Obstructive Diseases Flashcards
COPD treatment pathway with NO asthmatic features?
- SABA/SAMA PRN
- SABA PRN - LABA+LAMA regularly
- SABA PRN - LABA + LAMA + ICS
COPD treatment pathway WITH asthmatic features?
- SABA/SAMA PRN
- SABA/SABA PRN - LABA + ICS
- SABA PRN - LABA + LAMA + ICS
4 possible features suggesting asthmatic features in COPD?
- previous asthma diagnosis/atopy
- Raised blood eosinophil count
- Substantial variation in FEV1 over time (>400ml)
- Substantial diurnal variation in PEFR (>20%)
Formal spirometric testing not routinely recommended
- When is theophylline PO recommended in COPD?
- When would dose have to be reduced?
After trials of short + long acting bronchodilators, or people who cannot use inhaled therapy
If macrolide or fluoroquinolone antibiotics are prescribed (significantly increase blood theophylline levels)
- When is prophylactic antibiotic therapy recommended in COPD?
- What 4 thing must be done before prescribing this and why?
Azithromycin prophylaxis
- Patients who don’t smoke, have optimised treatments and continue to have exacerbations
- LFT’s
- ECG (azith prolongs QTc)
- CT thorax (exclude bronchiectasis)
- Sputum culture (exclude atypical and TB)
When are mucolytics considered in COPD?
2 examples?
Patients who have chronic productive cough - continue this if symptoms improve
Carbocysteine, neubilsed hyperosmolar saline
7 signs of cor pulmonale?
Signs of systemic fluid overload + increased right heart pressure:
Peripheral oedema Hepatomegaly Raised JVP (a + v waves) Right parasternal heave Loud P2 Pansystolic murmur (tricuspid regurg) Early diastolic Graham Steell murmur
(S2 = aortic + pul, A2 = aortic alone, P2 = pul alone)
In cor pulmonale what is found in:
- FBC?
- ABG?
- CXR?
- ECG?
- Increased Hb and haematocrit
- Hypoxia (w/ or w/o hypercapnia)
- Enlarged RA and RV, prominent pulmonary arteries
- P pulmonale, R axis deviation, RV hypertrophy
Management of cor pulmonale?
Treat underlying cause (e.g. COPD, pul infection)
Cardiac failure - diuretics (furosemide). Amiloride or K+ supplements if necessary.
ACEI, CCB and a-blockers not recommended
Consider venesection if haematocrit >55%
What is cor pulmonale?
4 broad causes and a few examples of each?
Right heart failure caused by chronic pulmonary hypertension
Causes:
- Lung diseases (COPD, bronchiectasis, fibrosis, severe chronic asthma)
- Pulmonary vascular disease (emboli, vasculitis, prim pul hypertension)
- MSK (kyphosis/scoliosis, MG, polio)
- Hypoventilation (sleep apnoea)
Criteria for long term O2 therapy in COPD?
How long are they on oxygen each day?
- Optimised all other treatments
- Very severe (FEV1<30%)
- Sats <92% on room air
- Signs of cor pulmonale (peripheral oedema, raised JVP, secondary polycythaemia)
Measure ABG twice 3 weeks apart:
- pO2 < 7.3
- pO2 7.3-8 PLUS polycythaemia/oedema/pulmonary hypertension
CANNOT be smoking
Taking supplementary O2 15 hours a day
What chromosome is affected in A1AT deficiency and what is not produced?
What does it cause?
Ix?
Management?
Chromosome 14 - lack of protease inhibitors which prevent destruction from enzymes such as neutrophil elastase
- Panacinar emphysema (mostly in lower lobes)
- Cirrhosis and hepatocellular carcinoma
- Cholestasis in children
A1AT concentrations
Spirometry: obstruction
Rx: Don’t smoke
Bronchodilators, physio
IV A1AT concentrates
Surgical - lung volume reduction, lung transplant
What is NRT?
When should it be prescribed?
Nicotine replacement therapy
Nicotine patches, gum, inhaler etc for people with high nicotine dependence in order to help stop smoking
Prescribe for their target stop date for smoking
What is Varenicline used for? MOA? When should it be started/stopped? SE? CI?
