Chronic SOB Flashcards by Léa Adamson

What is the definition of asthma?

A chronic inflammatory airway disease with intermittent airway obstruction and hyper-reactivity

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What are the associations with asthma?

Worse in the morning and night
Recurrent episodes
Hx atopy/eczema
FHx
Smoker
Pets
Occupation

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What can be seen on examination of a Pt with asthma?

May be normal
Dyspnoea
Nasal polyposis
Polyphonic, high-pitched expiratory wheeze

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What investigations would you do on a Pt with asthma?

Peak expiratory flow rate
Spirometry (FEV1:FVC ratio + reversibility with SABA)
FeNO test
Bloods

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What does an FEV1:FVC ratio of <0.7 indicate?

An obstructive pulmonary disease

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What are the types of obstructive pulmonary diseases?

Asthma

COPD

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What is the order of treatment for asthma (in accordance to the BTS guidelines)?

SABA
SABA + ICS
LABA + ICS
Trials (LTRA, LAMA, theophylline)
\+OCS

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When should you consider moving up to the next step of treatment (in accordance to the BTS guidelines)?

If the Pt needs to use the SABA 3+ times in a week

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What are the 4 categories of acute asthma?

Moderate
Acute-severe
Life threatening
Near fatal

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How do you define moderate asthma?

If the PEF is 50-75%

no features of severe asthma

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How do you define acute-severe asthma?

If the PEF is 33-50% of predicted
RR >25
HR >110
Inability to complete sentences in one breath

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How do you define life threatening asthma?

If the PEF is <33% of predicted
SpO2 <92%
PaO2 <8kPa
normal PaCO2 (not low)

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How do you define near fatal asthma?

If the pCO2 is raised

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What investigations would you do on a Pt with acute asthma?

Basic obs
PEF
O2 sat
ABG
Serum K+ and glucose

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A patient has come in with an exacerbation of asthma. What is the first treatment you would administer?

Oxygen.

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A patient has come in with a moderate exacerbation of asthma. Oxygen has been administered.

What is the next line of management?

Neb salbutamol 5mg
Oral prednisolone 40-50mg (5 days)
IV hydrocortisone 100mg

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A patient has come in with an acute-severe/life-threatening exacerbation of asthma. Oxygen has been administered.

What is the next line of management?

Neb salbutamol 5mg
Oral prednisolone 40-50mg (5 days)
IV hydrocortisone 100mg

PLUS:
Neb ipratropium bromide 0.5mg

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A patient has come in with an acute-severe exacerbation of asthma. Oxygen, salbutamol, prednisolone, hydrocortisone, and ipratropium bromide has been administered and the patient has not recovered. What is the next line of management?

IV magnesium sulphate AND call for senior help

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A patient has come in with an acute-severe exacerbation of asthma. Oxygen, salbutamol, prednisolone, hydrocortisone, ipratropium bromide, and magnesium sulphate has been administered and the patient has not recovered. A senior has arrived to help. What is the next line of management?

IV aminophylline

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A patient has come in with an acute-severe exacerbation of asthma. Oxygen, salbutamol, prednisolone, hydrocortisone, ipratropium bromide, magnesium sulphate, and IV aminophylline has been administered and the patient has not recovered. A senior has arrived to help. What is the next line of management?

ITU and intubate

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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

Her pCO2 is raised, classifying this exacerbation as near fatal.

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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 a blue inhaler. 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

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What is the definition of COPD?

Chronic airway obstruction that is not fully reversible, encompassing emphysema and chronic bronchitis.

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What signs on general inspection may indicate COPD?

Tar staining
Cyanosis
Barrel chest
Tripod-ing
Signs of RHF

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What signs on palpation and percussion may indicate COPD?

Reduced expansion | Hyper-resonance

What signs on auscultation may indicate COPD?

Reduced air movement Wheezing Coarse (hair-like) crackles

What FEV1 percentage indicates a mild COPD?

>80%

What FEV1 percentage indicates a moderate COPD?

50-80%

What FEV1 percentage indicates a severe COPD?

30-50%

What FEV1 percentage indicates a very severe COPD?

