Final: COPD/asthma Flashcards
what confirms diagnosis in asthma?
spirometry
- Tells us if there’s obstruction
- Asses for any reversibility after giving bronhodilator
Asthma differentials
- upper airway dz
- acute bronchiolitis, laryngotracheobronchitis
- allergic rhinitis
- sinusitis
- vocal cord dysfunction
- foreign body
- gerd
- copd
- CHF
- laryngeal and/or vocal cord dysufnction
- cystic fibrosis
- alpha 1 antitrypsin deficiency
- meds
*asthma clinical hallmarks
- Bronchospasm is often reversible
- episodic wheezing with or w/o hyper responsiveness
- dyspnea
- sputum production
- Chest tightness
- Cough
well controlled/intermittent asthma vs poorly controlled/persistent asthma in children, have sx’s
- well controlled/intermittent asthma :
- sx’s are < 2 days a week
- should be using SABA < 2 times a week
- night time awakenings < 2x/month
- poor/persistent asthma
- mild: > 2 days/week
- mod: daily
- severe: throughout day
- night time awakenings 3-4x/month
*sx’s of more serious asthma exacerbation
- marked breathlessness
- RR > 30, HR > 120
- inability to speak more than short phrases
- use of accessory muscles
- drowsiness should result in initial treatment while immediately consulting with a clinician.
initial treatment of asthma attack
- Inhaled SABA: up to 2 treatments 20 min apart of 2-6 puffs by MDI or nebulizer treatments.
if initial treatment has a good response (no wheezing/dyspnea), peak est. flow > 80%:
May continue inhaled SABA every 3–4 h for 24–48 hr
if initial treatment has an incomplete response (persistent wheezing/dyspnea/tachypnea), PEF 50-79%:
- add oral systemic corticosteroid
- continue inhaled SABA
- consult clinician for further action
if initial treatment has a poor response (marked wheezing/dyspnea), PEF < 50%:
add oral systemic corticosteroids
repeat inhaled SABA ASAP
if distress severe and non responsive, call doc AND go to ED, consider 911
asthma diagnosis
- (1) demonstration of episodic symptoms of airflow obstruction (e.g., wheeze, cough, shortness of breath),
- (2) evidence that airflow obstruction is at least partially reversible
- (3) exclusion of other conditions from the differential diagnosis.
*diagnostic hallmark of asthma
reversal of obstruction after the giving a bronchodilator (improved spirometric values < 80% and improved post SABA)
asthma diagnostics
- Pulse ox
- CBC if secondary infection
- Chest radiographs/sputum cx NOT recommended unless sus infectious illness
- Allergy evaluation
- Sweat test
- Pulmonary function tests
- Peak flow measurements
- peak expiratory flow rate
- maximal mid expiratory flow
- FVC
*
daily controller meds of asthma are:
low dose ICS and long acting beta agonist bronchodilator combos (ICS/LABA)
add on controller meds include (long acting anticholinergic, Anti-IgE, Anti-IL 5 and systemic corticosteroids
reliever asthma meds:
SABA (albuterol)
low dose ICS/formoterol
short acting anticholinergics
how to monitor peak flow meter at home
for moderate/severe asthma
record at least once daily in early afternoon, after 2-3 weeks
PEF > 80% measurement is what zone?
green
good asthma control; safe to proceed
PEF 60-80% zone
yellow
sx’s that interfere with daily activities (cough, wheeze, chest tightness, SOB, nocturnal awakening)
need temporary increase in med dose or frequency (inc bronchodilator, add/inc ICS or oral steroids)
PEF < 50%
red zone, danger, emergency treatment
inability to blow into the peak flow meter, accessory respiratory muscle use, difficulty walking or talking because of asthma, and cyanosis. Immediate use of inhaled rescue bronchodilator therapy and initiating or increasing oral corticosteroid therapy are necessary.
*atopic triad
- skin disorders (eczema)
- allergies? allergic rhinitis
- inhaler use/asthma
all 3 causes inflammation
Samter’s triad
chronic condition in pt’s with asthma
aka Aspirin Exacerbated Respiratory Disease
- atopic dermatitis/eczema
- nasal polyps
- aspirin or NSAID sensitivity
Exercise induced asthma management
if exercise regularly, use ICS as controller med
use 2 puffs B2 agonist and/or cromolyn MDI 15-30 mins prior to exercise [don’t use as controller med bc it builds tolerance]
most common cause of COPD? and others?
1: smoking
occupational
alpha 1 antitrypsin deficiency
gold standard for dx for COPD
spirometry required! confirms irreversible obstruction if FEV < 80% and FEV/FVC < 70% after given bronchodilator and it’s not reversible
on exam for COPD, the presence of of a postbronchodilator FEV1/FVC of ___ and FEV1 of _____ confirms airway limitation that is not fully reversible.
