Chronic SOB Flashcards
Define asthma
Asthma is a chronic inflammatory airway disease characterised by intermittent airway obstruction and hyper-reactivity
What are the symptoms of asthma
- wheeze
- cough
- SOB
patient would have recurrent episodes
There is also variation is symptom presentation (worst in morning and evening)
What is the aetiology of asthma
- history of atopy
- Family history
- Smoker
- occupation
- pets
What is the signs of asthma
- General inspection:
May be normal
May have nasal polyposis - On auscultation:
Wheeze
What are the investigations for asthma
- Spirometry:
FEV1/FVC ratio
<80% of predicted - Peak Expiratory Flow Rate (PEFR):
PEFR varies by at least 20% for 3 days in a week - Bloods:
Normal or raised eosinophils or neutrophilia
Criteria for diagnosing asthma
- FEV1/FVC <70%
- PEFR varies by at least 20% for 3 days in a week over several weeks OR PEFR increases by at least 20%
- Reversibility: 12% pre and post-brochodilator FEV1
Patient with asthma: what should the GP do on each visit
- Important for GP to check inhaler technique
- inhaler adherence
- Symptoms (adjust medication as needed)
It’s also important for the GP to promote smoking cessation, weight loss
What are the steps in asthma treatment
Step 1: Inhaled short-acting beta agonist (e.g. salbutamol)
Step 2: Step 1 + inhaled low dose corticosteroid (beclomethasone)
Step 3: Inhaled long-acting beta agonist (e.g. salmeterol)
Increase dose of inhaled corticosteroid (e.g. beclomethasone)
Step 4: consider trials of theophylline, oral beta agonist, oral leukotriene receptor antagonist
Step 5: Oral corticosteroids
How is acute asthma classified
Moderate: PEF 50-75%
Acute-severe: PEF 33-50%
Life threatening: PEF <33%
Near fatal: pCO2: raised
Investigations for acute asthma
- Basic observations (e.g. HR, spO2)
- measure and record PEF
- O2 saturation and maintain spO2 at 93-98%
- ABG:
repeat ABG if PaO2 <8kPa, unless spO2 >92%; or initial PaCO2 is normal or raised; or if patient deteriorates - Serum K+ and glucose
In acute asthma, what should be done if aminophylline is continued for >24 hours
Serum theophylline concentration should be taken
What is the management algorithm for acute exacerbation of asthma
- oxygen
- Neb. salbutamol, 5mg
- oral prednisolone 40-50mg
- IV hydrocortisone 100mg
- IV magnesium sulphate (+ senior help)
- IV aminophylline
- ITU + intubation
With patients with acute-sever or life-threatening asthma (or those with poor response to salbutamol therapy), what can you give in step 2
Neb. Ipatropium Bromide, 0.5mg
A 17 year-old girl presents to the local A&E complaining of worsening shortness of breath, despite use of what she describes as her ‘blue inhaler’. On examination her oxygen saturations are 95%, she is afebrile and has a BP of 101/67. The attending physician takes an ABG and the results are shown below. Grade the severity of this patient’s asthma attack.
pH: 7.25 pCO2: 7.4 kPa (4.5-6.0) pO2: 10.4 kPa (>10.5) HCO3: 23 mmol/l
A. I cannot tell from the information available B. Moderate C. Acute severe D. Life threatening E. Near fatal
E. Near fatal
A 26-year-old bus driver presents to the GP complaining of a worsening shortness of breath. On examination, the patient is afebrile, has a BP of 110/85 and has a marked wheeze on auscultation. The only medications the patient is on is Salbutamol, PRN. What is the next most appropriate treatment step as per the treatment guidelines for this condition?
