Primary care Flashcards
1
Q
What is the definition of CKD?
A
Abnormality of kidney structure or function GFR <60 Present >3 months Mostly (not always) irreversible (often) progressive
2
Q
What are common causes of CKD?
A
Diabetes (nephropathy) HTN Heart failure UT obstruction Glomerulonephritis Pyelonephritis Renal artery stenosis Systemic disease (SLE, amyloid, myeloma) Drugs (eg. NSAIDs) Hereditary (eg. polycystic kidney disease)
3
Q
What is CKD most commonly associated with in the western world?
A
old age diabetes obesity HTN CVD
4
Q
What are the common risk factors for CKD?
A
CVD Proteinuria AKI HTN Diabetes Smoking African/afro-carribean/asian Chronic NSAID use UT outflow obstruction
5
Q
What is the eGFR of stage 1 CKD (and what level of impairment does this indicate)?
A
>90 Normal (no impairment)
6
Q
What is the eGFR of stage 2 CKD (and what level of impairment does this indicate?)
A
60-90 Mild impairment *IN PRESENCE OF NO OTHER CLINICAL FEATURES OR SYMPTOMS, THIS IS NOT CLASSED AS RENAL DISEASE*
7
Q
What is the eGFR of stage 3a CKD (and what level of impairment does this indicate?)
A
45-60 Mild/moderate impairment
8
Q
What is the eGFR of stage 3b CKD (and what level of impairment does this indicate?)
A
30-45 Moderate/severe impairment
9
Q
What is the eGFR of stage 4 CKD (and what level of impairment does this indicate?)
A
15-30 Severe impairment
10
Q
What is the eGFR of stage 5 CKD (and what level of impairment does this indicate?)
A
<15 Established renal failure
11
Q
What are the common symptoms of early CKD?
A
There are usually no/limited symptoms at the early stages
12
Q
When do symptoms of CKD usually occur?
A
Usually in later stages (with severe impairment)
13
Q
What symptoms usually occur with (later stage) CKD?
A
Anorexia Nausea/vomiting Fatigue Weakness Pruritus Lethargy Peripheral Oedema Dyspnoea Insomnia Muscle cramps Pulmonary oedema Nocturia/polyuria Headache Sexual dysfunction
14
Q
What are the symptoms of ESRD (uraemia)?
A
Hiccups
Pericarditis
Coma
Seizures
15
Q
What signs might be present in clinical examination in CKD?
A
Fluid overload: peripheral and pulmonary oedema, Pleural effusion, LVH, HTN
Uraemia: excoriations/pruritis, confusion
Acidaemia: tachypnoea
(Dialysis fistula, kidney transplant scar)
16
Q
Which patients would you wish to screen for CKD?
A
Pts with Hx of AKI CVD HTN Structural renal tract disease, recurrent calculi, prostatic hypertrophy Multi system disease FHx of ESRD or hereditary renal diseases Chronic nephrotoxic drug use Opportunistic finding of haematuria
17
Q
What other differentials might you consider for someone with suspected CKD?
A
Heart failure Diabetes AKI or acute-on-chronic
hypothyroidism
heart failure
depression
18
Q
What investigations might you do to investigate CKD?
A
Bloods: FBC, U&Es, PTH, Lipids, bicarbonate
19
Q
What are common symptoms of COPD?
A
Exertion breathlessness Cough Sputum production Frequent winter ‘bronchitis’ or wheeze Weight loss Ankle oedema Fatigue
20
Q
What signs might you find when examining a patient with COPD?
A
Tachypnoea Accessory muscle use Pursed-lip breathing Tri-pod positioning drowsiness/confudion Tremor (CO2 flap) Cachexia hyperinflation of chest quiet breath sounds, wheeze prolonged forced expiratory time Cyanosis
21
Q
What do NICE say the key features that might lead you to suspect COPD are?
A
Pt >35 1 RF + exertion SOB Chronic cough Sputum production ‘bronchitis’ or wheeze ABSENCE OF FEATURES OF ASTHMA
22
Q
How might you assess a patient with suspected COPD for severity, complications etc.?
A
MRC dyspnoea scale (assess breathlessness level)
BODE index (assess prognosis)
Anxiety/depression
Smoking Hx
Cardiovascular examination
BMI
Activities of daily living
Management/exacerbations
23
Q
What investigations might you do in someone suspected with COPD?
A
FBC (anaemia or polycythaemia) Spirometry (post-bronchodilator) CXR (exclude other pathology)
24
Q
What are the diffferent levels of the MRC dyspnoea scale?
A
25
What would be considered Grade 1 dyspnoea using the MRC dyspnoea scale?