FEV1/FVC of < 70% and FEV1 < 80% confirms it’s not reversible
common complaints of COPD
dyspnea, cough, and/or sputum production
(late in the dz; when irreversible changes occurred)
PE for COPD
- confirmed with spirometry
- late stages:
- hyperinflation
- tobacco stained fingers
- clubbing
- increase in AP diameter
- increase intercostal spaces
- abnormal restriction of interspaces between inspiration (severe)
- increased resonance on percussion
- cor pulmonale (advanced)
COPD workup/labs
- forced expiratory time → determines of more testing is needed [take deep breath in & breathe out quickly and completely as possible with mouth open] while auscultation trachea
- 6 seconds or more = obstructive disease
- confirm with spirometry (FVC, FEV1, FEV1/FVC)
- any ratio < 70% FEV1/FVC
- pulse ox
- labs:
- CBC with diff
- ABG
- alpha 1 antitrypsin
- Chest xray (hyperinflation supports dx)
COPD: Chronic bronchitis
- Mild alteration in lung tissue compliance than emphysema and less parenchymal damage
- Obese
- Frequent cough with more sputum production
- Accessory muscles
- Coarse bronchi
- Wheezes
- R sided heart failure/cor pulmonale
- Edema, cyanosis
COPD: Emphysema
- Damage to alveolar wall, destruction of alveolar architecture, mismatch of ventilation and perfusion
- Thin, barrel chest
- Cough (not as much as bronchitis)
- Pursed lip breathing
- thin frame
- Accessory muscles
- Tripod position
- Hyperresonance
- Wheezing
- Heart sounds distant
medication for COPD for acute exacerbation
- oral prednisone 40mg QD x 5 days +
- increase frequency of bronchodilators (beta agonist and/or anticholinergics)
- and oral antibiotics:
- Group A mild exacerbation: B lactam, tetracycline, bactrim]
- Group B: moderate: Augmentin
- Group C: severe: fluoroquinolone
First-line for daily COPD symptoms:
short acting anticholinergic: ipratropium bromide (Atrovent)
med for stage 3 or 4 COPD with FEV < 60%
inhaled corticosteroids AND LABA therapy (Sameterol or formoterol)
lung cancer screening
- Age 50 to 80 with 20 pack year smoking history and curently smoke or have quit w/in the last 15 years
- Screen with low dose CT scan
- Stop screening if not smoked for 15 years or develops health problem that limits life expectancy or ability or willingness to have curative lung surgery
side effects of controller meds:
- ICS: decreased bone density, addrenal suppression, Ca and Vitamin D supplements
- LABA: black box in increase asthma related pulmonary death
inhaled corticosteroids recommended for long term use for pediatrics if:
- 4 wheezing episodes in a year affecting sleep and lasting more than 1 day AND have a positive asthma risk profile
- 2 or more exacerbations requiring oral corticosteroids in last 6 months
- child requires more than 2 doses of short acting bronchodilators per week for more than 4 weeks
positive asthma profile includes
- 1 or more of:
- atopic dermatitis
- sensitization to aeroallergen (pollen/spores in air)
- parental hx of asthma
OR
- 2 or more of:
- wheezing apart from colds
- more than 4% blood eosinophilia
- food sensitization
controller med for young children
- budesonide for children < 4 yrs old
- fluticasone
- beclomethasone
SE: growth suppression, delayed puberty, bone density
nebulizer or metered dose inhaler for children?
nebulizers or spacer( 1 way valve) equally good for SABA for exacerbations
PROPER TECHNIQUE
when does response to controller med happen?
4-5 weeks
if not by then, stop med and consider another dx
if have measurable response for 3 months, lower dose but children have high rates of remission
persistent asthma
- < 5 yrs old:
- if > 2 exacerbation in 6 months
- > 5 years old:
- > 2 exacerbations in 1 year but does not have daytime or nighttime impairment
lung function is included in 5 - 11 yr old criteria but not young children
mild intermittent / step 1 management
- sx’s < 2 days/week
- nighttime < 2 x/month
- no daily medicine needed
- normal FEV1 > 80%
- Saba when needed
mild persistent asthma / step 2 management
- sx’s > 2 days/wk
- night time awakenings 3-4x/month
- SABA use > 2 days/wk
- FEV > 80%
- controller: low dose inhaled CS
- or cromolyn, leukotriene modifier, or theophylline
- reliever as needed SABA
moderate persistent asthma / step 3 management
- Daily sx’s
- night time awakening more than once a week
- SABA used daily
- FEV 60-80%
- reliever: as needed SABA or low dose ICS/formoterol
- controller: low dose ICS and LABA
- or medium dose ICS
severe persistent asthma / step 4 management
- Sx’s throughout day
- night time awakening every night
- FEV < 60%
- reliever: as needed SABA or low dose ICS/formoterol
- controller: med/high dose steroids and LABA
- If needed, add oral steroids
when and how would you need to step up the asthma medications?
- when it is poorly controlled
- Symptoms >2 days/week
COPD Stage 1
Mild
FEV > 80%
chronic cough, sputum production
COPD Stage 2
Moderate
FEV 50-79%
worsening, SOB w/ exertion
COPD Stage 3
Severe
FEV 30-49%
increasing OSB with repeated exacerbation impacting QOL
COPD Stage 4
- very severe
- FEV < 30% or FEV < 50% + chronic respiratory failure present
- QOL very impaired, life threatening
COPD screening
- ONLY if have sx’s, use:
- spirometry
- chest xray to confirm hyperinflation/bullae
- chest CT to r/o malignancy
- alpha 1 antitrypsin deficiency
- 6 min walk test
COPD workup
CBC (polycythemia)
ABG
pulse ox
alpha 1 antitrypsin def
chest x ray (hyperinflation)
cardinal sx’s of COPD exacerbation
increased dyspnea
increased sputum volume
increased sputum purulence
Children >12 with moderate to severe asthma may benefit from? (2nd line)
omalizumab if ICS doesn’t help
