what to do but consider treatment duration, SE and patient preference
Reducing ICS - 25-50% at a time
MART therapy
-what is it
Combination of reliever and inhaler in 1
-ICS and fast acting LABA
Patients aged 12+ with asthma - NEWLY DIAGNOSED
-management
Step 1
Symptom relief - low dose AIR therapy (low dose ICS formoterol)
Exacerbation - low dose MART + acute management (PO pred)
Step 2 - low dose MART
Step 3 - moderate dose MART
Step 4 - FeNO check
High => specialist asthma referral
Normal => add LRTA or LAMA
-try other one if control not improved
Step 5 - specialist asthma referral
Patients aged 12+ with asthma - Transfer from old guidelines
-management
SABA only => AIR therapy
Any treatment regimen using regular low dose ICS => low dose ICS/formoterol MART
Any treatment regimen using regular moderate dose ICS => regular moderate dose ICS/formoterol MART
Any treatment regimen using high dose ICS => resp referral
Patients aged 5-11 with asthma - NEWLY DIAGNOSED
-management
Step 1 - BD low dose ICS + SABA
Can they manage MART? - MART is not currently licensed for U12s
Yes
Step 2 - low dose MART
Step 3 - moderate dose MART
Step 4 - specialist asthma referral
No -
Step 2 - BD ICS + SABA + LRTA (8-12wks)
Step 3 - low dose ICS/LABA + SABA (+- LRTA)
Step 4 - moderate dose ICS/LABA + SABA (+-LRTA)
Step 5 - specialist asthma referral
Patients aged U5 with asthma - NEWLY DIAGNOSED
-management
Step 1 - 8-12wk BD low dose ICS + SABA
Symptom resolution - No
-inhaler technique?
-environmental trigger
-alternative diagnosis?
Refer to asthma specialist if treatment failure unexplained
Symptom resolution - Yes
Step 2 - STOP ICS + SABA after 8-12wks => symptom review after 3 months
Recurrence? - Yes
Step 3 - regular low dose ICS + SABA
-titrate up to moderate dose if needed
Further trial without treatment within 12 months
Recurrence? - Yes
Step 4 - regular ICS + SABA + LRTA for 8-12wks and review
No improvement => stop LRTA and refer to asthma specialist
Asthma attacks in children - classification
-moderate
-severe
-life threatening
Moderate
Speak in sentences
SpO2 92%+
Peak flow 50%+
HR and RR
1-5 - U140 and U40
5+ - U125 and U30
Severe
Can’t complete sentences in 1 breath
Too breathless to talk or feed
SpO2 U92%
Peak flow 33-50%
HR and RR
1-5 - 140+ and 40+
5+ - 125+ and 30+
Life-threatening
SpO2 U92%
Peak flow U33%
Silent chest, cyanosed
Poor resp effort
Hypotensive
Exhaused
Confused
SABA - 1 puff every 30-60s
MAX 10 puffs
If not controlled with SABA => refer to hospital
Steroids - 1-2mg/kg OD (max 40mg)