Smoking cessation
Nicotinic receptor partial agonist
Start: 1 week before target date to stop smoking
Treatment course is 12 weeks - but monitor. Stop meds if they are smoking again
SE: nausea (common). Also headache, insomnia, abnormal dreams
CI: pregnancy, breast-feeding
What is Bupropion used for? MOA? When should it be started? What is there a risk of? CI?
Smoking cessation
NA & Dopamine reuptake inhibitor, Nicotinic antagonist
Start 1-2 weeks before target stop date. Prescription should be for 4 weeks or so
Seizures (1/1000)
CI: epilepsy, pregnancy, breast feeding. Eating disorder is relative CI.
How to test if pregnant women are smoking?
1st line smoking cessation?
Who should be referred?
Can any medications be used?
Carbon monoxide testing.
1st - CBT, motivational interviews, structured self-help, NHS stop smoking services
Refer if:
- Smoking, or stopped smoking <2 weeks ago
- CO >7ppm
Meds: Varenicline and Bupropion contraindicated. Mixed evidence for NRT
What is more effective of varenicline and bupropion?
Can smoking cessation meds be used in combination?
Varenicline
No.
5 steps in inhaler technique?
- Remove cap & shake
- Breathe out gently
- Put mouthpiece in mouth, begin to breathe in slow and deep, press canister down as continue to breathe
- Hold breath for 10 secs, or as long as comfortable
- For a second dose, wait around 30 seconds
What is post-operative atelectasis?
Cause?
When should it be suspected?
Management?
Common post-op complication where basal alveolar collapse leads to respiratory difficulty
Airways become obstructed by bronchial secretions
Presentation of dyspnoea and hypoxaemia roughly 72 hours post-op
Rx:
- Position patient upright
- Chest physiotherapy
4 recommended Ix for COPD?
Spirometry: FEV1 and post-bronchodilator FEV1/FVC
CXR: hyperinflation, flattened hemidiaphragm, bullae. Exclude cancer.
(If bullae are large they may look like pneumothorax)
FBC: exclude secondary polycythaemia
BMI (often low)
What are pink puffers and blue bloaters?
Spectrum of disease in COPD:
Pink puffers: increased alveolar ventilation, near normal PaO2, normal/low PaCO2. Breathless but not cyanosed. May go on to develop type 1 res failure
Blue bloaters: Decreased alveolar ventilation, low PaO2 and high PaCO2. Cyanosed but not breathless. May go on to develop cor pulmonale. Res centres relatively desensitised to CO2, rely more on hypoxic drive. Care with supplemental O2.
Management of severe acute exacerbation of COPD (in hospital)?
(7)
- nebuliser bronchodilators (SABA + SAMA)
- O2 therapy
(if hypercapnia on ABG, aim for 88-92% sats. If no hypercapnia aim for 94-98%)
3. IV hydrocortisone PO prednisolone (continue for 7-14 days)
- Antibiotics - Amoxicillin (Doxy 2nd line)
- Physio to aid sputum expectoration
- Consider IV Aminophylline if no response
- Consider NIV if resp rate >30 or pH<7.35 or PaCO2 rising despite treatment
4 Most common causes of acute COPD exacerbation?
H. Influenzae (most common)
Strep Pneumoniae
Moraxella Catarrhalis
Resp viruses (30% - rhino most common)
Management of non-severe exacerbation of COPD (e.g. in GP setting)?
- Increase bronchodilator use
- Prednisolone 30mg 5 days
- Prescribe antibiotics ONLY IF sputum purulent and signs of pneumonia
- 1st line - amox
- 2nd line - doxy
How to treat viral-induced wheeze in a young child?
SABA via spacer for roughly 8 weeks (in lowest effective dose). Monitor progress by decreased sleep disturbance.
If unwell enough, consider low dose Pred for 3 days
What is bronchiectasis?
List 6 causes?
Permanent dilatation of airways secondary to chronic infection or inflammation.
- Post-infective (TB, measles, pertussis, pneumonia)
- CF
- Immune deficiency (IgA, hypogammaglobulinaemia)
- ABPA
- Ciliary dyskinesia (Kartagener’s, Young’s)
