Obstructive Lung Diseases Flashcards
COPD is an umbrella term for what two disorders?
Bronchitis + emphysema
Presentation of COPD:
- Breathlessness exertional or at rest?
- Cough productive or non-productive?
Exertional breathlessness
Productive cough
What is the appearance of COPD on CXR?
Hyperinflated lungs or normal lung fields
(CXR done to exclude other pathologies)
(May also see bullae or flat hemidiaphragm)
What is polycythaemia and how it is connected with COPD?
Polycythaemia = high RBC concentration (high Hb)
Secondary polycythaemia is a complication of COPD due to excess erythropoetin production due to chronic hypoxaemia
What is the 1st line, 2nd line and 3d line management of COPD?
1st line smoking cessation + SABA or SAMA 2nd line - if no asthmatic features LABA + LAMA combination - if asthmatic features LABA + ICS 3rd line LABA + LAMA + ICS
Are COPD exacerbations mainly bacterial or viral?
Mainly viral eg rhinovirus
How can COPD lead to cor pulmonale
Chronic hypoxaemia > pulmonary hypertension > RV hypertrophy > cor pulmonale
What investigations should be done in hospital for a COPD exacerbation?
CXR + ABG + bloods + ECG + sputum culture
What is the commonest organism in bacterial COPD exacerbations?
Haemophilus influenzae
Are antibiotics given routinely for COPD exacerbations?
No - only if increased sputum purulence or clinical signs of pneumonia eg pyrexia
What is the management of a COPD exaceration?
30mg oral prednisolone OD for 5 days
Increase frequency of bronchodilator use (consider using nebulizer)
Antibiotics if suspect bacterial cause
Continue usual inhalers throughout
What method of breathing assistance is used for acute on chronic type 2 respiratory failure?
Non invasive ventilation NIV
Some COPD patients lose their _____ drive and rely on their _____ drive, meaning they can tolerate lower _____, for these patients if you give too much oxygen is can cause _____
Some COPD patients lose their HYPERCAPNIC drive and rely on their HYPOXIC drive, meaning they can tolerate lower OXYGEN SATURATIONS, for these patients if you give too much oxygen is can cause RESPIRATORY DEPRESSION
What type of oxygen delivery is used 1st line for patients who’ve lost their hypercapnic drive?
Venturi mask
2nd line NIV if CO2 still creeping up
What are the indications for long term oxygen therapy in COPD?
PaO2 <7.3 on 2 occasions despite maximal treatment and non-smoker
What type hypersensitivity is asthma? Which type of immunoglobulin is involved?
Type I hypersensitivity
IgE mediated
What is the basic pathophysiology of asthma?
Recurrent reversible airway obstruction
What is Samter’s triad?
Asthma + aspirin insensitivity + nasal polyps
Describe the wheeze in asthma
Expiratory polyphonic wheeze
Describe the pattern of symptoms in asthma
Diurnal variation - worse at night
Variability in symptoms
Can asthma cause a cough?
Yes
What is the 1st line investigation for asthma?
In those aged 5-17 what investigation is performed first?
In those aged 17+ what investigation is performed first?
Spirometry
Aged 5-17 - spirometry
Aged 17+ - exhaled nitric oxide FeNO test
What is spirometry? What does it measure?
Lung function test to measure FEV1, FVC and VC
Differentiates obstructive and restrictive lung diseases
What is peak flow?
Using a peak flow device measures how quickly you can blow air out lungs
When investigating asthma, patients are recommend to monitor their own peak flow, for how long should they do this and what is a positive sign?
Monitor peak flow for 2-4wk
Positive is diurnal variability greater than 20%
What finding on spirometry suggests obstructive airway disease?
FEV1/FVC ratio <70%
How is asthma diagnosed in those aged under 5 years?
Treat based on symptoms and clinical judgement - regularly review and then test when aged over 5 years
What investigation for asthma is a measure of airway inflammation?
FeNO exhaled nitric oxide test
What impedes the accuracy of the FeNO exhaled nitric oxide test?
Result lowered by smoking
What do you look for during spirometry to diagnose asthma?
Bronchodilator reversibility (12% improvement in FEV1 = reversible airflow obstruction)
When investigating asthma in someone aged 5-17 the first line investigation is spirometry, if a patient has obstructive lung disease with bronchodilator reversibility - is this sufficient to diagnose asthma or what other test would you do?
