CBM Flashcards
Common triggers for asthma
Allergens (e.g. pets, pollen, dust mites). Cold air Emotions Smoking Viral infection Pollution Drugs (e.g. NSAIDs, beta-blockers).
Pathophysiology of asthma
Triggers activate mast cells to relate spasmogens and chemotaxins.
EARLY PHASE - bronchospasm due to spasmogens
LATE PHASE - inflammation due to chemotaxins (causes attraction of eosinophils/monocytes).
Types of asthma
cause and timing of onset?
- EXTRINSIC - type I hypersensitivity
=> early onset/younger patients (may improve with age)
=> subtype - occupational asthma - INTRINSIC - non-immune mechanisms (often no cause identified).
=> late onset/middle-aged patients
Occupational asthma
extrinsic asthma (but may be later onset due to not working until adulthood)
Occurs due to occupational triggers - chemicals, enzymes in flour, animal substances, dust
Symptoms will be better on days off work/holidays
Asthma - symptoms
Wheeze, SOB, cough (worse at night/early morning/on exercise).
Chest tightness +/- reflux symptoms
Asthma - history
FHx or PMHx of atopy Typical Sx with diurnal variation Identifiable trigger(s)
Asthma - investigations
History + auscultation
Objective measurements - spirometry/BDR test/FeNO/PEF variability
What peak flow results are indicative of asthma?
PEF with >20% variability
What spirometry results are indicative of asthma?
FEV1:FVC <70%
What BDR results are indicative of asthma?
FEV1 >12% improvement after bronchodilator
or >200ml volume increase
What FeNO results are indicative of asthma?
FeNO >40ppb
Management of chronic asthma
- SABA + Low-dose ICS
- Add LABA or LTRA
- increase dose of ICS
- referral to specialist, potentially oral steroids.
Safety netting
Lifestyle factors - smoking, weight loss, avoiding triggers
Asthma reviews
What is important to remember with LABAs in the management of asthma?
do not use without an ICS
Safety netting in chronic asthma
Return if symptoms are getting worse/interfere with daily life/waking up at night.
Will have an annual review for their asthma.
Signs of an acute attack and how to manage:
- reliever inhaler isn’t helping
- too breathless to speak/eat/sleep
- very tight chest/coughing a lot
- RR increasing/feels like can’t get enough air in
=> Puff or PRN inhaler - up to 10 times. Ring 999 if no improvement.
Components of an annual asthma review
- LEVEL OF CONTROL?
- using SABA >3x per week
- night symptoms
- interfering with activities
- chest tightness, wheeze - EXACERBATIONS?
- COMPLIANCE/TECHNIQUE
- SIDE EFFECTS OF MEDICATIONS
What is COPD?
= chronic, progressive, POORLY REVERSIBLE airway obstruction
including chronic bronchitis and emphysema
Chronic bronchitis
CHRONIC BRONCHITIS (“blue bloaters”)
- increased mucous production and inflammatory cells, scarred/thickened epithelium => increased airway resistance
- chromic productive cough
- poor alveolar ventilation => T2RF (CO2 retention, loss of hypoxic drive)
Emphysema
EMPHYSEMA (“pink puffers”)
- Increased protease activity destroys alveoli, decreased elasticity and recoil, enlarged air spaces (decreased SA).
- increased RR and HR to compensate for reduced gas exchange
- cachexia (higher energy demand for respiration).
- poor gas exchange => T1RF (normal CO2)
Risk factors for COPD
Smoking
Occupational dust
Childhood infections
Alpha1-antitrypsin deficiency
COPD - symptoms
Productive cough (clear, white sputum)
Progressive dyspnoea + wheeze
Frequent LRTIs
COPD - signs
Increased RR, flapping tremor, cyanosis, barrel-chest
Reduced chest expansion, hyper-resonance
Polyphonic expiratory wheeze, decreased breath sounds.
What might you hear on auscultation in a person with COPD?
Polyphonic expiratory wheeze
(or decreased breath sounds).
MRC Dyspnoea scale
1 - only SOB on strenuous exercise
2 - SOB if hurrying/walking up hill
3 - SOB on flat
4 - Stop for breath after 100m
5 - SOB with ADLs, at rest, etc.
COPD - diagnosis
- Hx and Examination
- Spirometry + BDR
=> BDR - no improvement
=> FEV1 <80%
=> FEV1:FVC <0.7
=> PEF - little variation
- CXR
What might a CXR show in COPD?
hyperinflation
flat diaphragms
decreased peripheral markings
What might an ABG show in COPD?
Decreased O2
Either normal or increased CO2 (depending on type of respiratory failure).
Severity of COPD by spirometry
Mild - FEV1 >80%
Moderate - FEV1 50-79%
Severe - FEV1 30-49%
Very severe - FEV1 <30%
What is the only intervention in COPD that decreases mortality?
Smoking cessation
COPD - management
- SMOKING CESSATION
- OPTIMISE WEIGHT
- PULMONARY REHAB
=> exercises to improve SOB
=> educate and promote self-management - MUCOLYTICS (e.g. carbocysteine)
=> may help chronic productive cough
=> review after 4 weeks, stop if no benefit. - VACCINATIONS
=> pneumococcal and flu
How can you help someone stop smoking pharmacologically?
Nicotine replacement - patches/gum
Varenicline - nicotine receptor partial agonist.
Bupropion - NA/DA reuptake inhibitor
E-cigarettes - lack long-term evidence but potentially safer
When is inhaled therapy for COPD offered?
only when lifestyle interventions have been tried and still SOB
inhaled therapy for COPD
SABA or SAMA (salbutamol or ipratropium)
If asthmatic features
=> LABA + ICS (e.g. Fostair)
=> Add LABA for triple therapy
If no asthmatic features (steroids won’t help)
=> LABA + LAMA
What are asthmatic features in COPD?
