Chronic Shortness of Breath Flashcards
What is the definition of asthma?
asthma is a chronic inflammatory airway disease characterised by intermittent airway obstruction and hyper-reactivity
it can be acute or chronic
What symptoms does someone with asthma typically present to the GP with?
-
cough
- this tends to be worse at night
- wheeze
- shortness of breath
- symptoms tend to be worse in the winter when it is cold
- a patient does not tend to present acutely with an asthma attack
What features are important in the history of someone with asthma?
- recurrent episodes
- diurnal variation (worst in the morning & evening)
- history of atopy (tendency to allergy)
- family history
-
smoking
- this doesn’t cause asthma, but will exacerbate it
- occupation
- pets
What signs are present on general inspection and auscultation in someone with asthma?
General inspection:
- this tends to be normal
- there may be nasal polyposis
Auscultation:
- there is a polyphonic wheeze heard all over the chest
What are the 4 different investigations that are done in asthma?
- spirometry (FEV1 : FVC ratio)
- FeNO test
- PEFR
- blood tests
What results are expected from spirometry in a patient with asthma?
- FEV1 / FVC ratio < 0.7
- this shows an obstructive pattern
- FEV1 is reduced as not as much air can be forced out in 1 second due to obstruction
- there is reversibility and >/= 12% difference with a SABA
What is a FeNO test and what result would be seen in asthma?
- this test measures the amount of nitric oxide that is being expired
- this tends to be higher in asthma and will be >/= 35-40 parts/billion
What are the typical PEFR results that are seen in someone with asthma?
- PEFR varies by >/= 20% for >/= 3 days a week over several weeks
- often the patient is asked to keep a PEFR diary over a few weeks
What is the order of tests that are done when diagnosing someone with asthma?
- do spirometry and see if it shows obstruction that is reversible
- FeNO test is done to see if levels are 40ppb or more
- look to see if there is variability in PEFR readings over 2-4 weeks
What is the initial treatment given to someone who has just been diagnosed with asthma?
- they are given a short-acting beta-2 agonist (SABA)
- this is salbutamol in the blue inhaler
- this acts as a bronchodilator
When is additional treatment considered for someone who is only taking a SABA for their asthma?
What is the next step up in treatment?
- if they are using their blue inhaler more than twice a week
- they are given an inhaled corticosteroid (ICS) in a brown inhaler
- the ICS is taken once daily (usually in the morning)
- patients should wash their mouth out afterwards to prevent candidiasis
What is the next treatment step up from a SABA and ICS in treatment of asthma?
- a leukotriene receptor antagonist (LTRA) is added
- some people are sensitive to leukotrienes and some are not so decide whether or not to keep them on this treatment depending on whether they improve
- if the LTRA is not effective, switch out the LABA for a SABA
If someone is taking a LABA and ICS and this is still not effective, then what treatment is performed?
- the dose of ICS is increased from moderate to high
- if high dose ICS is still not effective then trials are started
- e.g. theophylline LAMA
What are the 5 stages in the treatment of asthma?
What are examples of these medications?
- start with a SABA - such as salbutamol
- then an ICS such as beclometasone or budesonide is added
- then a LTRA such as montelukast is added
- then the SABA is exchanged for a LABA + ICS
- this is usually symbicort, which is budesonide + formoterol
- finally, an oral corticosteroid, such as prednisolone is added
What are the 4 categories of asthma according to severity?
- moderate acute asthma
- acute severe asthma
- life-threatening asthma
- near-fatal asthma
What are the criteria for moderate acute asthma according to the BTS guidelines?
- increasing symptoms
- PEFR > 50-75% at best or predicted
- no features of acute severe asthma
What are the features of acute severe asthma according to BTS guidelines?
any one of:
- PEFR 33-50% best or predicted
- respiratory rate >/= 25 per minute
- heart rate >/= 110 bpm
- inability to complete sentences in one breath
What are the features of life-threatening asthma according to BTS guidelines?
any one of the following in a patient with severe asthma:
- altered consciousness level
- exhaustion
- arrhythmia
- hypotension
- cyanosis
- silent chest
- poor respiratory effort
- PEFR <33% best or predicted
- SpO2 < 92%
- PaO2 < 8 kPa
- “normal” PaCO2 between 4.6 - 6.0 kPa
What are the features of near-fatal asthma according to BTS guidelines?
- raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures
What are the PEFR readings for the different types of asthma?
- moderate has a PEFR of 50-75%
- acute-severe has a PEFR of 33-50%
- life threatening has a PEFR of <33%
- near fatal asthma is characterised by a rise in pCO2
Why is having normal pCO2 in asthma a concern?
- if pCO2 is normal then this means that the diaphragm is starting to tire
- there is not as much ventilation occurring, so pCO2 starts to rise
- if ventilation is impaired and CO2 cannot be blown off, this is near-fatal
What is the A-E approach for managing asthma?
What specific things need to be done for asthma?
- Airway
- Breathing
- Circulation
- Disability
- Exposure
Specifically for asthma:
- basic obs - including HR, SpO2
- PEFR
- ABG (including K+ and glucose)
- repeat ABGs if O2 is low**, _PaCO2 is normal/raise_d** or patient deteriorates
When should a patient with asthma be admitted to hospital?
- a patient with moderate asthma should be given a salbutamol inhaler and discharged
- in acute-severe asthma, the patient should be admitted if their PEFR does not go up
- they should be given corticosteroids and admitted for 24 hours
- life-threatening and near fatal asthma need to be admitted
What is the treatment for patients with asthma who have been admitted to hospital?
