CSI 6: Breathlessness Flashcards
What can lung conditions cause the airways to become?
Inflamed and narrowed or filled with phlegm hence its harder for air to move in and out of the lungs.
Can make the lungs stiff and less elastic so it’s harder for them to expand and fill with air
6 Lung conditions that cause long-term (chronic) breathlessness:
COPD
Obesity
Interstitial lung disease (Pulmonary fibrosis and sarcoidosis)
Bronchiectasis
Asbestosis
Lung cancer
5 lung conditions that cause short term (acute) breathlessness:
Asthma flare up or COPD
Pe (pulmonary embolism) or blood clot on lung
Lung infection - pneumonia or TB
pneumothorax or collapsed lung
Pulmonary oedema (Build up of fluid in lung - heart failing to pump efficiently)
Explain how a heart conditions can cause long-term (chronic) breathlessness.
Issues with rhythm, valves or cardiac muscles of heart.
Heart can’t increase pumping strength in response to exercise, or lungs become congested and filled with fluid
Often worse when supine(during sleep)
2 Heart conditions that cause acute breathlessness
Heart attack
Abnormal heart rhythm
In addition to feeling you can’t breathe during a panic attack what else happens? (5)
- have a pounding heart
- feel faint and sick
- sweat
- have shaky limbs
- feel that you’re not connected to your body
What happens if you breathe too quickly in response to panic attack?
More oxygen breathed in then needed leading to hyperventilation
Explain why being unfit or having an unhealthy weight can lead to SoB.
When unfit, muscles (including respiratory muscles) get weaker.
need more oxygen to work, so the weaker our muscles, the more breathless we feel.
Being an unhealthy weight can also contribute to make us feel breathless. List all the reasons why.
underweight- respiratory muscles will be weaker.
overweight- more effort to breathe and move around.
more weight around the chest and stomach- restricts how much your lungs can move.
People who are a BMI of 25 or more are more likely to get breathless compared to people with a healthy weight.
severely overweight -develop obesity hypoventilation syndrome; when poor breathing leads to lower oxygen levels and higher carbon dioxide levels in their blood.
6 Other causes of long-term (chronic) breathlessness.
- smoking
- conditions that affect how your muscles work, such as muscular dystrophy, MG or motor neurone disease
- postural conditions that alter the shape of your spine, and affect how your ribs and lungs expand - for example scoliosis and kyphosis
- anaemia
- kidney disease
- thyroid disease
What are the 4 barriers to diagnosing breathlessness?
- think breathlessness is as a normal part of ageing, - don’t tell their doctor
- feel responsible for causing their illness and don’t feel they deserve help
- not realise they can get any help for their breathlessness
- not actually feel out of breath when they see their doctor (would be sitting down and may have only walked a short distance), so may forget what their breathlessness feels like and find it hard to describe
What 3 tools can be used to diagnose breathlessness?
- Use the MRC breathlessness scale
- Ask questions about breathlessness
- Do some tests to help diagnose what’s causing the breathlessness
Describe the 6 steps of the MRC breathlessness scale
- Not troubled by breathlessness
- Breathlessness on vigorous exertion - e.g. running
- Breathless walking up slopes
- Breathless walking at normal space on flat; having to stop from time to time.
- Stopping for breath after a few minutes on the level.
- Too breathless to leave the house.
Questions Dr’s may ask about breathlessness?
Duration
Onset
Frequency
Pattern
Time
Relieving factors e.g. lying flat
Exacerbating factors e.g. pollen, pets, medication
Smoking
Coughing/phlegm
Chest pain, palpitations, ankle swelling
Normal activity levels
Occupation
Whether breathlessness is related to certain times at work
History of heart, lung or thyroid disease, or of anaemia
Family history of breathlessness
Lifestyle changes made due to breathlessness (if any)
Feeling worried, frightened, depressed or hopeless
Coping mechanisms
What tests may help doctors to help diagnose the cause of breathlessness?
Breathing and lung function tests
Respiration rate (breaths per min)
Chest auscultation (listening)
Look and feel how chest moves during breathes
HR and rhythm
Check if fluid is building up in ankles or lungs
BP and temperature
Check height, weight, waist and BMI
Examine head, neck and armpits to see if lymph glands are swollen
Inspect eyes, nails, skin and joints
Check blood sats with a pulse oximeter
If there are signs that patient is anxious/depressed, a short questionnaire
6 clinical tests at GP surgery, local testing centre or hospital that can be used to diagnose breathlessness
CXR
Spirometry test
ECG - if breathlessness is intermittent, wear a portable recorder for
24 hours or 7 days to record heart’s electrical activity
Echocardiogram - this is a non-invasive ultrasound of heart which can tell how well it’s working
Blood tests to detect anaemia, allergies or any thyroid, liver, kidney or heart problems
What is SoB on exertion?
