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asthma + COPD + pulmonary HTN + cor pulmonale Flashcards

1
Q

what is chronic asthma?

A

episodic, reversible airway obstruction due to bronchial hyperactivity to a variety of stimuli

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2
Q

what is the epidemiology of chronic asthma?

A

incidence 5-8%, more in children than adults

peak at 5yo then most outgrow by adolescence

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3
Q

what is the acute pathophysiology of chronic asthma?

A

acute- 30 mins
mast cell antigen interaction nleads to histamine release

bronchoconstriction, mucus plugs, mucosal swelling

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4
Q

what is the chronic pathophysiology of chronic asthma?

A

TH2 cells release IL-3,4,5 which leasd to mast cell, eosinophil + B cell recruitment

airway remodelling

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5
Q

what are the causes of chronic asthma?

A

1) atopy
- T1 hypersensitivity to variety of antigens
- dust mites, pollen, food, animals, fungs

2) stress- cold air, viral URTI, exercise, emotion

3) toxins- smoking, pollution, factory
- drugs: NSAIDs, BB

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6
Q

what are the symptoms of chronic asthma?

A

cough +/- sputum often at night
wheeze
dyspnoea
diurnal variation with morning dipping

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7
Q

what are important parts of the history in chronic asthma?

A 
precipitants
diurnal variation 
exercise tolerance
life effects- sleep + work 
other atopy: hay fever + eczema
home + job environment
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8
Q

what are the signs in chronic asthma?

A 
tachypnoea, tachycardia
widespread polyphonic wheeze
hyperinflated chest
recuced air entry 
signs of steroid use
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9
Q

what are associated diseases with chronic asthma?

A

GORD
ABPA
churg-strauss (inflammation of blood vessels- symptoms: fatigue, weight loss, nasal passage inflammation, numbness+weakness)

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10
Q

what are the ddx for chronic asthma?

A 
pulmonary oedema (cardiac asthma)
COPD
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11
Q

what investigations would you do in chronic asthma?

A

1) bloods- FBC (eosinophilia), IgE (raised), aspergillus serology
2) CXR
3) spirometry
4) PEFR monitoring/diary
5) atopy- skin-prick, RAST

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12
Q

what is seen on CXR for chronic asthma?

A

hyperinflation

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13
Q

what is seen on spirometry in chronic asthma?

A

obstructive pattern with FEV1:FVC<0.75

>/15% improvement in FEV1 with beta-agonist

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14
Q

what does PEFR monitoring show in chronic asthma?

A

diurnal variation >20%

morning dipping

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15
Q

what is the general management of chronic asthma?

A 
TAME
technique for inhaler use 
avoid- allergens, smoking/smoke, dust 
monitor- peak flow diary 2-4x/d
educate
- liaise with specialist nurse
- need for tx compliance
- emergency action plan
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16
Q

what is the drug ladder for chronic asthma?

A

1) SABA PRN- salbutamol
2) low-dose ICS- beclometasone
3) LABA- salmeterol
4) higher dose ICS. stop LABA if unhelpful.
5) LTRA- montelukast
SR theophylline
MR beta agonist PO
6) oral steroids- prednisolone. maintain high dose ICS + refer to asthma clinic.

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17
Q

how does acute asthma present?

A

acute breathlessness + wheeze

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18
Q

what is important in the history with acute asthma?

A

precipitant- infx, travel, exercise
usual + recent treatment
previous attacks + severity- ICU
best PEFR

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19
Q

what investigations do you do in acute asthma?

A

PEFR
ABG
- paO2 usually normal or slightly lowered. PaCO2 lowered
- if paCO2 raised send to ITU for ventilation

bloods- FBC, UE, CRP, blood cultures

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20
Q

what are the signs of severe acute asthma?

A 
any one of:
PEFR<50%
RR>25
HR>110
can't complete sentence in one breath
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21
Q

what are the signs of life-threatening acute asthma?

A

any one of: 33 92 CHEST
pefr<33%
SPO2<92%, PCO2>4.6kPa, PAO2<8kpa

cyanosis, confusion
hypotension
exhaustion
silent chest, poor resp effort
tachycardia/brady/arrythmias
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22
Q

what are the ddx of acute asthma?

A

pneumothorax
acute exacerbation of COPD
pulmonary oedema

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23
Q

what is the admission criteria of acute asthma?

A

life threatening attack
feature of severe attack persisting despite initial treatment

may discharge if PEFR>75% 1h after initial treatment

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24
Q

when can you discharge someone admitted for acute asthma?