- they are given O2
- they are then given nebulised salbutamol (5mg) and nebulised ipratropium bromide (0.5mg)
- this is followed by PO prednisolone (40-50mg) for 5 days
- IV hydrocortisone 100mg is also given
If patient doesn’t respond to treatment in hospital for severe asthma, what is involved in senior support?
- IV magnesium sulphate
- IV aminophylline
- ITU + intubation
How often can salbutamol and ipratropium bromide be given?
- salbutamol can be given back-to-back PRN
- ipratropium bromide can be given every 4 hours PRN
What symptoms does someone with COPD typically present to their GP with?
- shortness of breath
- a cough that is productive
- some wheeze
What are important factors to take into consideration when taking a history from someone with COPD?
- the patient’s age
- family history
- smoking status
- their occupation
What might be seen on inspection and palpation in a patient with COPD?
Inspection:
- tar staining
- cyanosis
- barrel chest
Palpation:
- reduced expansion
- hyper-resonance [on percussion]
What signs are present on auscultation in someone with COPD?
What other signs might be present?
Auscultation:
- reduced air movement
- wheezing
- coarse crackles (hair-like crackles)
Other:
- signs of right heart failure
How is the severity of COPD characterised?
What would the FEV1 % be in each of these scenarios?
Mild COPD:
- FEV1 > 80%
- post-bronchodilator FEV1/FVC < 0.7
Moderate COPD:
- FEV 1 is between 50 to 79%
- post-bronchodilator FEV1/FVC < 0.7
Severe COPD:
- FEV1 is between 30 to 49%
- post-bronchodilator FEV1/FVC is <0.7
Very severe COPD:
- FEV1 is <30%
- post-bronchodilator FEV1/FVC is < 0.7
What is involved in the stepwise approach to treatment for COPD?
- treatment starts with either a SABA or a SAMA
- if the patient has asthmatic features, they are then given a LABA + ICS
- this includes diurnal variation in cough, wheeze, sensitivity to cold weather, etc.
- if the patient has NO asthmatic features, they are then given a LABA + LAMA
- the final step up in treatment involves LAMA + LABA + ICS
- the LABA is consistent
What are examples of SABA, ICS, LABA + ICS and oral CS used to treat COPD?
- SABA - salbutamol
- ICS - beclometasone or budesonide
- LABA + ICS - this is symbicort (budesonide + formoterol)
- oral CS - prednisolone
What is involved in the general management of COPD?
- smoking cessation
- annual influenza vaccination
- a one-off pneumococcal vaccination
- long-term oxygen therapy is a treatment but there are very strict criteria in order to get this
What oxygen is given to someone who is admitted to hospital with an acute exacerbation of COPD?
they are given 24% O2 through a blue venturi
- in a healthy person, when pCO2 rises, the patient begins to hyperventilate
- in COPD, this is constant and eventually the brain switches and begins breathing normally, leading to retention of CO2
- they switch from a hypercapnic to a hypoxic drive
What is the next stage up following giving 24% oxygen to treat exacerbations of COPD?
- nebulised salbutamol 5mg and nebulised ipratropium bromide 0.5mg
- this is followed by PO prednisolone (40-50mg) for 5 days
- and IV hydrocortisone (200mg)
- IV amoxicillin / co-amoxiclav are given if there are infective features
What is involved in the senior support treatment for COPD?
- IV aminophylline
- followed by BiPAP
How does CPAP work?
it provides a continuous positive pressure throughout inspiration and expiration
this splints the airways open
it involves pushing air into the airways, as there must be some pressure otherwise the alveoli would collapse
In what conditions is CPAP used?
- type 1 respiratory failure due to pneumonia or acute pulmonary oedema
- obstructive sleep apnoea
What is BiPAP?
What are the 2 different types?
BiPAP provides a differing air pressure throughout inspiration and expiration
these are both positive pressures - but one is more positive than the other
iPAP involves pushing air into the lungs to ventilate the bases / apices of the lungs
ePAP is lower to recruit alveoli and maintain them open for ventilation
What will be visible on general inspection, ausculation and other signs in someone with idiopathic pulmonary fibrosis?
- clubbing is visible on general inspection
- on auscultation there are bi-basal, fine, inspiratory crepitations
- these sound like velcro
- there may be signs of right heart failure if disease is advanced
What is seen on a CXR and a high resolution CT scan in someone with idiopathic pulmonary fibrosis?
Chest X-ray:
- this shows late changes
- ground-glass appearance / reticulonodular
- cor pulmonale
- honeycombing
HR - CT:
- this shows early changes
- ground-glass appearance
What will be present on general inspection and auscultation in someone with hypersensitivity pneumonitis?
- there may be clubbing but this is rare
- mild pyrexia
- on auscultation there are bi-basal, fine, inspiratory crepitations
What does a CXR and HR-CT look like in someone with hypersensitivity pneumonitis?
- the chest X-ray shows late changes, but is often normal
- HR-CT shows early changes and often has a ground-glass appearance
What will be present on general inspection and auscultation in asbestosis and silicosis?
Asbestosis:
- there is clubbing on general inspection
- on auscultation there is bi-basal, fine inspiratory crepitations
Silicosis:
- on auscultation there is decreased breath sounds
- for both there may be signs of right heart failure