When you have additional requirements on top of your baseline needs, and don’t acquire enough oxygen to meet the needs.
2 general Differential diagnoses that can present with SoB on exertion.
Respiratory
Cardiovascular
7 respiratory diagnoses presenting with SoB
- Asthma
- COPD
- Pulmonary fibrosis (lung tissue becomes fibrotic and scarred)
- Lung cancer
- PE
- Pneumothorax
- Lower RTI
7 cardiovascular diagnoses presenting with SoB
- Congestive heart failure (fluid builds up within the heart and causes it to pump inefficiently)
- Pulmonary oedema (fluid collects in the numerous air sacs in the lungs, making it difficult to breathe -mainly caused by heart problems)
- Valvular defects
- Acute coronary syndrome
- Anaemia
- Renal or heart failure
- Deconditioning (being unfit/significant loss in muscle mass -affects heart and respiratory muscles)
What is FVC?
Is the amount of air that can be forcibly exhaled from your lungs after taking the deepest breath possible
What is FEV1 (forced expiratory volume in 1 second)?
Maximum amount of air that the subject can forcibly expel during the first-second following maximal inhalation.
What is the normal FEV1/FVC ratio?
70-80%
Mechanism of restrictive diseases
- Lung capacity is restricted, so FVC is lower
- If airways are unaffected, FEV1 will be normal
- Therefore FEV1/FVC ratio could be slightly increased
OR
- If FEV1 is proportionally lower, FEV1/FVC ratio could be normal
- Won’t necessarily affect rate of flow but affects lung volume
- Can’t fully fill lungs
5 causes of restrictive diseases
- scoliosis
- interstitial lung disease e.g. pulmonary fibrosis; alveoli are less stretchy so can’t get as much air in
- MD
- obesity
- sarcoidosis, an autoimmune disease
Spirometetry results for restrictive diseases
FEV1/FVC = normal/slightly higher
FVC = lower
Mechanism of obstructive diseases
- Measure on outflow with FVC.
- FVC is normal; although airways are tighter, they can get a normal amount of air in and out, just takes longer.
- FEV1 is lower because they can’t get air out quick enough.
4 causes of obstructive diseases
- COPD which includes emphysema and chronic bronchitis
- asthma
- bronchiectasis
- CF
Spirometry results for obstructive diseases
FEV1/FVC = normal/lower
Confirmed if FEV1 = <80% of the predicted value and FEV1/FVC = <70%
What 2 conditions can lead to COPD?
Bronchitis and emphysema
Explain the pathophysiology of bronchitis.
- could be caused by infection
- thickened airway walls
- narrower lumen
- overproduction of mucus due to overactivity/increased number of goblet cells in response to inflammation and irritants
- symptoms could include phlegm cough (had for at least 3 months for 2 consecutive years)
Explain the pathophysiology of emphysema
- interconnections between alveoli gets broken down and results in increased sacs results in smaller SA:V ratio, resulting in less efficient GE
- no elastic recoil that helps to push air out
- narrowing of airways
What are the 4 signs of hyperinflation?
More than 7 anterior ribs visible at mid-clavicular line
Flattening of diaphragm
Heart may appear small and narrow
Emphysema on CXR can be seen as hyperinflation there may also be bullae present
What is bullae?
Air-filled spaces with thin wall, bordered only by remnants of alveolar septae or pleura.
Often caused by emphysema.
What does bullae look like on a CXR?
Areas of low density → Black = lots of air
May be outlined by resembling bubbles.
8 factors that help treat COPD
stop smoking
eating well and maintaining a healthy weight
keeping well in the cold
take prescribed medications
control breathing
keeping active
looking after mental health
pulmonary rehabilitation (PR); exercise and education programme to help people with COPD cope with getting out of breath
3 types of Inhaled medications for COPD
Short-acting bronchodilator therapy
Long-acting bronchodilator therapy
Inhaled corticosteroids (ICS)
2 mechanisms of Short-acting and long acting bronchodilator therapy
Beta-2 agonists ; SNS dilates airways through beta adrenergic receptors
Muscarinic antagonists ; antagonistically works against paraNS that keeps airways constricted
both come in long acting and short acting forms
2 examples of short-acting bronchodilator therapies
- short acting beta agonists (SABA) → Salbutamol (Ventolin)
- short acting muscarinic antagonists (SAMA) → Ipratropium bromide (Atrovent)
2 examples of long-acting bronchodilator therapies
- Long acting beta agonists (LABA) →Formoterol, Salmeterol (Serevent)
- Long acting muscarinic antagonists (LAMA) → Tiotropium (Spiriva), Glycopyrronium
Mechanism of Inhaled corticosteroids
- Anti-inflammatory for airways
- reduces the risk of flare-ups or exacerbations
- useful for people whose condition is an overlap of asthma and COPD
- numerous different inhaler devices exist
- numerous drug combinations exist within a single inhaler
2 Examples of Inhaled corticosteroids
Alone - not licensed in COPD → Beciomestasone, Fluticasone (Flixotide)
In combination e.g. with a LABA → Fluticasone + Vilaterol (together = Relvar)
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What are the symptoms associated with smoking cessation treatments?
