Asthma & COPD in Primary Care

Question 1

What are the risk factors for asthma?

Answer 1

Personal or family history of atopic disease.
Male sex for pre-pubertal asthma and the female sex for the persistence of asthma from childhood to adulthood.
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.

Question 2

How is asthma diagnosed in primary care?

Answer 2

Presence of more than one variable symptom of wheeze, cough, breathlessness, and chest tightness.

Personal/family history of other atopic conditions, particularly atopic eczema/dermatitis and/or allergic rhinitis.

The results of fractional exhaled nitric oxide (FeNO) testing.

Spirometry should be offered to all symptomatic people over the age of five years. The FEV1/FVC ratio is normally greater than 70%. Any value less than this suggests airflow limitation. However, a normal spirometry result when the person is asymptomatic does not rule out asthma.

Bronchodilator reversibility (BDR)

Question 3

What is the management of asthma in primary care?

Answer 3

Assess baseline asthma status.
Self-management and personalised asthma plan.
Ensure that the person is up to date with all routine vaccinations, including all childhood immunizations, and the annual influenza vaccination.
Advice avoidance of asthma triggers.
Initiate drug treatment.

Question 4

When should SABA and ICS be used for the treatment of asthma?

Answer 4

SABA - should be prescribed for every patient with symptomatic asthma as a reliever.
ICS - this should be prescribed to patients who are using their SABA three times a week or more, have symptoms three/week or more, or are experiencing nighttime symptoms at least once a week.
LTRA -

Question 5

What patients may need to be on a higher dose of ICS and why?

Answer 5

Smokers. Previous or current.
Smoking reduces the effectiveness of ICS.

Question 6

What should be assessed before initiating an add-on therapy for a patient on SABA and ICS?

Answer 6

Inhaler technique. Adherence. Avoidance of triggers.

Question 7

A patient (over the age of 17) has uncontrolled asthma despite using SABA and ICS appropriately with the correct technique what is the next option for add-on therapy? What can be used instead if adherence may be an issue?

Answer 7

Leukotriene receptor antagonist.
Long-acting Beta Agonist + ICS inhaler.

Question 8

A patient (over the age of 17) has uncontrolled asthma despite using SABA, low-dose ICS and LTRA appropriately with the correct technique, what is the next option for add-on therapy?

Answer 8

LABA + ICS inhaler.
Clinical judgement based on adherence and response to LTRA should be used when deciding whether to continue treatment.

Question 9

A patient (over the age of 17) has uncontrolled asthma despite using SABA, LABA + ICS and LTRA appropriately with the correct technique, what is the next option for add-on therapy?

Answer 9

Change the person’s ICS and LABA maintenance therapy to a maintenance and reliever therapy (MART) regimen with a low maintenance ICS dose.
MART treatment consists of a single inhaler containing both ICS and a fast-acting LABA, which is used for both daily maintenance therapy and the relief of symptoms as required.

Question 10

When should a muscarinic receptor antagonist be considered in the step-wise treatment of asthma?

Answer 10

If asthma is uncontrolled on a moderate maintenance ICS dose with a LABA (either as MART or a fixed-dose regimen), with or without an LTRA.

Question 11

When should you consider decreasing maintenance therapy?

Answer 11

Once a person’s asthma has been controlled with their current maintenance therapy for at least 3 months.

Question 12

How often should a patient with asthma be followed up?

Answer 12

Annually.

Question 13

What are the parameters for a moderate asthma attack?

Answer 13

PEFR more than 50–75% best or predicted (at least 50% best or predicted in children) and normal speech, with no features of acute severe or life-threatening asthma.

Question 14

What are the parameters for an acute-severe asthma attack?

Answer 14

PEFR 33–50% best or predicted, respiratory rate of at least 25/min, pulse rate of at least 110/min or inability to complete sentences in one breath, or accessory muscle use, with oxygen saturation of at least 92%.

Question 15

What are the parameters for a life-threatening asthma attack?

Answer 15

PEFR less than 33% best or predicted, oxygen saturation of less than 92%, altered consciousness, exhaustion, cardiac arrhythmia, hypotension, cyanosis, poor respiratory effort, silent chest, or confusion.

Question 16

How are asthma exacerbations treated in primary care? (not needing hospital admission).

