Asthma/ COPD/ OSA Flashcards
What drug is in the blue inhaler?
SABA - salbutamol - releiver
What drug is in the brown inhaler?
beclometasone - preventor
A 14-year-old girl presents to the General Practice with a previous history of shortness of breath and a dry cough that develops whenever she has a sports lesson.
She usually uses a blue inhaler to relieve the symptoms, however over the past two weeks she has been waking up from episodes of dyspnoea and her mum is worried that she is more wheezy than usual.
What additional medication can be prescribed to control her symptoms?
Beclomethasone Inhaler
A 55-year-old overweight woman presents to her general practitioner (GP) as she has been having trouble with her sleep. She often wakes up multiple times at night gasping for air, she also feels that her sleep is unrefreshing and is thus very tired during the day and has even fallen asleep at work. In addition, she has been having headaches most mornings.
The GP suspects a diagnosis of obstructive sleep apnoea (OSA).
Which investigations is most likely to confirm this diagnosis?
Polysomnography
A 25-year-old known asthmatic presents to the emergency department with an acute deterioration in his condition.
His vital signs reveal a heart rate of 135, blood pressure of 95/60 and saturation of 85%. An arterial blood gas (ABG) is taken which shows:
pH 7.3 7.35 - 7.45
PaO₂ 7 kPa 11 - 15
PaCO₂ 7.5 kPa 4.6 - 6.4
Bicarbonate 24 mmol/L 22 - 30
Which is the next best step in the management of this patient?
Intubation and ventilation
An 18-year-old female is being investigated for suspected asthma. The doctor reviews her history and feels that there is an intermediate probability of asthma.
According to British Thoracic Society guidelines, what is the first line of investigation to make a diagnosis of asthma?
Fractional exhaled nitric oxide testing
A 50-year-old male patient presents to their GP complaining of daytime somnolence. They are investigated and subsequently diagnosed with obstructive sleep apnoea (OSA).
What scoring system will have been utilised in order to categorise the severity of the patient’s symptoms?
Epworth Sleepiness Scale
A 40 year old female presents to her GP with fatigue. She works as a teacher and has been struggling to stay awake at work. She is often found napping in the classroom. Her husband, who has attended clinic with her today, reports that she snores loudly at night, and sometimes appears to stop breathing. She has a past medical history of type 2 diabetes mellitus and hypertension. On examination, she has a Body Mass Index of 36.
What is the single most appropriate investigation to provide a diagnosis?
Polysomnography
A 35-year-old woman presents to her GP with a cough, wheeze and chest tightness. She has been using her salbutamol inhaler more frequently and has had one exacerbation in the past year.
What is the next step in management according to the UK BTS guidelines?
Start regular preventer therapy
When should prednisolone be added?
This should only be considered if symptoms are not controlled despite good inhaler technique, and having tried other agents
High probability of asthma clinically
try treatment
Intermediate probability of asthma
perform spirometry with reversibility testing
Low probability of asthma
consider referral and investigating for other causes
Acute presentation meds in order >
(O SHITMA n)
Oxygen (at least 60%)
Salbutamol (neb)
Hydrocortisone (IV) OR oral prednisolone
Ipratropium (neb)
Theophylline (oral)
Magnesium sulphate (IV)
An anaesthetist (to intubate)
Complications of COPD
Cor pulmonary - right-sided heart failure
COPD - If the patient is well enough to remain at home. What is their treatment?
- Oral prednisolone (steroid)
- Increase SABA/SAMA
- Antibiotics if evidence of infection
COPD - Hospital management
Ipratropium
Salbutamol
Oxygen (target spO2 88-92%)
Amoxicillin (/doxycycline)
Prednisolone
For COPD cor Pulmonale on ECG shows up as what?
very large P wave
Signs of COPD
Wheezing - chronic bronchitis
Reduced breath sounds - emphysema
Symptoms of COPD
- Progressive dyspnoea
- Chronic cough
- Regular exacerbations
Explain chronic bronchitis
Chronic Bronchitis - Inflammation of airways
Cigarette smoke → chronic neutrophilic inflammation → scarring and fibrosis
Hypertrophy of mucus-secreting glands and hyperplasia of goblet cells
Explain emphysema
Emphysema - breakdown of elastic recoil of the lung
Inflammation → neutrophils release proteases → break down elastin walls of alveoli → loss of elastic recoil
Genetic predisposition of COPD is
alpha-1 antitrypsin deficiency
What is the primary cause of obstructive sleep apnoea (OSA)
Blockage of airways, usually at the level of the oropharynx, leading to multiple pauses in respiration during sleep
What demographic is most commonly affected by OSA?