Yes is obstructive pathology with bronchodilator reversibility if aged 5 - 16 can diagnose asthma.
If uncertain about diagnosis then do FeNO exhaled nitric oxide test - if positive then to peak flow variability - can then diagnose
When investigating asthma in someone aged 17+ first measure FeNO exhaled nitric oxide, if this is positive can you then diagnose asthma or what other tests would you do?
If aged 17+ and FeNO positive then do spirometry, if obstructive do bronchodilator reversibility. If all positive can then diagnose. If uncertain monitor peak flow variability - can then diagnose.
What role does a CXR have in investigating asthma?
In an older patient - done to exclude other pathologies
What role does aeroallergen skin prick tests / specific IgE tests have in investigating asthma?
Not relevant in asthma diagnosis - but after diagnosis has been made can be used for identifying triggers
After starting/ switching a new asthma medication, patients should be reviewed in 4-8 weeks. True or False
True
What drug is a blue inhaler?
Salbutamol SABA
AKA ventolin
What drug is a brown inhaler?
ICS eg beclomethasone, budesonide
What type of drug is formoterol?
LABA
What type of drug is ipratropium?
SAMA
What type of drug is tiotropium?
LAMA
What type of drug is salmeterol?
LABA
Give instructions for how peak flow is measured
Explain and demonstrate Ensure set to zero, sitting up straight or standing Take big breath in Create tight seal with lips around mouthpiece Exhaled as forcefully as can Note reading Repeat twice more Use highest reading
What is the 1st line management of asthma in both age groups (aged 5-16 and 17+)
If infrequent short lived wheeze = SABA reliever alone
If S+S >3X/wk or causing waking at night or uncontrolled on SABA alone = low dose ICS maintenance
If asthma is uncontrolled on SABA and ICS, what is the next step in management? (In both age groups)
Add LTRA and review in 4-8 weeks
What type of inhaler is purple?
Fostair - combination inhaler ICS-LABA
If asthma is uncontrolled on SABA + ICS + LTRA, what is the next step in management?
Use SABA reliever
For preventer use ICS-LABA combination
Stop LTRA
If asthma is uncontrolled on SABA reliever, and ICS-LABA preventer, what is the next step in management?
(in both age groups)
Switch ICS-LABA to MART regimen
If asthma is uncontrolled on SABA reliever and MART regimen preventer, what is the next step in management? (in both age groups)
Increase ICS dose
If asthma is uncontrolled on SABA reliever and after increasing the dose of ICS in the MART regimen, what is the next step in management in those aged 5 - 16 or aged 17+?
If aged 5-16 seek advice and either increase ICS dose or trial theophylline
If aged 17+ increase ICS dose again or trial LAMA or trial theophylline or refer
(mechanism of theophylline is phosphodiesterase inhibitor)
What are the categories of acute asthma?
Moderate, severe, life threatening, near fatal
What are the feature of near fatal asthma?
Raised PaCO2 >6
What is the PEFR % of predicted/baseline in moderate, severe and life-threatening acute asthma?
Moderate: 50-75%
Severe: 33-50%
Life-threatening <33%
Inability to complete sentences is a feature of what severity of acute asthma?
Severe
What are the RR and HR cut offs for severe acute asthma?
RR > 25 or HR > 110
SpO2 <92% is a feature of what severity of acute asthma?
Life-threatening
A silent chest is feature of what severity of acute asthma?
Life-threatening
What is the PaCO2 in life-threatening asthma?
Normal
Hypotension is a feature of what severity of acute asthma?
Life-threatening
Poor respiratory effort / exhaustion is a feature of what severity of acute asthma?
Life-threatening
Altered consciousness is a feature of what severity of acute asthma?
Life-threatening
What is the role of cardiac monitoring in acute asthma?
Since salbutamol can cause arrhythmias
When should you involve ITU in acute asthma?
Alert if severe
Transfer if life-threatening
What is the 1st line management of acute asthma?
NEB SABA 5mg salbutamol via oxygen driven nebulizer at rate 6-8 liters \+ NEB ipratropium \+ PO prednisolone 40mg (continued for 5 days) \+ ABG \+ Oxygen
(if can’t give PO prednisolone give IV hydrocortisone)
In the management of acute asthma if the patient is deteriorating after been given NEB SABA, NEB ipratropium and PO prednisolone, what is the next step in Mx? And what if they continue deteriorating after that?
IV magnesium 2mg
>
IV aminophylline