Not troubled by breathlessness except for during strenuous exercise
26
What would be considered Grade 2 dyspnoea using the MRC dyspnoea scale?
SOB when hurrying on flat or walking up slight uphill
27
What would be considered Grade 3 dyspnoea using the MRC dyspnoea scale?
Walks slower than most people on level ground, stops after a mile or so OR stops after 15 minutes of walking at own pace
28
What would be considered Grade 4 dyspnoea using the MRC dyspnoea scale?
Stops for breath after walking for about 100 yds or after a few mins on level ground
29
What would be considered Grade 5 dyspnoea using the MRC dyspnoea scale?
Too breathless to leave house or breathless when undressing
30
What are the four components that make up the BODE index?
**B**MI
**O**bstruction: FEV1 % Predicted After Bronchodialator
**D**yspnoea: MMRC Dyspnea Scale
**E**xercise tolerance: 6 Minute Walk Distance
31
How does BMI score in BODE?
\> 21 (0 points)
\<= 21 (1 point)
32
How does airflow obstruction score in BODE?
FEV1 % Predicted After Bronchodialator:
\>= 65% (0 points)
50-64% (1 point)
36-49% (2 points)
\<= 35% (3 points)
33
How does dyspnoea score in BODE?
MMRC 0: Dyspneic on strenuous excercise (0 points)
MMRC 1: Dyspneic on walking a slight hill (0 points)
MMRC 2: Dyspneic on walking level ground; must stop occasionally due to breathlessness (1 point)
MMRC 3: Must stop for breathlessness after walking 100 yards or after a few minutes (2 points)
MMRC 4: Cannot leave house; breathless on dressing/undressing (3 points)
34
How is exercise tolerance scored in BODE?
6 minute walking distance:
## Footnote
\>= 350 Meters (0 points)
250-349 Meters (1 point)
150-249 Meters (2 points)
\<= 149 Meters (3 points)
35
What dose the BODE index predict?
Approximate four year survival
36
What 4 year survival predicted to be if you score 0-2 on the BODE index?
80%
37
What 4 year survival predicted to be if you score 3-4 on the BODE index?
67%
38
What 4 year survival predicted to be if you score 5-6 on the BODE index?
57%
39
What 4 year survival predicted to be if you score 7-10 on the BODE index?
18%
40
What bronchodilator is inhaled in post-bronchodilator spirometry?
Salbutamol or terbutaline
41
How long after inhaling the bronchodilator is the second spirometry test done?
15-20 minutes
42
What FEV1/FVC ratio is suggestive of airflow obstruction? (therefore could indicate COPD if irreversible)
\<0.7
43
How is severity of obstructive disease graded using sprirometry?
FEV1 as a percentage of the predicted FEV1
44
What percentage of predicted FEV1 indicates stage 1 (mild) obstructive disease?
80%\<
45
What percentage of predicted FEV1 indicates stage 2 (moderate) obstructive disease?
50-79%
46
What percentage of predicted FEV1 indicates stage 3 (severe) obstructive disease?
30-49%
47
What percentage of predicted FEV1 indicates stage 4 (V severe) obstructive disease?
\<30%
48
What other illnesses might you want to investigate in someone with suspected COPD?
Asthma
Bronchiectasis
Heart failure
Lung cancer
Interstitial lung disease
Anaemia
TB
49
When might you refer someone with COPD to a respirtory specialist?
Persistent haemoptysis
Diagnostic uncertainty
v. severe or progressively worsening COPD
Suspected cor pulmonale
Onset \<40 years
FHx of alpha-1 anti-trypsin deficiency
Frequent infections
Need to begin O2 therapy
Need to begin nebuliser therapy
Lung surgery
50
What is the first stage of pharmacological management for someone with COPD?
(SOB or exercise limitation)
SABA (short acting beta agonists): Salbutamol or terbutaline
OR
SAMA (short acting muscarinic antagonist): ipratropium
51
Name 2 inhaled SABA drugs
Salbutamol
terbutaline
52
Name an inhaled SAMA drug
ipratropium
53
What is the second stage of pharmacological management of COPD?
**If FEV1 \> 50% predicted**
(eg. exacerbation or SOB persisting after stage 1)
LABA (long acting beta-agonist): formoterol or salmetrol
LAMA (long acting muscarinic antagonist): tiotropium\*
\*Stop SAMA if starting LAMA
54
If a patient is on a SAMA and you want to commence LAMA, what must you do?
STOP SAMA
55
Which inhlaer should continue throughout all stages of COPD management?
SABA
56
What is the second stage of pharmacological management of COPD?