<30%

What investigations would you do on a Pt with COPD?

``` Spirometry (FEV1:FVC <0.7) Bloods ABG CXR Serum alpha-1 antitrypsin ``` OTHER: ECG if features of cor pulmonale, peak flow if suspect asthma, CT if CXR abnormality

What is the management for mild COPD?

SABA or SAMA

What is the management for moderate/severe COPD?

if asthmatic features: LABA +ICS | if no asthmatic features: LABA + LAMA

What is the management for very severe COPD?

LABA+LAMA+ICS

What other long-term management is available for COPD?

- Smoking cessation - Annual influenza + pneumococcal vaccination - Long term 02 therapy (15hr/day) - Lung volume reduction surgery

When should you give long-term O2 therapy?

If the pO2 < 7.3 kPa If the pO2 7.3-8.0 kPa AND they have: - secondary polycythaemia - nocturnal hypoxaemia - peripheral oedema - pulmonary hypertension

What is the first line management of a Pt with IE-COPD?

24% O2 (via a blue Venturi mask) NOTE: hypoxia kills quicker than hypercapnia (always give more O2 if you’re unsure / you have no ABG results)

A patient with IE-COPD has been put on a blue Venturi mask. What is the next line of management?

Neb salbutamol 5mg Neb ipratropium bromide 0.5mg Oral prednisolone 40-50mg IV hydrocortisone 200mg IV amoxicillin / co-amoxiclav

A patient with IE-COPD has been put on a blue Venturi mask. The patient has been given salbutamol, predmisolone, hydrocortisone, and ipratropium bromide. What is the next line of management?

IV amoxicillin

What is the next line in the management of IE-COPD if the patient isn't responding to nebulisers/steroids/Abx?

Call for senior support 500mg IV aminophylline NIV (BiPAP)

A patient with IE-COPD has been put on a blue Venturi mask. The patient has been given salbutamol, prednisolone, hydrocortisone, ipratropium bromide, amoxicillin and aminophylline. What is the next line of management?

BiPAP

State the indications for CPAP and BiPAP

CPAP- T1RF eg. sleep apnoea | BiPAP- T2RF eg. COPD

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 a SABA and 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

What are the respiratory causes of clubbing?

Malignancy Empyema/suppurative lung disease Interstitial lung disease Cystic fibrosis

What is the definition of interstitial lung disease?

ILD is an umbrella term for a large group of disorders causing lung tissue fibrosis.

Name some ILDs

Idiopathic pulmonary fibrosis Hypersensitivity pneumonitis/extrinsic allergic alveolitis Sarcoidosis Pneumoconiosis

What might a Pt with idiopathic pulmonary fibrosis present with?

SOBOE Dry cough No wheeze

What are some RF for IPF?

Smoking Occupation (metal/wood exposure) Exposure to animals/vegetable dust Drugs (bleomycin, methotrexate, amiodarone)

What would you look for on examination of a Pt with IPF?

Clubbing Bi-basal, fine, inspiratory crackles RHF (late stage ILD)

What investigations would you do on a Pt with IPF?

- Bloods + ABG - Biopsy- gold standard, not always necessary/feasable - CXR- late presentation - HRCT- early presentation (sensitive) - Spirometry- shows restrictive pattern (FEV1/FVC >0.8)

What would you see in a CXR in IPF?

Ground-glass appearance Reticulonodular appearance Cor pulmonale Honeycombing appearance

What would you see in a HRCT in IPF?

Ground-glass appearance

What might a Pt with hypersensitivity pneumonitis present with?

SOBOE Dry cough Fever

Which occupations are RF for hypersensitivity pneumonitis? State the aetiological agent for each occupation

Inhalation of antigenic organic dusts - Farmer's: mouldy hay w/ thermophilic actinomycetes - Bird fancier's: feathers/bird droppings - Mushroom worker's: compost w/ thermophilic actinomycetes - Malt worker's: mouldy barley w/ aspergillus clavatus - Plumbers --> humidifier lung: water-containing bacteria

What signs should you see in a Pt with Hypersensivity pneumonitis?

Clubbing (rare) Mild pyrexia- MAY MIMIC ATYPICAL PNEUMONIA Bi-basal fine inspiratory crackles

What investigations would you do on a Pt with Hypersensitivity pneumonitis? What would they show

Bloods + ABG = T2RF CXR = often normal unless late pres (same as IPF) HRCT = ground glass Lung function tests- spirometry = restrictive pattern (FEV1/FVC > 0.8) Broncho-alveolar lavage = increased cellularity

What causes pneumoconiosis?

Inhalation of coal/silica/asbestos dust Nodules of collagen and dying macrophages form around the particles

What is a typical pneumoconiosis patient?

ex. coal worker/builder- LONG LATENCY May be asymptomatic for decades SOB Dry cough

Compare the examination findings of pneumoconiosis caused by silicosis (coal worker) vs asbestosis (builder)

Both show signs of RHF SILICOSIS- decreased breath sounds (upper lobe predominant) + no clubbing ASBESTOSIS- clubbing, fine bi-basal inspiratory creps (lower lobe predominant)

What investigations would you do on a Pt with pneumoconiosis?

CXR HRCT Lung function tests- restrictive pattern

What would you see in a CXR of a Pt with pneumoconiosis?

Simple- micro-nodular mottling | Complicated- bilateral lower zone reticulonodular shadowing and pleural plaques

What would you see in a CT of a Pt with pneumoconiosis?

Fibrotic changes

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

What is the definition of sleep apnoea?

Recurrent collapse of pharyngeal airway and apnoea (cessation of airflow for >10s) during sleep; followed by arousal from sleep

What may a Pt with sleep apnoea present with?

Chronic fatigue Snoring Unrefreshed sleep

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

What are the criteria for a diagnosis of asthma?

SPIROMETRY- - FEV:FVC <0.7 (obstructive pattern) - SABA reversibility >12% difference FeNO TEST - ≥35-40 parts / billion PEFR - varies by ≥20% , ≥3x/week over several weeks

What is the order of treatment for asthma (in accordance to the NICE guidelines)?

1. SABA 2. SABA + ICS 3. SABA + ICS + LTRA 4. LABA + ICS + LTRA 5. SABA + ↑ICS + LTRA 5. Trials- theophylline, LAMA 6. Oral corticosteroids

Give 2 examples of ICS

beclometasone | budesonide

Give an example of an LRTA

montelukast

Give an example of a LABA + ICS combo inhaler

symbicort (budesonide + formoterol)

Which oral CS would you prescribe in severe asthma?

prednisolone

What are the clinical signs of life-threatening asthma?