Answer 16

Use a short-acting beta-2 agonist via a large-volume spacer to relieve acute symptoms. For an adult, give 4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs. Each puff should be given one at a time and inhaled with five tidal breaths. Repeat every 10–20 minutes according to clinical response.

Consider advising quadrupling inhaled corticosteroid (ICS) at the onset of an asthma attack and for up to 14 days in order to reduce the risk of needing prescribed oral steroids.

For those people who are not suitable for increased ICS dosing consider prescribing a short course of oral prednisolone.

Question 17

When should a person be followed up after an acute asthma exacerbation if they were not admitted to the hospital? What should be assessed?

Answer 17

48 hours after the initial presentation.
Review symptoms and check peak expiratory flow.
Check inhaler technique.
Consider stepping-up treatment by increasing inhaled corticosteroids (if they have not already increased their ICS dose) or adding in new preventive therapy.
Address potentially preventable contributors to the exacerbation, such as exposure to trigger factors and non-compliance with treatment.
Provide advice on lifestyle, vaccinations, diet, exercise, and smoking.
Advise on recognizing poor asthma control (worsening symptoms or peak flow readings), early signs of an exacerbation (sudden persistent worsening symptoms), what to do at the early signs of an exacerbation (increasing beta-2 agonist and starting oral corticosteroids), and seeking medical help if symptoms are not controlled.

Question 18

When should a patient be admitted to hospital for an asthma exacerbation?

Answer 18

Admit all people with features of a life-threatening asthma exacerbation.
Admit people with any feature of a severe asthma attack persisting after initial bronchodilator treatment.
Admit people with a moderate asthma exacerbation with worsening symptoms despite initial bronchodilator treatment and/or who have had a previous near-fatal asthma attack.

Question 19

What are the risk factors for COPD?

Answer 19

Smoking.
Occupational exposure.
Air pollution.
Genetics. (Alpha-1-antitrypsin deficiency)
Lung development in utero.
Asthma.

Question 20

How is COPD diagnosed?

Answer 20

People over 35 with one or more of the following:
Breathlessness — typically persistent, progressive over time, and worse on exertion.
Chronic/recurrent cough.
Regular sputum production.
Frequent lower respiratory tract infections.
Wheeze.

A postbronchodilator FEV1/FVC less than 0.7 confirms persistent airflow obstruction.
Consider other causes in older people without typical symptoms of COPD who have an FEV1/FVC ratio less than 0.7.
Consider COPD in younger people who have symptoms of COPD, even when their FEV1/FVC ratio is above 0.7.

Question 21

What are the parameters for the stages of COPD?

Answer 21

Stage 1, mild — FEV1 80% of predicted value or higher.
Stage 2, moderate — FEV1 50–79% of predicted value.
Stage 3, severe — FEV1 30–49% of predicted value.
Stage 4, very severe — FEV1 less than 30% of predicted value or FEV1 less than 50% with respiratory failure.

Question 22

What signs may be present that are indicative of COPD?

Answer 22

Cyanosis.
Raised jugular venous pressure and/or peripheral oedema (may indicate cor pulmonale).
Cachexia.
Hyperinflation of the chest.
Use of accessory muscles and/or pursed lip breathing.
Wheeze and/or crackles on auscultation of the chest.

Question 23

What are some of the differentials for COPD?

Answer 23

Asthma
Bronchiectasis
Heart failure
Lung cancer
Interstitial lung disease
Anaemia
Cystic Fibrosis
TB
Upper airway obstruction

Question 24

What is the management of COPD in primary care?

Answer 24

Explain the diagnosis, risk factors for progression and the importance of a healthy diet and physical activity.
Smoking cessation.
Offer pneumococcal and influenza vaccinations.
Offer pulmonary rehabilitation if indicated.
Develop a personalised self-management plan in conjunction with the person.
Optimise treatment for comorbidities.

Question 25

What medication can be offered if a person with COPD is breathless and has exercise limitations?

Answer 25

Offer a short-acting beta-2 agonist (SABA) or short-acting muscarinic antagonist (SAMA) to use as needed to relieve breathlessness and improve exercise tolerance.