A

been stable on dsicharge meds for 24h

PEFR>75% with diurnal variablity <20%

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25
what is the discharge plan for someone who was admitted with acute asthma?
1) TAME- technique, avoid, monitor, educate 2) PO steroids for 5 days 3) GP appointment within 1 week 4) resp clinic appointment within 1 month
26
what is the management of acute asthma?
O2, NEBS, STEROIDS OSHITME 1. Sit-up 2. 100% O2 via non-rebreathe mask (aim for 94-98%) 3. Nebulised salbutamol (5mg) and ipratropium (0.5mg) 4. Hydrocortisone 100mg IV or pred 50mg PO (or both) 5. Write “no sedation” on drug chart senior help 6. magnesium sulfate 7. theophylline- ICU to monitor 8. escalate care- intubation + ventilation in ICU
27
what is the management of acute asthma when life threatening?
 Inform ITU  MgSO4 2g IVI over 20min  Nebulised salbutamol every 15min (monitor ECG)
28
what is the management of acute asthma once improving?
 Monitor: SpO2 @ 92-94%, PEFR  Continue pred 50mg OD for 5 days  Nebulised salbutamol every 4hrs
29
what is the management of acute asthma if no improvement in 15-30mins?
IV treatment  Nebulised salbutamol every 15min (monitor ECG)  Continue ipratropium 0.5mg 4-6hrly  MgSO4 2g IVI over 20min  Salbutamol IVI 3-20ug/min  Consider aminophylline - Load: 5mg/kg IVI over 20min - Unless already on theophylline  Continue: 0.5mg/kg/hr - Monitor levels  ITU transfer for invasive ventilation
30
what further monitoring do you do in the management of acute asthma?
 PEFR every 15-30min (Pre- and post-β agonist)  SpO2: keep >92%  ABG if initial PaCO2 normal or ↑
31
what is the definition of COPD?
1) airway obstruction : FEV1<80%, FEV1:FVC<0.7 2) chronic bronchitis- cough + sputum production on most days for 3 months of 2 successive years 3) emphysema- histological diagnosis of enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls
32
what is the epidemiology of COPD?
prevalence- 10-20% of >40s
33
what are the causes of COPD?
smoking pollution A1ATD
34
what are the symptoms of COPD?
cough + sputum dyspnoea wheeze weight loss
35
what are the signs of COPD?
``` tachypnoea prolonged expiratory phase wheeze early-inspiratory crackles cyanosis cor pulmonale- raised JVP, oedema, loud P2 signs of steroid use ``` hyperinflation: - lowered cricosternal distance - loss of cardiac dullness - displaced liver edge
36
what are pink puffers?
emPhysema - increased alveolar ventilation- so breathless but not cyanosed - normal or near normal PAO2 - normal or low PACO2 - progress-> T1 resp failure
37
what are blue bloaters?
Bronchitis - reduced alveolar ventilation- so cyanosed but not breathless - low PAO2 and raised PACO2- rely on hypoxic drive - progress- T2 resp failure + cor pulmonale
38
what are the complications of COPD?
``` acute exacerbation +/- infx polycythaemia pnuemothorax (ruptured bullae) cor pulmonale lung carcinoma ```
39
how do you measure dyspnoea?
mMRC dyspnoea score 1. Dyspnoea only on vigorous exertion 2. SOB on hurrying or walking up stairs 3. Walks slowly or has to stop for breath 4. Stops for breath after <100m / few min 5. Too breathless to leave house or SOB on dressing
40
what investigations do you do for COPD?
1) BMI 2) Bloods- FBC (polycythaemia), a1-AT level, ABG 3) CXR 4) ECG 5) spirometry 6) ECHO
41
what can be seen on CXR for COPD?
hyperinflation >6ribs anteriorly prominent pulmonary arteries peripheral oligaemia bullae
42
what can be seen on ECG for COPD?
R atrial hypertrophy- p pulmonale | RVH, RAD
43
what can be seen on spirometry for COPD?
FEV1<80% FEV1:FVC<0.7 raised TLC raised RV
44
what can be seen on ECHO in COPD?
PHT
45
what is the management of COPD?
1) assess severity 2) general measures 3) mucolytics 4) breathlesness and/or exercise limitation measures 5) exacerbations or persistent breathlessness 6) persistent exacerbations or breathlessness 7) LTOT
46
how is severity assessed in COPD?
mild FEV1>80% mod FEV1 50-79% severe FEV1 30-49% very severe FEV1<30%
47
what general measures can be arranged in the management of COPD?
1) lifestyle measures: smoking cessation- nicotine, bupropion/varenicline BMI- weight loss, poor nutrition pulmonary rehab/exercise ``` 2) review screen+mx co-morbidities eg CVD, osteoporosis, lung ca review 1-2/yr pneumococcal + influenza vaccine air travel risky FEV1<50% ```
48
when would you consider mucolytics in COPD + what can be used?
if chronic productive cough | carbocisteine- CI in peptic ulcers
49
what treatment is given if COPD patients are breathless +/or have exercise limitation?
SABA +/or SAMA (ipratropium PRN SABA PRN may continue at all stages
50