A. Replace the blue inhaler with a brown, low-dose inhaled corticosteroid
B. Replace the blue inhaler with a long-acting beta-agonist medication
C. Replace the blue inhaler with a long-acting muscarinic agonist medication
D. Add an inhaled low-dose corticosteroid to her medications, taken OD
E. Add oral corticosteroid tablets to her medications, taken OD
D. Add an inhaled low-dose corticosteroid to her medications, taken OD
Define COPD
COPD is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible. It encompasses both emphysema and chronic bronchitis
What are the symptoms of COPD
- SOB
- Productive cough
- some wheeze
What is the aetiology of COPD
- Increased age
- Family history
- smoker
- occupation
What are the signs of COPD
General inspection: 1. Tar staining 2. Cyanosis 3. Barrel Chest Palpitation: 1. Reduced expansion 2. Hyper-resonance on percussion Auscultation: 1. Reduced air movement 2. wheezing 3. coarse (hair-like) crackles Other: signs of HF
What does COPD not cause
clubbing
How is COPD classified
In all cases post-bronchodilator FEV1/FVC is <0.7
FEV1%: >80% Mild 50-79% Moderate 30-49% severe <30% very severe
What are the investigations for COPD
1. Spirometry FEV/FVC ratio: <0.7 2. Pulse oximetry low oxygen saturation 3. ABG PaCO2: >50 mmHg and/or PaO2: <60 mmHg (suggestive of respiratory insufficiency) 4. CXR hyperinflation
If a young person (<45 years old) is diagnosed with COPD, which investigation should be done
Alpha-1 antitrypsin
looking for deficiency
How is COPD medicated with regards to its classification
Mild:
Short acting muscarinic antagonist, SAMA (ipatropium bromide)
Short acting beta agonist, SABA (salbutamol)
Moderate:
SABA (salbutamol) + LABA (salmeterol) OR
SAMA (ipatropium bromide) + LAMA (tiotropium)
Severe:
LABA (salmeterol or formoterol) + LAMA OR
LABA + inhaled corticosteroids, ICS (budesonide)
Very severe:
LAMA + LABA + ICS
What measures can be taken to improve survival in patients with COPD
- smoking cessation
- Long-term oxygen therapy (15 hrs/day)
- Lung volume reduction therapy
What is the general conservative management of COPD
- Smoking cessation
- Annual influenza vaccine
- Pneumococcal vaccine
What is the criteria for long term oxygen
- pO2 of <7.3 kPa
- pO2 7.3-8kPa and one of the following:
a. secondary polycythaemia
b. nocturnal hypoxaemia
c. peripheral oedema
d. pulmonary hypertension
What is the management algorithm of an infective exacerbation of COPD
- (blue venturi) 24% O2
- Neb. Salbutamol 5mg
(Neb. Ipratropium Bromide 0.5mg) - oral prednisolone, 40-50mg
- IV hydrocortisone, 200mg
- IV Amoxicilline
- 500mg IV aminophylline
- BiPAP
A 72-year-old man attends the GP complaining of increased shortness of breath and a cough productive of clear sputum. The GP notes the gentleman has a history of diagnosed COPD and decides to review his medications. The man hands the GP two inhalers, one a SABA and the other a LABA. After conducting spirometry, the GP calculates an FEV1 of 40% expected. What is the next most appropriate treatment step?
A. Replace the SABA with a LAMA
B. Replace the LABA with an LAMA
C. Add a LAMA
D. Add an ICS
E. I need to conduct more tests to determine what medications to review
A. Replace the SABA with a LAMA
Which of the following is not a respiratory cause of clubbing?