Nicotine cravings, irritability, depression, restlessness, poor concentration, light-headedness, sleep disturbances and increased appetite.
What is ‘abrupt quitting’?
When a smoker makes a commitment to stop smoking on or before a particular date (the quit date), rather than by gradually reducing their smoking.
What should choice of drug treatment for smoking cessation be based off?
Smoker’s age, likely adherence, preferences, whether they’re pregnant or breastfeeding, medical conditions, and previous experience of smoking-cessation aids, as well as contra-indications and side-effects of each preparation.
What are the most-effective drug treatment options for smoking cessation?
Varenicline or combination of long-acting NRT (transdermal patch) and short acting NRT (lozenges, gum, inhalator, nasal spray, oral spray) , most effective treatment options
What is used if the combination isn’t appropriate for smoking cessation?
Bupropion hydrochloride or single therapy NRT should be considered instead.
Should any combination of NRT, varenicline and bupropion hydrochloride be prescribed together?
No
A quit date should be agreed when drug treatment is prescribed for smoking cessation, and treatment should be available before the person stops smoking smokers should be prescribed enough treatment to last 2 weeks after their agreed quit date and be re-assessed shortly before their supply finishes.
Overview of NRT drug treatment
Nicotine addiction is the main reason for smoking
amount of nicotine in NRT is lower and less addictive than smoking tobacco, and doesn’t contain chemicals
Can help with withdrawal symptoms
Where to access NRT treatment
- can be bought from pharmacies and some shops
- is available on prescription from a
doctor or NHS stop smoking service
What are NRTs available as
- skin patches
- chewing gum
- inhalators (which look like plastic cigarettes)
- tablets, oral strips and lozenges
- nasal and mouth spray
How to use NRTs
Patches release nic. Slowly - applied for 16 or 24h
Short-acting nicotine preparations used when an urge to smoke occurs to prevent cravings
Combination treatment is more effective
Usually pasta 8-12 weeks before reducing dose or stopping
What is the ‘harm reduction’ approach’?
Harm reduction approaches include stopping smoking whilst using NRT to prevent relapse, and smoking reduction or temporary abstinence with or without the use of NRT.
Who can use NRT treatments
Adults and children over 12 years
Pregnant women
Breastfeeding women
Possible effects of NRT
- skin irritation when using patches
- irritation of nose, throat or eyes when using a nasal spray
- difficulty sleeping (insomnia), sometimes with vivid dreams
- an upset stomach
- dizziness
- headaches
Usually mild
How does Varenicline (Champix) work?
Reduces nicotine cravings
Blocks reward and reinforcing effects of smoking
Where to access Varenicline (Champix)
Only available on prescription; usually need to see GP or contact an NHS stop smoking service to get it
How to use Varenicline
1-2 tablets a day
Take 1-2weeks before trying to quit
12week treatment but longer if necessary
Who can use Varenicline
Safe for most
(NOT for children under 18, pregnant or breastfeeding women, people with severe kidney problems)
Possible side effects of Varenicline
- feeling and being sick
- difficulty sleeping (insomnia), sometimes with vivid dreams
- dry mouth
- constipation or diarrhoea
- headaches
- drowsiness
- dizziness
How does bupropion hydrochloride work?
It’s not clear exactly how it works, but it’s thought to have an effect on the parts of the brain involved in addictive behaviour.
Where to access Bupropion hydrochloride
Only available on prescription
How to use Bupropion hydrochloride
1-2 tablets a day
Take 1-2 weeks before trying to quit
Treatment usually lasts 7-9 weeks
Who can use Bupropion hydrochloride
Safe for most
(NOT RECOMMENDED for children under 18, pregnant or breastfeeding, people with epilepsy, bipolar disorder, eating disorders)
Possible side effects of Bupropion hydrochloride
- dry mouth
- difficulty sleeping (insomnia)
- headaches
- feeling and being sick
- constipation
- difficulty concentrating
- dizziness
In terms of smoking, what should pregnant women be advised to do and why?
