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RESP > asthma + COPD + pulmonary HTN + cor pulmonale > Flashcards

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
Q

what is the discharge plan for someone who was admitted with acute asthma?

A

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

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26
Q

what is the management of acute asthma?

A

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

  1. magnesium sulfate
  2. theophylline- ICU to monitor
  3. escalate care- intubation + ventilation in ICU
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27
Q

what is the management of acute asthma when life threatening?

A

 Inform ITU
 MgSO4 2g IVI over 20min
 Nebulised salbutamol every 15min (monitor ECG)

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28
Q

what is the management of acute asthma once improving?

A

 Monitor: SpO2 @ 92-94%, PEFR
 Continue pred 50mg OD for 5 days
 Nebulised salbutamol every 4hrs

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29
Q

what is the management of acute asthma if no improvement in 15-30mins?

A

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

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30
Q

what further monitoring do you do in the management of acute asthma?

A

 PEFR every 15-30min (Pre- and post-β agonist)
 SpO2: keep >92%
 ABG if initial PaCO2 normal or ↑

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31
Q

what is the definition of COPD?

A

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

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32
Q

what is the epidemiology of COPD?

A

prevalence- 10-20% of >40s

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33
Q

what are the causes of COPD?

A

smoking
pollution
A1ATD

34
Q

what are the symptoms of COPD?

A

cough + sputum
dyspnoea
wheeze
weight loss

35
Q

what are the signs of COPD?

A 
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
Q

what are pink puffers?

A

emPhysema

  • increased alveolar ventilation- so breathless but not cyanosed
  • normal or near normal PAO2
  • normal or low PACO2
  • progress-> T1 resp failure
37
Q

what are blue bloaters?

A

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
Q

what are the complications of COPD?

A 
acute exacerbation +/- infx
polycythaemia
pnuemothorax (ruptured bullae)
cor pulmonale
lung carcinoma
39
Q

how do you measure dyspnoea?

A

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
Q

what investigations do you do for COPD?

A

1) BMI
2) Bloods- FBC (polycythaemia), a1-AT level, ABG
3) CXR
4) ECG
5) spirometry
6) ECHO

41
Q

what can be seen on CXR for COPD?

A

hyperinflation >6ribs anteriorly
prominent pulmonary arteries
peripheral oligaemia
bullae

42
Q

what can be seen on ECG for COPD?

A

R atrial hypertrophy- p pulmonale

RVH, RAD

43
Q

what can be seen on spirometry for COPD?

A

FEV1<80%
FEV1:FVC<0.7
raised TLC
raised RV

44
Q

what can be seen on ECHO in COPD?

A

PHT

45
Q

what is the management of COPD?

A

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
Q

how is severity assessed in COPD?

A

mild FEV1>80%
mod FEV1 50-79%
severe FEV1 30-49%
very severe FEV1<30%

47
Q

what general measures can be arranged in the management of COPD?

A

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
Q

when would you consider mucolytics in COPD + what can be used?

A

if chronic productive cough

carbocisteine- CI in peptic ulcers

49
Q

what treatment is given if COPD patients are breathless +/or have exercise limitation?

A

SABA +/or SAMA (ipratropium PRN

SABA PRN may continue at all stages

50
Q

what treatment is given if COPD patients have exacerbations or persistent breathlessness?

A

FEV1>50% LABA or LAMA (tiotropium) stop SAMA

FEV1<50% LABA+ICS combo or LAMA

51
Q

what treatment is given to COPD patients if they have persistent exacerbations or breathlessness?

A

LABA + LAMA+ ICS
roflumilast/theophylline (PDIs) considered
consider home nebs

52
Q

what is the aim of LTOT in COPD?

A

paO2>/8KPA for >/15h/day (increases survival by 50%)

53
Q

when is LTOT indicated in COPD patients?

A

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
Q

when is surgery indicated for COPD?

A

recurrent pnemothoraces
isolated bullous disease
lung volume reduction

55
Q

what are the causes of acute exacerbation of COPD?

A

viral URTI 30%

bacterial infx

56
Q

what is the presentation of acute exacerbation of COPD?

A

cough + sputum
breathlessness
wheeze

57
Q

what is important to ask in a history of acute exacerbation of COPD?

A

smoking status
exercise capacity
current treatment
previous exacerbations

58
Q

what investigations would you do for acute exacerbation of COPD?

A 
PEFR
bloods- FBC UE ABG CRP cultures
sputum culture
CXR- infection/pneumothorax
ECG
59
Q

what ddx for acute exacerbation of COPD?

A

pneumothorax
pulmonary oedema
PE
asthma

60
Q

what is needed on discharge of acute exacerbation of COPD?

A 
spirometry
establish optimal maintenance threapy 
GP + specialist follow up 
prevention using home oral steroids + abs
pneumococcal + flu vaccine
home assessment
61
Q

what is the management of acute exacerbation of COPD?

A

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
Q

what are the options for ventilation in acute exacerbation of COPD?

A

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
Q

what is pulmonary HTN?

A

PA pressure>25mmhg

64
Q

what are the categories of causes of pulmonary HTN?

A

left heart disease
lung parenchymal disease
pulmonary vascular disease
hypoventilation

65
Q

what are the left heart disease causes of pulmonary HTN?

A

mitral stenosis
mitral regurg
left ventricular failure
L->R shunt

66
Q

what are the lung parenchymal disease causes of pulmonary HTN?

A 
1) mechanism
chronic hypoxia-> hypoxic vasoconstriction 
perivascular parenchymal changes
2) COPD
3) asthma- severe, chronic
4) ILD
5) ILD, CF, bronchiectasis
67
Q

what rae the pulmonary vascular disease causes of pulmonary HTN?

A 
idopathic pulmonary HTN
pulmonary vasculitis- scleroderma, SLE, wegener's
sickle cell
PE- acute/chronic
portal HTN- portopulmonary HTN
68
Q

what are the hypoventilation causes of pulmonary HTN?

A

OSA
morbid obesity (pickwickian syndrome)
thoracic cage abnormality- kyphosis, scoliosis
neuromuscular- MND, MG, polio

69
Q

what investigations would you do for pulmonary HTN?

A

ECG
ECHO
R heart catheristaion- gold standard

70
Q

what can be seen on ECG for pulmonary HTN?

A

p pulmonale
RVH
RAD

71
Q

what can be seen on ECHO for pulmonary HTN?

A

velocity of tricuspid regurg jet
RA/V enlargement
ventricular dysfx
valve disease

72
Q

what can be seen on r heart catherisation for pulmonary HTN?

A

mean pulmonary artery pressure
pulmonary vascular resistance
CO
vasoreactivity testing to guide treatment

73
Q

what is cor pulmonale?

A

RHF due to chronic PHT

74
Q

what are the symptoms of cor pulmonale?

A

dyspnoea
fatigue
syncope

75
Q

what are the signs of cor pulmonale?

A 
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
Q

what investigations would you do for cor pulmonale?

A 
bloods- FBC UE LFT ESR ANA RF
ABG (hypoxia +/- hypercapnoea)
CXR
ECG
ECHO
spirometry
right heart catherisation
77
Q

what would you see on CXR for cor pulmonale?

A

enlarged RA+V
prominent pulmonary arteries
peripheral oligaemia

78
Q

what can you see on ECG with cor pulmonale?

A

p pulmonale

RVH

79
Q

what can be seen on ECHO with cor pulmonale?

A

RVH
TR
increased PA pressure

80
Q

what is the prognosis of cor pulmonale?

A

50% 5 years

81
Q

what is the management of cor pulmonale?

A

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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