A. Squamous cell lung cancer
B. Interstitial lung disease
C. COPD
D. Cystic fibrosis
E. An empyema (lung abscess)
C. COPD
Define interstitial lung disease
Interstitial lung disease (ILD) is an umbrella term for a large group of disorders that cause scarring (fibrosis) of the lungs. The scarring causes stiffness in the lungs which makes it difficult to breathe. ILD conditions can include for example:
- idiopathic pulmonary fibrosis
- Hypersensitivity pneumonitis/EAA
- Sarcoidosis
- Pneumoconiosis
What are the symptoms of idiopathic pulmonary fibrosis
- SOBOE
- Dry cough
- No wheeze
What are the risk factors for idiopathic pulmonary fibrosis
- Animal/vegetable dusts
- smoking status
- occupation
- Drugs:
- bleomycin
- Methotrexate
- Amiodarone
What are the signs of idiopathic pulmonary fibrosis
General inspection: Clubbing Auscultation: Bi-basal, fine, inspiratory crepitations Other: Signs of RHF
What is the gold standard for diagnosing idiopathic pulmonary fibrosis
Biopsy
Sometimes biopsy may not be appropriate for diagnosing idiopathic pulmonary fibrosis, what is the next best investigation
High resolution CT
- looking for ground glass
perhaps a CXR for late presentation
What are the symptoms of hypersensitivity pneumonitis/EAA
- SOBEA
- Fever
- Dry cough
What are the risk factors for hypersensitivity pneumonitis
- Acute +/- chronic history
- keep pets
- Occupation
a. Pick mushrooms
b. Bird keeper
c. Farmer
d. Plumber
e. Malt-worker
What are the signs of hypersensitivity/EAA
General Inspection 1. Clubbing (rare) 2. Mild pyrexia Auscultation 1. Bi-basal, fine, inspiratory crepitations
What is the gold standard investigation for hypersensitivity pneumonitis
High resolution CT
round glass
What are the investigations for hypersensitivity pneumonitis
- Bloods, ABG
- CXR - often normal although may shoe ground glass, reticulonodular, cor pulmonale, honeycombing
- High resolution CT
ground glass - Lung function tests
- broncho-alveloar lavage
increased cellularity
What are the symptoms for pneumoconiosis
- SOB
- Dry cough
often asymptomatic
What is the risk factors for pneumoconiosis
- Occupation
a. Coal-worker
b. builder - Long latency
Pneumoconiosis: a builder is more likely to get
Asbestosis
Pneumoconiosis: a coal-worker is more likely to get
Silicosis
What are the signs of asbestosis
- Clubbing
- Bi-basal inspiratory crepitations
- signs of RHF
What are the signs of silicosis
- Decreased breath sounds
2. signs of RHF
What is simple pneumoconiosis
where it is asymptomatic
What is complicated pneumoconiosis
where it is symptomatic
What are the investigations for pneumoconiosis
- CXR
simple: micro-nodular mottling
complicated: bilateral lower zone reticulonodular shadowing and pleural plaques - CT
fibrotic changes - Lung function tests
A 65-year-old man with a medical background of benign prostatic hyperplasia, presents to the GP with a 1 week history of worsening shortness of breath on exertion. He has a temperature of 38.5C, reports no weight loss but does mention some mild fatigue from his ‘pet pigeons keeping him up all night’ recently. On auscultation, the GP can determine fine, bi-basal inspiratory crackles. What is the most likely diagnosis?
A. COPD B. Lung cancer C. Bronchiectasis D. Hypersensitivity pneumonitis E. Idiopathic pulmonary fibrosis
D. Hypersensitivity pneumonitis
Define sleep apnoea
Characterised by recurrent collapse of the pharyngeal airway and apnoea (cessation of airflow for >10s) during sleep, followed by arousal from sleep
What are the symptoms of sleep apnoea
- Chronic fatigue
- unrefreshed sleep
- snoring
What are the risk factors for sleep apnoea
- obesity
- smoker
- alcohol
- fatigue
- truck driver
What are the investigations for sleep apnoea
- Sleep study
polysomnography (airflow monitoring, respiratory effort, pulse oximetry and HR) - TFTs
A tall 26-year-old woman comes into the GP complaining of chronic fatigue. Upon further questioning she reports that she ‘can never get a good night’s sleep’ and that she tends to fall asleep a lot at her workplace as a call centre customer service representative. She also mentions that she thinks it may have something to do with a condition her mother had. The only significant finding upon examination is patches of stretchy skin, especially around the neck area. What is the most likely underlying condition leading to disrupted sleep?
A. Obesity B. Bad sleeping position C. Marfan’s syndrome D. Down’s syndrome E. Chronic fatigue syndrome
C. Marfan’s syndrome
