COPD & Asthma Flashcards
VS findings in Asthma
RR often 25-40 breaths/min
tachycardia
pulsus paradoxus
SpO2 near 90% on RA
What is Pulsus Paradoxus?
What value suggests moderate severity of exacerbation?
Exaggerated inspiratory decrease in systolic BP
15mmHg
Thoracic Exam findings in asthma:
Inspection
accessory muscle use
hyperinflation
prolonged expiratory phase
Thoracic Exam findings in asthma:
Percussion
hyperresonance w/ loss of normal variation in dullness d/t diaphragmatic movemtn
tactile fremitus is diminished
Thoracic Exam findings in asthma:
Auscultation
wheezing (often louder during expiration)
Loss of intensity or absence of breath sounds known as Silent Chest (signs of severe airway obstruction)
Physical findings in COPD include?
Cyanosis may occur
pursed lip breathing
Thoracic Exam findings in COPD
Inspection
use of accessory muscles
hyperinflation
increased/large anteroposterior thoracic dimension
use of arms to fix shoulder girdle to allow the use of accessory muscled (tripod position)
retraction of the low rib cage w/ inspiration d/t altered biomechanics of the flattened diaphragm (hoover sign)
What inspection finding may suggest respiratory muscle fatigue in patients w/ COPD?
paradoxical abdominal wall motion w/ inspiration
Thoracic Exam findings in COPD
Percussion
Shows increased resonance
Thoracic Exam findings in COPD
Auscultation
Rhonchi w/ inspiration
Wheezes ww/ forced exhalation
decreased breath sounds in those w/ emphysema
asymmetry raises possibility of pneumothorax
Thoracic Exam findings in COPD
Cardiac findings include?
Diminished heart sounds d/t increased retrosternal space
Elevated JVP
Accentuated pulmonic valve closure (P2)
R ventricular heave
hepatic congestioin
peripheral edema
raises the possibility of pulmonary HTN
Differential diagnosis for Asthma
Chronic Upper Airway Cough Syndrome
Inducible Laryngeal Obstruction
Hyperventilation, dysfunctional breathing
Bronchiectasis
Cystic Fibrosis
Congenital Heart Disease
Alpha1-antitrypsin deficiency
Inhaled Foreign Body
COPD
Cardiac Failure
Medication related cough
Parenchymal lung disease
PE
Central airway obstruction
Tuberculosis
Pertussis
Differential Diagnosis for COPD
Asthma
Lung CA
Tuberculosis
Bronchiectasis
L Heart Failure
Interstitial Lung Disease
Cystic Fibrosis
Idiopathic Cough
Chronic Allergic Rhinitis
Post Nasal Drip Syndrome
Upper Airway Cough Syndrome
Gastroesophageal Refulx
Medication Induced Cough
Diagnostic requirements for asthma
Positive post-bronchodilator response defined as 12% and at least 200 ml increase in FEV1
PFT findings c/w asthma
PEFR, FEV1, MMEFR, are all decreased
After exacerbation PFTs may show low FEV1, low forced vital capacity and slightly elevated total lung capacity and residual volume
Exhaled NO findings c/w asthma
A concentration of 20-25 parts/billion is a convenient and reliable level that can be used to distinguish people w/ asthma
ABG findings in patients w/ asthma
PAO2 at sea level is 55-70 mmHg usually
PaCO2 usually between 25-35 mmHg
What is concerning when a patient w/ a hx of several days of moderate to severe airflow obstruction reason to be concerned?
It may indicate the mechanical load on the respiratory system is greater than can be sustained by the ventilatory muscles and that respiratory failure is imminent.
Other blood findings in patients w/ asthma?
Blood eosinophilia is common but not universal
Chest radiograph of a patient w/ asthma?
often normal
severe asthma is associated w/ hyperinflation (indicated by depression of the diaphragm and abnormally lucent lung fields)
Complications of severe asthma found on radiographs?
subQ emphysema
pneumomediastinum
pneumothorax
Diagnostic criteria for COPD
Post-Bronchodilator ratio of FEV1/FVC < 0.7
Recommended screening for all patients COPD
alpha-1 antitrypsin deficiency
Radiograph findings in patients w/ COPD?
hyperinflation evidenced by flattened diaphragmatic silhouette
Increased retrosternal air space on the lateral image
decreased parenchymal markings
bullae in pts w/ emphysema
Patients w/ suspected exacerbation may show evidence of what?
infiltrate suggestive of pneumonia
What type of imaging is more sensitive in demonstrating parenchymal loss c/w emphysema, bullae, and pulmonary vascular changes suggestive of pulmonary HTN?