``` Altered consciousness level Exhaustion (reduced respiratory effort) Arrhythmia Hypotension Cyanosis Silent chest ```

Near fatal asthma is characterised by what?

Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

Describe the progressive steps of management of asthma

1. OXYGEN 2. Neb salbutamol 5mg 3. IV hydrocortisone 100mg + oral prednisolone 40-50mg 4. Neb ipratropium bromide (if severe/unresponsive) 5. IV MgSO4 6. IV aminophylline 7. ITU + intubation

For each severity of asthma, state whether the patient would be admitted or not

moderate (PEF 50-75%) = no admission acute-severe (PEF 33-50%) = admit if no response life-threatening (PEF <33%) = admit near fatal (PCO2 raised) = admit if no admission, quadruple inhaled ICS instead of PO prednisolone

State the dosing and frequency of salbutamol and ipratropium bromide in asthma exacerbation

salbutamol can be given back-to-back PRN | ipratropium bromide can be given every 4 hours PRN

How does chronic COPD classically present?

SOB Chronic productive cough some wheeze

CVS causes of clubbing

``` Malignancy Infective (bacterial) Endocarditis Tetralogy of Fallot Congenital cyanotic heart disease Atrial myxoma ```

Resp causes of clubbing

Malignancy Interstitial lung disease Empyema lung abscess Cystic fibrosis

GI causes of clubbing

Malignancy Coeliac’s disease IBD Cirrhosis

COPD DOESN'T CAUSE WHAT SIGN?

CLUBBING

What is the other name for hypersensitivity pneumonitis?

Extrinsic allergic alveolitis

What 3 mechanisms cause fibrosis in pneumconiosis?

1. Direct cytotoxicity of particles 2. Particle ingestion by macrophages => free radical production 3. Pro-inflammatory cytokines from macrophages

chronic asbestos exposure can lead to which 2 pathologies?

1. Asbestosis (a pneumoconiosis) | 2. Mesothelioma (most common cancer from asbestos exposure)

compare CT appearance of asbestosis and silicosis

both show : bilateral lower zone reticulonodular shadowing + pleural plaques ``` asbestosis = fibrotic changes silicosis = eggshell calcification ```

What is the classic patient suffering from sleep apnoea?

``` OBESE Smoker, alcohol Truck driver Macroglossia Marfan's ```

Investigations for sleep apnoea

1. Sleep study - polysomnography (airflow monitoring; respiratory effort; pulse oximetry and HR) 2. TFTs 3. Glucose / IGF-1 if ? acromegaly (then random IGF-1, OGTT)

Chronic SOB Flashcards

asthma, COPD, ILD, HSP