Chronic conditions Flashcards
COPD chronic management
- SABA or SAMA bronchodilators
- If still SOB determine if asthmatic/steroid responsive features:
a. No asthmatic features – add LAMA + LABA combination e.g. DuaKlir, if already on SAMA switch it to SABA
b. Asthmatic/steroid responsive features – add LABA + ICS, e.g. Fostair/Symbicort/Seretide, if don’t work can use LABA + ICS + LAMA e.g. Trimbo - Extra options: salbutamol/ipratropium nebs, oral theophylline (monitor dose narrow Tw, reduce dose if on macrolides/fluoroquinolones), oral mucolytics ‘consider’
- Consider prophylactic Abx e.g. azithromycin – only if non-smoker optimised on standard treatments but still having exacerbations, and must do CT thorax to r/o bronchiectasis + sputum culture for atypicals
- LTOT – severe COPD causing chronic cypoxia, polycythaemia, cyanosis or cor pulmonale
Asthma chronic management
BTS:
- SABA for mild intermittent sx, if using >3x week step up
- Low dose ICS e.g. beclometasone
- LABA (salmeterol) – only continue if have good response [nb in children <5 you add the LRTA first]
- Increase dose of LABA if it has had some effect, or add oral LRTA (montelukast), or oral beta-2 agonist/oral theophylline, or inhaled LAMA (tiotropium)
- Titrate ICS to high dose, combine, specialist
- Oral steroids/steroid sparing agents
NICE:
- SABA
- Low dose ICS
- Oral LRTA
- LABA, if LRT no effect stop it and increase the ICS
- Consider changing to MART
- Consider ICS high dose or oral theophylline or inhaled LAMA
- Daily steroid
COPD acute exacerbation
- O2 aim for 88-92% sats
- Bronchodilators: salbutamol/terbutaline (SABA) nebs, consider adding nebulised ipratropium (SAMA). Drive with O2 unless hypercapnoeic + acidotic
- Steroids: oral pred 30mg/IV hydrocortisone 100mg
- Others if needed: Abx if purulent sputum/evidence of pneumonia, consider IV aminophylline/IV salbutamol, consider naloxone if on opioid analgesia
Asthma acute exacerbation
- High flow O2, sit pt up, get senior ED/ICU help if pt can’t talk
- High dose nebulised B2 agonist (salbutamol 5mg, terbutaline 10mg)/10 puffs salbutamol into spacer (often good for kids as they will tolerate better than the neb). Consider continuous nebulisation
- Steroid – 40-50mg oral prednisolone or 100mg IV hydrocortisone
- Nebulised ipratropium bromide (500mcg) if poor response
- IV aminophylline, IV salbutamol – senior decision
- Consider fluids, avoid giving ‘routine’ Abx unless obv infection, repeat ABG within an hour, monitor for hypokalaemia
o Referral to ITU: drowsy, confusion, exhaustion, coma, resp arrest, worsening hypoxia, hypercapnia, acidotic, deteriorating peak flow
o Cardiac arrest – usually PEA. May be due to prolonged severe hypoxia, hypoxia-related arrhythmias or tension pneumothorax. Aim to intubate
Atrial fibrillation management (primary care)
Emergency AF in hospital: new onset within 48h/reversible cause you rhythm control (with drugs, or electrical if unstable)
Incidental non-sx AF with CHADVASC of 0 – no treatment. E.g. incidental finding of AF with a HR of 60.
Anticoagulate if CHADVASC >1
Rate control: aim for HR<100 to prolong diastolic filling. o Recommended 1st line for all pt, except reversible causes, new onset within past 48h, causing HF. Options: beta blocker – CCB (diltiazem, not in HF) – digoxin (in sedentary pt)
Rhythm control: done if new onset <48h(emergencies), causing HF or rate control doesn’t help. May cardiovert electrically (need to be anti coagulated for 3w beforehand) or pharmacologically with BB, dronedarone or amiodarone (esp if have HF)
Diagnosis of HTN
Current threshold sustained levels 140 and/or 90 and up, confirmed with AMPM or HBPM.
measure in both arms, manually best as automated may be inaccurate if pulse is irregular, if in clinic is 140/90 or more take another reading, if this is substantially different take a third. Record the lower
- ABPM during usual waking hours
- HBPM – do 2 measurements at least a minute apart with person seated, do morning + evening for a week. Use average of the days after first day
- Classify severity based on criteria
- Examine fundi for retinopathy
When should you refer someone with HTN to hospital as an emergency?