Chest CT
ABG findings c/w COPD
Chronic hypercarbia typically accompanied by a respiratory acidosis w/ a compensatory elevation in the serum pH and the serum bicarbonate level that incompletely corrects the acidemia
Management goal for asthma
long term symptom control (few/no asthma symptoms, no sleep disturbance d/t asthma, and unimpaired physical activity)
minimized long term risk of:
asthma-related mortality
exacerbations
persistent airflow-limitation and side-effects of treatment
Management goal for COPD
reduce symptoms and future risk of exacerbations
management strategy should predominantly be based on assessment of symptoms and the history of exacerbations
Main Nonpharmacologic management strategies for asthma (non-exacerbation)
smoking cessation
avoidance of triggers
encourage physical activity
pulmonary rehab programs
weight reduction
Suggested Vaccines for asthmatics
influenza
RSV
Pneumococcal
pertussis
covid-19
Pharmacologic Management (non-exacerbation)
Track 1 Symptoms per step
Step 1
Step 2
Step 3
Step 4
Step 5
- infrequent asthma symptoms (1-2 d/wk w/ normal or mildly reduced lung function)
- asthma symptoms < 3-5 d/wk w/ normal or mildly reduced lung function
- asthma symptoms most days (4-5 d/wk or more); waking d/t asthma once a week or more, or low lung funciton
- Daily asthma symptoms, waking at night w/ asthma once a wk or more w/ low lung volumes
- Initial asthma presentation is during an acute exacerbation
Pharmacologic Management (non-exacerbation)
Track 1 Medications per step
Step 1
Step 2
Step 3
Step 4
Step 5
1-2: As needed-only low dose ICS-formoterol (budesonide-formoterol)
3. Low dose maintenance ICS-formoterol w/ reliever ICS-formoterol
4. Medium dose maintenance ICS-formoterol
5. Add on LAMA (like glycopyrolate) Refer for assessment of phenotype. consider high dose maintenance ICS-formoterol. +/- anti-IgE, anti-IL5/5R, anti-IL4Ra, anti-TSLR
Main Nonpharmacologic management strategies for COPD (non-exacerbation)
Smoking cessation
Pulmonary Rehab
exercise training
disease specific education
COPD Vaccinations
Influenza
Covid-19
Pneumococcal
Pertussis
Shingles
RSV
Group A requirements and med management for COPD
mMRC 0-1, CAT < 10 0-1 moderate exacerbations (not leading to hospital admission)
Should be prescribed a bronchodilator (albuterol - SABA) (salmeterol - LABA)
Group B requirements and med management for COPD
mMRC >/= 2, CAT >/= 10, 0-1 moderate exacerbations (not leading to hospital admission) / year
LABA + LAMA (Vilanterol/Umeclidinium)
Group E requirements and med management for COPD
> /= 2 exacerbations or >/= 1 leading to hospitalization
should be prescribed LABA + LAMA (Olodaterol/tiotropium)
What to prescribe Group E if eos >/= 300
LABA + LAMA + ICS (Fluticasone/umeclidinium/vilanterol)
Mild or Moderate Exacerbation presentation for Asthma
Talks in phrases
Prefers sitting to lying
not agitated
RR increased
No accessory muscle use
HR 100-120
SpO2 on RA 90-95%
PEF > 50% predicted or best
Severe Exacerbation presentation for Asthma
Talks in words
sits hunched forward
agitated
RR > 30/min
Accessory muscle use
HR > 120bpm
SpO2 on RA < 90%
PEF </= 50% predicted or best
Exacerbation presentation requirements for COPD
Worsening dyspnea, and/or cough and sputum in < 14 days
Often associated w/ increased local and systemic inflammation caused by airway infection, pollution, or other insults to lungs
Exacerbation presentation w/ no respiratory failure
RR </= 24 breaths/min
HR < 95 bpm
no accessory muscle use
no changes to mental status
hypoxemia improved w/ supplemental O2 given via Venti mask 24-35%
no increase in PaCO2
Exacerbation presentation w/ non-life-threatening acute respiratory failure
RR >24 breaths/min
Using Accessory muscles
no change in mental status
hypoxemia improved w/ supplemental O2 via venti mask > 25% FiO2
Hypercarbia PaCO2 increased compared w/ baseline or elevated between 50-60 mmHg
Exacerbation presentation w/ life-threatening acute respiratory failure
RR > 24 breaths/min
using accessory muscles
acute mental status changes
hypoxemia not improved w/ supplemental O2 via venti mask or requiring > 40% FiO2
Hypercarbia PaCO2 increased compared w/ baseline or elevated > 60 mmHg or the presence of acidosis
Exacerbation diagnosis for asthma
decrease in airflow quantified by PEF or FEV1 compared w/ previous lung function values
What is most reliable in the acute setting for indicators of the severity of asthma exacerbation?