Overweight, middle-aged men
Name some causes of OSA other than obesity
- Enlarged tonsils/adenoids
- Oropharyngeal deformity
- Neurological issues (e.g., stroke)
- Drugs (depressants)
- Post-operative anesthesia
How do apnoeas occur during sleep?
Apnoeas occur when the airway at the back of the throat is sucked closed when breathing in during sleep
What are the consequences of untreated OSA?
Daytime sleepiness, impaired intellectual performance, hypercapnia, and hypoxia
How can excessive daytime sleepiness be measured?
Epworth Sleepiness Scale
What investigations are commonly used to diagnose OSA?
Overnight sleep studies;
- Oximetry
- Domiciliary readings
- Full polysomnography (golden standard)
What surgical procedure involves the removal of excess tissue in the throat to widen the airway?
Uvulopalatopharyngoplasty (UPPP)
In which cases is UPPP less effective?
Less effective in severe cases of OSA
What surgical procedure involves repositioning the jaw to enlarge the upper airway?
Mandibular advancement surgery
What is a common indication for mandibular advancement surgery?
Recessed jaw
What is the most effective surgical intervention for severe cases of OSA?
Tracheostomy, which creates a surgical airway through the neck to bypass upper airway obstruction completely
Which surgical procedure is highly effective but may be reserved for severe cases where other treatments have failed?
Tracheostomy
A 67-year-old male patient has had two admissions to the hospital in the past 6 weeks for acute exacerbations of COPD. Today, he is at his local GP practice to discuss his COPD management. The GP decides to prescribe a rescue pack containing short courses of prednisolone and doxycycline. He explains to the patient that they should take prednisolone if they have breathlessness that is not relieved by their salbutamol inhaler. Under which circumstances should the doctor advise the patient to take the doxycycline?
Change in volume and colour of sputum
= indicates an infection
A 28-year-old woman has presented to her GP with a sore throat. She is otherwise clinically well and does not have any coryzal symptoms. On examination, there is no lymphadenopathy but the oropharynx is erythematous with white patches. Her medical history is unremarkable aside from taking regular inhalers for asthma. What is the most likely cause of the examination findings?
Oral thrush is the white spots
Therefore - Beclomethasone inhaler
A 57-year-old man presents to his general practitioner (GP) complaining of increasing breathlessness. He also reports a cough productive of white sputum and an occasional wheeze. His social history is significant for smoking with a 35-pack-year history.
Respiratory examination reveals a prolonged expiratory phase, reduced chest expansion and widespread wheeze on auscultation. Vital signs are stable. His GP suspects a diagnosis of chronic obstructive pulmonary disease (COPD).
Which investigations is most likely to confirm this diagnosis?
Spirometry
What diseases qualify for long-term oxygen therapy?
Nocturnal hypoxia
Polycythaemia - haemoglobin (>180 g/l in male patients)
Peripheral oedema
Pulmonary hypertension
+ with PaO2 of 7.3-8kPa
A 60-year-old male has recently been diagnosed with Chronic Obstructive Pulmonary Disease (COPD) after being admitted to hospital with breathlessness. He was not suffering from any complications of this condition and after being stabilised on first-line medical management, was discharged home.
Which of these chest x-ray (CXR) findings was most likely seen in this patient?
Flattened hemi-diaphragms
A 21-year-old female with a history of asthma is admitted to the emergency department with an acute exacerbation.
Which criteria would suggest the need for urgent intubation and ventilation?
- Patient is exhausted with a silent chest
- Oxygen saturations <92%
- Normal PaCO2 (4.6 - 6.0kPa)
(PaO2 should be <7.3kPa for long term oxygen therapy) - PEF<33% of best or predicted suggests life-threatening asthma
The first line in the management of acute asthma is what?
Salbutamol 5mg nebuliser
Respiratory rate 20 is a feature of what attack?
Acute moderate attack
Heart rate - 150BPM is a feature of what attack?
Acute severe attack
Inability to complete full sentences is a feature of what attack?
Acute severe attack
Peak expiratory flow rate 35% of best is a feature of what attack?
Acute severe attack
Features suggesting a life-threatening attack include what?