- BP >180/110 with signs of papilloedema and/or retinal haemorrhage
- if suspect phaeochromocytoma (HTN, labile/postural hypotension, headache, palps, pallor, diaphoresis)
Drug management of HTN
- <55y use ACEi (or ARB), or >55y and African/Caribbean use CCB (or if not tolerated use TLD). Beta blockers in younger people if problems with the others or women of child bearing age
a. If Diabetic always use ACEi 1st unless CI, as good evidence for preventing nephropathy (even if already have reduced GFR) - Add CCB or ACEi/ARB or TLD (e.g. indapamide)
- Add a 3rd drug from the above
- Consider a fourth or referral. E.g. low dose spironolactone, or higher dose TLD, or alpha/beta blocker
BP targets in diabetics
<130/80 if have end organ damage, or <135/85
HTN in pregnancy management
labetalol 1st line or methyldopa/nifedipine.
if high risk of PET need low dose aspirin from 12w
What is heart failure?
heart can’t maintain circulation due to structural/functional impairment of ventricular filling/ejection. May have reduced or preserved LV ejection fraction. Can be acute (new presentation or deterioration) or chronic/stable
Stable angina management
- Refer to cardiology - may have PCI or CABG
- Advice about the diagnosis + when to call 999
- Medical management
o Immediate sx relief – GTN spray PRN, take when sx start then repeat after 5m if still sx, if still sx after another 5m take again + call 999
If CCB use verapamil or diltiazem if alone, or if with BB use nifedipine. Do not give verapamil with BB due to complete HB risk
o Long-term – beta blocker and/or CCB. Specialist options include long-acting nitrates (isosorbide mononitrate), ivabradine (inhibits Sa node If), nicorandil, ranolazine
Nitrate tolerance – try reducing dose frequency
o Secondary prevention: aspirin (if have had MI they also have another anti platelet for 12m), atorvastatin, atenolol, ACEi
Causes of HF
- Myocardial – CAD, HTN, cardiomyopathies
- Valvular heart disease e.g. AS
- Pericardial disease – constrictive pericarditis, pericardial effusion
- Congenital heart disease
- Arrhythmias e.g. AF, ventricular arrhythmias (also a comp)
- High output states – anaemia, thyrotoxicosis, phaeochromocytoma, sepsis, liver failure, AV shunts, Paget’s disease, vit B1 deficiency
- Volume overload – end-stage CKD, nephrotic syndrome
- Obesity
- Drugs – alcohol, cocaine, NSAIDs, beta blockers, CCBs (can worsen pre-existing HF, esp non-DHP like verapamil, never give verapamil + BB together)
How do you assess a pt with HF?
- HF sx: breathlessness (exertion, rest, orthopnoea, PND, nocturnal cough), fluid retention (ankle swelling, feeling bloated, abdo swelling, weight gain), fatigue, reduced exercise tolerance, lightheadedness/syncope
- HF RF: MI, HTN, AF, DM, alcohol, drugs, FH HF/SCD<40y
- Examination signs: tachycardia, rhythm of pulse, laterally displaced apex beat, murmurs, S3/S4 HS (gallop rhythm), HTN, raised JVP, hepatomegaly, resp signs (tachypnoea, basal creps, pleural effusions), dependent oedema (legs, sacrum), ascites, obesity
Causes of peripheral oedema and/or breathlessness
- SOB: COPD, asthma, PE, lung cancer, anxiety
- Peripheral oedema: venous insufficiency, prolonged inactivity, nephrotic syndrome, drugs (CCB, NSAID), hypoalbuminaemia (renal/hepatic disease), pelvic tumour