Stop smoking completely
Informed about risk
NHS stop smoking services
When should NRT be used in pregnant females?
NRT should only be used in pregnant females if non-drug treatment options have failed.
Clinical judgement should be used when deciding whether to prescribe NRT following a discussion about its risks and benefits. Subsequent prescriptions should only be given to pregnant females who have demonstrated they are still not smoking.
How do concomitant drugs work?
Polycyclic aromatic HC found in tobacco smoke increase the metabolism of some drugs by inducing hepatic enzymes, often requiring an increase in dose.
3 types of inhalers
Metered Dose Inhalers (with or W/O spacer)
Dry powder Inhalers (Single/multiple dose)
Nebulisers (Jet/Ultrasonic/Mesh)
Formulation of pMDI (puffer) inhalers
Drug suspended or dissolved in propellant (with surfactant and cosolvent)
Advantages of pMDI
Portable and compact
Multidose device
Relatively inexpensive
Can’t contaminate contents
Available for most inhaled medications
Dose indicator (new-generation devices)
Disadvantages of pMDI
Contains propellants
Not breath actuated
Many patients can’t use it correctly
High oropharyngeal deposition
Formulating of DPI inhalers
Drug blend in lactose, drug alone, drug/excipient particles.
Advantages of DPI
Portable and compact
Breath actuated (no co-ordination needed)
Doesn’t contain propellants
Dose indicator (new generation devices)
Locking mechanism when empty (new generation devices)
Disadvantages of DPI
Requires a minimum inspiratory flow
May not be appropriate for emergency situations
Many patients can’t use it correctly
Most types are moisture sensitive
Formulation of pMDI and spacer
Drug suspended or dissolved in propellant (with surfactant and cosolvent)
Advantages of pMDI and spacer
Low dependence on inspiratory flow rate.
Easier to coordinate
Large drug doses delivered more conveniently
Less oropharyngeal deposition
Low dependence on inspiratory flow rate
Higher lung deposition than a pMDI
Disadvantages of pMDI and spacer
Less portable than a pMDI
Plastic spacers may acquire static charge
Additional cost to a pMDI
Formulation of SMI (soft mist inhaler)
Aqueous solution or suspension
Advantages of SMI
Portable and compact
Multidose device
Low dependence on inspiratory flow rate (slow moving aerosol)
High fine particle fraction
High lung deposition
Doesn’t contain propellants
Dose indicator
Locking mechanism when empty
Disadvantages of SMI
Not breath actuated
What should you ask the patient to do in order to assess which inhaler to prescribe?
Ask the patient to try both inhalation manoeuvres:
- Quick and deep - can the patient take a quick deep breath in within 2-3 seconds
- Slow and steady - can the patient take a slow, steady breath in over 4-5 seconds.
Inhaler prescription options:
Can perform quick and deep only (DPI)
Can perform both (DPI, pMDI, SMI)
Can perform slow and steady only (pMDI or SMI)
What are spacers?
Large, empty devices (or tubes) that are usually made out of plastic. Help get the best from asthma medicine if you use a metered dose inhaler (MDI).
Function of MDI
- deliver a dose of medicine in a fine spray (aerosol) form
- can be difficult to use them correctly as you need to breathe in at exactly the same time as you press down on your inhaler to release the medicine
- also need to breathe in very slowly and deeply
How can spacers help manage airway disease better?
- make it easier to get the right amount of medicine
- using a spacer helps the medicine get straight to your lung
- inhaler is fixed on one end of the spacer and the mouthpiece at the other
- when you press on your inhaler, the medicine collects in the chamber of the spacer, so you can breathe it in without needing to get the timing and speed exactly right
- an asthma inhaler with a spacer can also help if you’re having an asthma attack
How does a spacer help you use less medicine?
- a spacer slows the medicine down as it comes out of the inhaler, so more gets taken down into the lungs
- makes the medicine more efficient, so may need to use less
Explain how spacers reduce the risk of side effects.
- spacers reduce the small risk of side effects if you’re taking preventer (steroid) medicine
- more of the medicine gets into your lungs, less medicine is absorbed into the rest of your body, lowering the risk of side effects
- this also reduces the risk of voice changes and oral thrush: a fungal infection that can be a side effect of asthma inhalers, particularly in children
What are the 2 breathing techniques you can use with your spacer?
1) tidal or multiple breathing techniques
2) single breath and hold technique