Oxygen saturations <90
Peak expiratory flow rate <33% of best Silent chest
Bradycardia
Hypotension
Exhaustion
Steps for those with asthma - drugs
Step 1: short-acting inhaled β2 agonist (eg. salbutamol)
Step 2: add low-dose inhaled corticosteroid steroid (ICS)
Step 3: add long-acting β2 agonist (eg. salmeterol)
(A) if no benefit, stop this and increase the ICS dose
(B) if benefits but inadequate control, continue and increase the ICS dose
Step 4: trial of oral leukotriene receptor antagonist, high-dose steroid, oral β2 agonist, oral theophylline
(C) Patients escalated to steps 3 and 4 should be referred to a respiratory specialist
Churg–Strauss syndrome-associated syndromes and what occurs
sinusitis
asthma
purpura
peripheral neuropathy
= Patients are pANCA positive and have raised IgE levels.
High-risk features for a severe attack include what?
Previous intensive care admission
Those on step 3 or higher of the stepwise asthma treatment pathway
Hospital admission in the last year
Signs of a severe attack
Inability to speak in complete sentences
Respiratory rate >25 breaths per minute
Peak flow 33–50% predicted
Heart rate >110 bpm
Signs of a life-threatening attack
Peak flow <33% of predicted
Silent chest
Altered consciousness: confusion or drowsiness
Bradycardia
Hypotension
Hypoxia
Cyanosis
Exhaustion
Why would you use a CXR for asthma?
To exclude pneumothorax or consolidation
A falling respiratory rate is a sign of patient fatigue. Which means?
- PaCO2 will return towards normal – this is a very concerning sign and the patient requires urgent escalation
- Type 2 respiratory failure (low paO2 and high paCO2) due to hypoventilation is a sign of a life-threatening attack
A 26-year-old man is recovering in the Respiratory ward following an acute asthma attack.
He is treated with 5mg of nebulised salbutamol hourly and 0.5mg ipratropium bromide. He is currently on nebulised salbutamol every four hours. He has been using a 3L/min nasal cannula intermittently. His normal asthma management comprises a salbutamol inhaler of 100micrograms as when needed. He wants to be discharged as soon as possible.
What needs to happen?
Stable on salbutamol inhaler for 24 hours
Patients with severe COPD who remain breathless despite maximal medical therapy should be considered for lung volume reduction surgery if what?
(1) They have upper lobe-predominant emphysema
(2) FEV1 >20% predicted
(3) paCO2 <7.3 kPa
(4) TLCO >20% predicted
Increased symptoms after taking aspirin are a sign of what?
Asthma
A PaO2 <8 kPa and one of pulmonary hypertension, polycythaemia, peripheral oedema or nocturnal hypoxia is a sign for what to happen?
Begin long-term oxygen therapy
FEV1 of 70% for a test indicates what?
Moderate COPD.
(eg) if testing this is likely what is to be found, if you don’t know if the patient for sure has COPD
Hypercarbia has 2 effects. Explain these.
i) Stimulates chemoreceptors to increase respiratory drive (but over time this effect dampens, so you need a higher CO2 to stimulate respiration than in a normal person, hence giving 100% O2 to COPD patients is a bad idea)
ii) Kidneys retain bicarbonate (to bind with H+ ions that are acidic) to neutralise pH
So, overall fully compensated COPD would give you normal pH, elevated CO2 and elevated bicarbonate.
What leads to excess mucus and what leads to difficult expiration?
Chronic bronchitis leads to excess mucus.
Emphysema leads to difficult expiration
A 67-year-old man with a history of Chronic Obstructive Pulmonary Disease (COPD) comes to the Emergency Department with increased shortness of breath. His observations are as follows:
Heart rate (HR): 96
Respiratory rate (RR): 30
Oxygen saturations (SATS): 87% on room air
Blood pressure (BP): 141/89
Temperature: 37.5
His Arterial Blood Gas shows evidence of high CO2 levels with normal pH. This is similar to previous blood gas results during his previous admission.
At this stage of his assessment, which form of oxygen delivery system is most appropriate for use in this patient?
Venturi mask
What occurs to the total lung capacity in COPD?
Increases
What ECG changes may be seen in a patient with COPD?
(1) Right axis deviation
(2) Prominent P waves in inferior leads
(3) Inverted P waves in high lateral leads (I, aVL)
(4) Low voltage QRS
(5) Delayed R/S transition in leads V1-V6
(6) P pulmonale
(7) Right ventricular strain pattern
(8) RBBB - right bundle branch block
(9) Multifocal atrial tachycardia
Drug steps for COPD
Step 1: short-acting β2 agonist/short-acting muscarinic antagonist – these are continued as the patient goes up the management steps
Step 2
for patients with persistent exacerbations but no asthmatic features or evidence of steroid responsiveness -
(1) ADD a LABA and a LAMA
for patients with persistent exacerbations with asthmatic features or evidence of steroid responsiveness
(2) INCREASE management to a combination of LABA and ICS
Step 3
for patients on a long-acting β2 agonist + long-acting muscarinic antagonist combination who are still getting daily symptoms that affect their activities of daily living
(3) CONSIDER a 3-month trial of LAMA + LABA + ICS (triple therapy)
If this does not work
(4) REVERT back to LABA + LAMA
For any patient on step 2 who is getting more than one severe or two moderate exacerbations in a year
(5) START LAMA + LABA + ICS
Step 4: if patients are still symptomatic, consider specialist referral
Features of severe asthma include what?