Previous asthma/atopy OR increased eosinophils
Substantial FEV1 variation
Substantial diurnal PEF variation
What role do SABAs/SAMAs have in COPD?
Relieve acute bronchochonstriction
What role do LABAs/LAMAs have in COPD?
Increase FEV1 and improve SOB
What are some anti-muscarinic side effects?
Constipation Urinary retention Dry mouth Blurred vision Confusion
What are signs of an acute COPD exacerbation?
Altered sputum volume/colour
Reduced exercise tolerance
Fever/malaise/lethargy
COPD exacerbation - management
Bronchodilators (neb) - SABA & SAMA
Oral corticosteroids - 30mg prednisolone o.d. 5 days
Oxygen - aim for 88-92%
Possibly antibiotics
COPD exacerbation - investigations
Sputum sample (if purulent)
Bloods - FBC, U&Es, ABG
CXR, ECG
COPD - safety netting
- Signs of exacerbation (increased SOB, increased cough/wheeze, cyanosis, confusion).
=> May give rescue pack (steroid + Abx) - Warn of risk of pneumonia and pneumothorax
COPD - follow up
At least once a year!
- Measure FEV1 and FVC
- Assess on MRC dyspnoea scale
- Review for referral to specialist services
COPD complications
Acute exacerbations Polycythaemia Respiratory failure Cor pulmonale Pneumothorax Lung carcinoma
What is Atrial Fibrillation?
= a rapid, irregular heart rhythm due to uncoordinated contraction of the atria.
What are the types of AF?
- PAROXYSMAL - recurrent, sudden, self-limiting episodes
- PERSISTENT - AF >7 days
- PERMANENT - long-term AF
Causes of AF
“Mrs SMITH”
S - sepsis M - mitral valve stenosis I - IHD T - thyrotoxicosis H - HTN
Complications of AF
- STROKE!
- Vascular dementia
- decreased left ventricular function
- decreased QoL
Symptoms of AF
SOB
Syncope / dizziness
Palpitations
Chest pain
Diagnosis of AF
- Examination - irregularly irregular pulse
- 12-lead ECG (if normal do 24-hour ECG)
- Bloods - FBC, TFT, U&Es, LFTs, glucose
- CXR / echo - investigate cause
What signs indicate AF on an ECG?
Absent P-waves
Irregular R-R interval
>150 bpm
What are the aims of management of AF?
- Rate and Rhythm control
2. Stroke prevention (anticoagulation)
AF - Rate & Rhythm control
RATE - Target HR 60-80 bpm
=> beta-blocker (OR RL CCB if contraindicated BB, OR combine either with digoxin).
RHYTHM
=> flecanide/amiodarone
=> cardioversion
=> ablation
What options should be avoided in rate management in AF?
NOT BB + RL CCB
NOT Digoxin as monotherapy
AF - haemodynamically unstable patient
Acute heart failure/chest pain/hypotension
=> CARDIOVERSION
AF - Stroke Prevention
Anticoagulation
- Assess stroke risk with CHA2DS2-VASc score
- Assess bleeding risk with HASBLED score
=> HASBLED of 3+ needs closer anti-coag monitoring/alternative
CHA2DS2-VASc score
C - congestive HF H - HTN A2 - age >74 (score = 2), age 65-74 (score =1) D - diabetes S2 - prev stroke/TIA (score = 2) Va - vascular disease Sc - sex category - female
HASBLED score
H - HTN A - Abnormal liver/renal function S - Stroke B - bleeding predisposition L - labile INR E - elderly >65 D - drugs (NSAIDs, aspirin, alcohol, etc)
What lifestyle factors can be managed in AF?
weight loss, diet, exercise
reduce alcohol and caffeine, reduce smoking
optimise co-morbidities
AF - Safety netting and follow-up
Safety Net:
- Signs of MI/stroke (LoC, severe chest pain/SOB, dizziness)
Follow-up:
- in 1 year to check Sx of AF
- annual review of stroke and bleed risk.
Risk factors for HTN
Age >65 Male FHx Obesity Sedentary lifestyle High salt diet Alcohol/caffeine DM Renal disease
Primary vs Secondary HTN
Primary (95% cases) - cause unknown
Secondary (5% cases)
- renal disease (80%)
- endocrine
- drugs
- other (pregnancy, aortic coarctation).
What are renal causes of secondary HTN?
Glomerulonephritis
CKD
Renal artery stenosis
PCKD
What drugs can cause secondary HTN?
Steroids, NSAIDs, OCP
What are endocrine causes of secondary HTN?
Conn’s (increased aldosterone)
Cushing’s (increased cortisol)
Acromegaly (increased GH)
Phaeochromocytoma (increased adrenaline)
What is essential HTN?
What are the symptoms?
Gradual increase in BP over years
Asymptomatic
What is malignant HTN?
What are the symptoms?
Rapid, sustained increase in BP
Headaches, visual disturbances, renal dysfunction
Complications/consequences of HTN
Heart - LVH (eventually failure)
Aorta - AAA, aortic dissection
Brain - IC haemorrhage and stroke
Kidney - CKD
Eyes - hypertensive retinopathy
Stage 1 HTN
Clinic BP >140/90
ABPM >135/85
Stage 2 HTN
Clinic BP >160/100
ABPM >150/95
Stage 3 HTN
Clinic SBP >180 or DBP >110