what treatment is given if COPD patients have exacerbations or persistent breathlessness?
FEV1>50% LABA or LAMA (tiotropium) stop SAMA FEV1<50% LABA+ICS combo or LAMA
51
what treatment is given to COPD patients if they have persistent exacerbations or breathlessness?
LABA + LAMA+ ICS roflumilast/theophylline (PDIs) considered consider home nebs
52
what is the aim of LTOT in COPD?
paO2>/8KPA for >/15h/day (increases survival by 50%)
53
when is LTOT indicated in COPD patients?
clinically stable non-smokers with PAO2<7.3 (stable on 2 occassions>3weeks apart) PAO2 7.3-8 PHT/cor pulmonale/polycythemia/nocturnal hypoxaemia terminally ill patients
54
when is surgery indicated for COPD?
recurrent pnemothoraces isolated bullous disease lung volume reduction
55
what are the causes of acute exacerbation of COPD?
viral URTI 30% | bacterial infx
56
what is the presentation of acute exacerbation of COPD?
cough + sputum breathlessness wheeze
57
what is important to ask in a history of acute exacerbation of COPD?
smoking status exercise capacity current treatment previous exacerbations
58
what investigations would you do for acute exacerbation of COPD?
``` PEFR bloods- FBC UE ABG CRP cultures sputum culture CXR- infection/pneumothorax ECG ```
59
what ddx for acute exacerbation of COPD?
pneumothorax pulmonary oedema PE asthma
60
what is needed on discharge of acute exacerbation of COPD?
``` spirometry establish optimal maintenance threapy GP + specialist follow up prevention using home oral steroids + abs pneumococcal + flu vaccine home assessment ```
61
what is the management of acute exacerbation of COPD?
1) controlled o2 therapy 2) nebulished bronchodilators (salbutamol/ipratropium) 3) steroids hydrocortisone 200mg IV +pred 40mg PO 7-14d 4) abx if infx- doxy 200mg stat + 100mg OD PO 5days 5) NIV if no response - repeat nebs + consider IV aminophylline
62
what are the options for ventilation in acute exacerbation of COPD?
consider NIV BiPAP if ph<7.35 +/or RR>30 consider invasive ventilation if ph<7.26 - depends on pre-morbid state- exercise capacity, home O2, comorbs
63
what is pulmonary HTN?
PA pressure>25mmhg
64
what are the categories of causes of pulmonary HTN?
left heart disease lung parenchymal disease pulmonary vascular disease hypoventilation
65
what are the left heart disease causes of pulmonary HTN?
mitral stenosis mitral regurg left ventricular failure L->R shunt
66
what are the lung parenchymal disease causes of pulmonary HTN?
``` 1) mechanism chronic hypoxia-> hypoxic vasoconstriction perivascular parenchymal changes 2) COPD 3) asthma- severe, chronic 4) ILD 5) ILD, CF, bronchiectasis ```
67
what rae the pulmonary vascular disease causes of pulmonary HTN?
``` idopathic pulmonary HTN pulmonary vasculitis- scleroderma, SLE, wegener's sickle cell PE- acute/chronic portal HTN- portopulmonary HTN ```
68
what are the hypoventilation causes of pulmonary HTN?
OSA morbid obesity (pickwickian syndrome) thoracic cage abnormality- kyphosis, scoliosis neuromuscular- MND, MG, polio
69
what investigations would you do for pulmonary HTN?
ECG ECHO R heart catheristaion- gold standard
70
what can be seen on ECG for pulmonary HTN?
p pulmonale RVH RAD
71
what can be seen on ECHO for pulmonary HTN?
velocity of tricuspid regurg jet RA/V enlargement ventricular dysfx valve disease
72
what can be seen on r heart catherisation for pulmonary HTN?
mean pulmonary artery pressure pulmonary vascular resistance CO vasoreactivity testing to guide treatment
73
what is cor pulmonale?
RHF due to chronic PHT
74
what are the symptoms of cor pulmonale?
dyspnoea fatigue syncope
75
what are the signs of cor pulmonale?
``` raised JVp with prominent a wave left parasternal heave loud P2+/- S3 murmurs - PR- graham steell EDM - TR- PSM pulsaile hepatomegaly fluid- ascites + peripheral oedema ```
76
what investigations would you do for cor pulmonale?
``` bloods- FBC UE LFT ESR ANA RF ABG (hypoxia +/- hypercapnoea) CXR ECG ECHO spirometry right heart catherisation ```
77
what would you see on CXR for cor pulmonale?
enlarged RA+V prominent pulmonary arteries peripheral oligaemia
78
what can you see on ECG with cor pulmonale?
p pulmonale | RVH
79
what can be seen on ECHO with cor pulmonale?
RVH TR increased PA pressure
80
what is the prognosis of cor pulmonale?
50% 5 years
81
what is the management of cor pulmonale?
treat underlying condition decrease pulmonary vasc resistance - LTOT - CCB eg nifedipine - sildenafil PDE-5-i - prostacycline analogues - bosentan (endothelin receptor antagonist) cardiac failure- aceI + BB + diuretics heart lung transplant

RESP (4 decks)

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