Decrease in PEF or FEV1 when compared w/ previous lung function values
What is more sensitive to the measure of the onset of an exacerbation?
frequency of symptoms
Mild COPD Exacerbation diagnosis requirements
Dyspnea Visual Analog Scale < 5
RR< 24 breaths/min
HR < 95bpm
Resting Spo2 >/= 92% on RA
CRP < 10 mg/L
Moderate COPD Exacerbation diagnosis requirements
Dyspnea Visual Analog Scale >/= 5
RR >/= 24 breaths/min
HR >/= 95 bpm
Resting SpO2 < 92% on RA and/or change >3% of previous
CRP >/= 10mg/L
ABG may show hypoxemia (PaO2 </= 60 mmHg), hypercapnia (PaCO2 > 45 mmHg) but no acidosis
Severe COPD Exacerbation diagnosis requirements
Dyspnea Visual Analog Scale >/= 5
RR >/= 24 breaths/min
HR >/= 95 bpm
Resting SpO2 < 92% on RA and/or change >3% of previous
CRP >/= 10mg/L
ABG shows new onset/worsening hypercapnia and acidosis (PaCO2 > 45 mmHg and pH < 7.35)
Exacerbation management for Asthma
Assess exacerbation severity from the degree of dyspnea, RR, HR, SpO2 and lung function while starting SABA and O2 therapy
Infection control procedures should be followed
When and where to transfer a patient w/ asthma exacerbation?
Immediate transfer to acute care facility or ICU for signs of severe exacerbation or the patient is drowsy, confused or has silent chest.
What prescribe patients during transfer?
SABA (albuterol) and Ipratropium bromide
controlled O2
systemic corticosteroids (prednisone 50mg PO 5-7 day course)
What to do after 1 hr from interventions to treat asthma severe asthma exacerbations?
Reassess response of symptoms O2 saturation and lung function
Only give ipratropium bromide for what?
What to consider for patients w/ severe exacerbation not responding to initial treatment?
Severe exacerbations
IV Mag Sulfate
Exacerbation management for Severe but not life-threatening COPD Exacerbation?
Assess severity of symptoms, blood gases, chest radiograph
Increase doses and/or frequency of SABA
Combine SABA and anticholinergics (Salbutamol/ipratropium)
Consider use of LABA (Salmeterol) when patient becomes stable
Use spacers or air-driven nebulizers when appropriate
Consider systemic corticosteroids (PO prednisone 40 mg for 5 days
Consider ABx when signs of infection are present
Classes of abx to use during COPD exacerbation w/ signs of infection?
aminopenicillin w/ clauvanic acid (augmentin, Unasyn)
macrolide (azithromycin, Clarithromycin, erythromycin, fidoxomicin, telithromycin)
tetracycline
quinolone (Ciprofloxacin, norfloxacin, ofloxacin, levofloxacin, moxifloxacin)
Considerations during management of COPD Exacerbations at all times?
monitor IVF balance
consider SQH or LMWH for DVT prophylaxis
ID and treat associated conditions (e.g. heart failure, arrhythmias, PE etc.)
Indications for transfer to Respiratory or Medical ICU
Severe dyspnea that responds inadequately to initial emergency therapy.
Changes in mental status
Persistent or worsening hypoxemia (PaO2 < 40mmHg) and/or severe/worsening respiratory acidosis (pH < 7.25) despite supplemental O2 and NIV
Need for invasive mechanical ventilation
Hemodynamic instability - need for vasopressors
Indications for NIV include at least one of the following
1.Respiratory Acidosis (PaCO2 >/= 45 mmHg and arterial pH </= 7.35)
2. Severe dyspnea w/ clinical signs suggestive of respiratory muscle fatigue increased WOB, or both, use of accessory muscles, paradoxical motion of the abdomen, or retraction of the intercostal spaces
3. Persistent hypoxemia despite supplemental O2 therapy
Indications for Invasive MV
Unable to tolerate NIV or NIV failure
S/p respiratory or cardiac arrest
Diminished consciousness, psychomotor agitation inadequately controlled by sedation
Massive aspiration or persistent vomiting
Persistent inability to remove respiratory secretions
Severe hemodynamic instability w/o response to fluids and vasoactive drugs.
Severe ventricular or supraventricular arrhythmias
Life-threatening hypoxemia in patients unable to tolerate NIV