Question 26

What medication can be offered if a patient continues to experience breathlessness and exercise limitations despite using SABA or SAMA and they have no asthmatic features to their COPD?

Answer 26

Offer a long-acting beta-2 agonist (LABA) plus a long-acting muscarinic antagonist (LAMA).
If the person continues to have day-to-day symptoms adversely affecting quality of life:
Consider a 3 month trial of LABA plus LAMA plus inhaled corticosteroids (ICS).
If there is no improvement at 3 months change back to LABA plus LAMA.
If symptoms have improved, continue with LAMA plus LABA plus ICS and review at least annually.

Question 27

What medication can be offered if a patient continues to experience breathlessness and exercise limitations despite using SABA or SAMA and they have asthmatic features to their COPD?

Answer 27

Consider offering LABA plus ICS.
If person continues to have day-to-day symptoms adversely affecting quality of life or has 1 severe (needing hospitalization) or 2 moderate exacerbations of COPD within a year, offer LABA plus LAMA plus ICS.

Question 28

What is the main risk of ICS use in a person with COPD?

Answer 28

Increased risk of pneumonia.

Question 29

When should oral mucolytic therapy be considered for a person with COPD?

Answer 29

Consider mucolytic therapy if a person with stable COPD develops a chronic cough productive of sputum.

Question 30

What features are suggestive of an acute exacerbation of COPD?

Answer 30

Worsening breathlessness.
Increased sputum volume and purulence.
Cough.
Wheeze.
Fever without an obvious source.
Upper respiratory tract infection in the past 5 days.
Increased respiratory rate or heart rate increase 20% above baseline.

Question 31

What features are suggestive of an acute-severe exacerbation of COPD?

Answer 31

Marked breathlessness and tachypnoea.
Pursed-lip breathing and/or use of accessory muscles at rest.
New-onset cyanosis or peripheral oedema.
Acute confusion or drowsiness.
Marked reduction in activities of daily living.

Question 32

How are COPD exacerbations managed in primary care? (not needing hospital admission)

Answer 32

Advise the person to increase the doses or frequency of short-acting bronchodilators (not exceeding the maximum dose).

If the person is likely to become fatigued, a nebulizer may be appropriate.

If there are no contraindications, consider oral corticosteroids for people with a significant increase in breathlessness that interferes with daily activities.
Offer 30 mg oral prednisolone once daily for 5 days
Consider the need for osteoporosis prophylaxis for people requiring frequent courses of oral corticosteroids (3–4 courses per year).

Question 33

If the use of antibiotics is indicated for an exacerbation of COPD what are the options?

Answer 33

Amoxicillin 500 mg three times a day for 5 days.
Doxycycline 200 mg on first day, then 100mg once a day for 5-day course in total.
Clarithromycin 500 mg twice a day for 5 days.

Question 34

When should a patient be admitted for a COPD exacerbation?

Answer 34

Severe breathlessness.
Inability to cope at home (or living alone).
Poor or deteriorating general condition including significant comorbidity (such as cardiac disease or insulin-dependent diabetes).
Rapid onset of symptoms.
Acute confusion or impaired consciousness
Cyanosis.
Oxygen saturation less than 90% on pulse oximetry.
The target oxygen saturation should be 88– 92% in most cases.
Worsening peripheral oedema.
New arrhythmia.
Failure of exacerbation to respond to initial treatment.
Already receiving long-term oxygen therapy.
Changes on chest X-ray.

Question 35

What are the palliative options for a person with COPD?

Answer 35

Advanced care planning in place.

Optimize treatment associated with COPD symptoms such as:
Breathlessness:
Discuss simple measures (such keeping the room cool, improving air circulation with a fan or open window, and relaxation and breathing techniques) to help relieve breathlessness.
Consider the need for drug treatments (such as opiates) and oxygen.
Cough
Secretions
Pain
Insomnia
Depression
Anxiety

Question 36

What is complete control of asthma defined as?

Answer 36

No daytime symptoms.
No night-time waking due to asthma.
No need for rescue medication.
No asthma attacks.
No limitations on activity including exercise.
Normal lung function (FEV1 and/or PEF > 80% predicted or best). However, be aware that lung function measurements cannot be used reliably to guide asthma management in children under five years of age.
Minimal side effects from medications.