(1) PEFR 33-50%
(2) RR >=25
(3) HR >=110
(4) Inability to complete sentences in 1 breath
Features of life-threatening asthma include what?
(1) PEFR <33%
(2) SATS <92%/
(3) PaO2 <8kPa
(4) Normal CO2 (4.6-6kPa)
(5) Poor respiratory effort (signs of exhaustion)
(6) Altered GCS/ agitation (signs of hypercapnia)
(7) Hypotension
Features of moderate asthma include what?
Increased symptoms with
PEFR of 50-75% but with no features of severe asthma
The indications for use of long-term oxygen therapy in COPD include what?
Clinically stable non-smokers with PaO2 of <7.3
(approximately equal to oxygen saturations of 88%)
measured at least twice, a minimum of 3 weeks apart, despite maximum treatment
OR
A PaO2 of 7.3-8.0 with concurrent secondary complications of COPD
(one of the following):
Pulmonary hypertension
Secondary polycythaemia
Peripheral oedema
Nocturnal hypoxaemia
OR
In terminally ill patients for palliation
Non-rebreathing mask used when?
Used in critical illness/emergency
Venturi mask mask used when?
For type II respiratory failure with specific target saturation - start at 24
Variable performance mask (Hudson mask)
- Uncomfortable
- Do not use in hypercapnia or type II resp failure
Nasal cannulae
- FiO2 25-50% (dependent on nasal breathing)
- Well tolerated
Objective signs of poor asthma control include
reduced effectiveness of bronchodilator
reduce exercise tolerance
asthma attack within the last two years
history of waking up at night with wheezing/cough/chest pain or daytime asthma symptoms (three times a week or more)
A 10 year old girl is brought in to the GP surgery by her mother for poorly controlled asthma. She has been having increasing frequency of her asthma exacerbations. She is currently using a salbutamol inhaler as required and a paediatric low-dose beclometasone inhaler. She uses both devices with a spacer and has good inhaler technique.
What is the next best step in her management?
SHE IS A CHILD therefore steps are different
trial of either oral leukotriene receptor antagonist, high-dose steroid, oral β2 agonist, oral theophylline
This child has trialled SABA and a paediatric low-dose ICS which is currently not adequate control for her asthma. She has a good inhaler technique, which suggests the next step in management requires addition of medication
When is a laba added in children
When the add-on medication isn’t working 4-8 weeks. You stop the add on medicine and add a LABA
Immediate management for emergency asthma
Sit-up
100% O2 via a non-rebreathe mask (aim for 94-98%)
Nebulised salbutamol (5mg) +/- ipratropium (0.5mg) depending on the response to salbutamol.
Hydrocortisone 100mg IV or prednisolone 50mg PO
What is life-threatening bad CO2 levels?
PaCO2 4.6-6.9 kPa
A 10 year old boy presents to his GP with his mother. Over the last six weeks, he has had four distinct episodes of breathlessness and cough. Three of these episodes have been after visiting a friend’s house who owns three cats and whose parents smoke, but today he had an episode at his own home. He feels otherwise well and is afebrile, with normal vital observations for his age. On auscultation of the chest, the GP hears widespread wheeze.
If a chest x-ray was performed, what would be the most likely finding?
Hyperinflation
A 12-year-old girl with a history of asthma comes in for a regular review. She was diagnosed 3 years ago, and has had a good response to a combination inhaler (Symbicort: budesonide with formoterol 200/6 one puff twice a day). Over the past 6 months, her asthma has been very well controlled, with no exacerbations, and no requirement for her salbutamol reliever inhaler.
On examination, she appears well, with normal observations and a normal chest examination.
What is the most appropriate next step?
Reduce dose
Which drug used in the management of asthma can cause nightmares, especially in the paediatric population?
Montelukast
first-line management for an IECOPD is what?
- salbutamol and ipratropium nebulisers
- corticosteroids
- Either oral prednisolone or IV hydrocortisone can be given
- antibiotics