**If FEV1 \< 50% predicted**
(eg. exacerbation or SOB persisting after stage 1)
LAMA\*
\*Stop SAMA
OR
LABA + ICS (combined inhaler)
if ICS not tolerated/refused:
LAMA + LABA
57
What is the third stage of pharmacological management of COPD in a patient with FEV1 \>50%, who has been on a LABA?
LABA + ICS (combined inhaler)
OR
LABA or LAMA (if above not tolerated)
58
What is the third stage of pharmacological management of COPD in a patient with FEV1 \>50%, who has been on a LAMA?
LAMA +
LABA + ICS (combined inhaler)
59
What is the third stage of pharmacological management of COPD in a patient with FEV1 \< 50%?
LAMA +
LABA + ICS (combined inhaler)
60
What is the final stage of pharmacological treatment of COPD for someone who is on either:
LABA + ICS (combined inhaler)
OR
LAMA + LABA
LAMA +
LABA + ICS (combined inhaler)
61
What service can patients with COPD be referred to, to help them self-manage their condition and cope with ADLs?
Pulmonary rehabilitation
62
What are possible additional treatments someone with COPD may need to be given?
PO Theophylline or aminophylline (COPD not responding to inhaled therapy OR unable to use inhaled therapy)\*
\*use with caution in elderly
Mucolytic (if chronically producing sputum)
Anxiolytic/anti-depressants
Nutritional supplements
Diuretics (if oedema eg. cor pulmonale)
Flu or pneumonia vaccination
Steroids - CANNOT BE STARTED IN 1o CARE
63
What migh you advise patients on to help them self-manage their COPD?
diet, exercise (20-30 mins, 4x a week), smoking cessation
How to prevent exacerbations: how to use treatments correctly (eg. inhaler technique etc.), need for vaccinations etc.
Recognising early signs of exacerbation: increasing SOB, fever, sputum production
What to do during exacerbations: AGREE AN ACTION PLAN
how to increase SABA use, When to contact doctor
Explain how to use rescue medication
64
When is rescue medication given to patients and what does it include?
Given to patients with frequent exacerbations
PO corticosteroids (if SOB interferes with ADL)
PO ABX (discoloured or increased sputum)
When to inform doctor: starting treatment, uncertain about when to start treatment OR not getting better
65
What self-help website could you suggest to pts. with COPD?
British lung foundation - guidance on COPD
66
How often should be people with COPD be followed up?
v. severe = twice a year
mild-severe = once a year
67
What should be included in a COPD follow up?
MRC dyspnoea scale
Sx review (SOB, exercise tolerance, exacerbation frequency)
S/e review
Complications
Inhaler technique
Vaccinations/cessations etc.
Spirometry
BMI
Cardio-resp exam (if necessary)
O2 sats, need for O2 therapy, anxiety/depression (if appropriate or v. severe)
68
How might we try to prevent COPD?
Smoking cessation
PPE when using chemicals or around fumes/dusts
Reduce risk of exacerbations
69
What are the risk factors for COPD?
SMOKING
Exposure to dusts/fumes/chemicals eg. cooking fuel or heating in poor ventilation
genetic - alpha-1-antitrypsin deficiency (usually starts at younger age)
70
When might you suspect a patient has end-stage COPD?
COPD V. severe
MRC dyspnoea grade 4/5
Unresponsive to treatment
Frequent exacerbations
Significant weight loss
Significant comorbidities
Probably life-expectancy 6-12 months
71
How might you manage a patient in end-stage COPD
**Optimise medical treatment (symptom control)**:
Breathlessness
Cough
Secretions/mucus
Pain
Insomnia
Mental health
**Advance care planning**
**Co-ordinate care:** Respiratory nurse specialist, district nurse, palliative care team and social services
**Discuss:** disease process, treatments, what dying might be like, whether want to involve family
72
How might you advise a patient with COPD to manage their breathlessness? If this doesn't work, how would you manage it with drugs?
Fan on side of face or open window
Sit/lean forward (tripod positioning)
Pursed-lip breathing
Drugs: opioid = first line
opioid insufficient = benzo
Oxygen (if not already on)
73
What are the common symptoms of an acute exacerbation of COPD?
Acute confusion
Reduced activities of daily living
Increasing SOB
Increased HR
Pursed-lip breathing
Accessory muscle use
Now onset cyanosis or peripheral oedema
74
How might you investigate whether there has been an acute exacerbation of COPD?
temp
O2 sats
Resp examination (AUSCULTATION)
?CXR if prolonged
75
When should you admit someone with an acute exacerbation of COPD?
SEVERE breathlessness
Rapid onset
Acute confusion or reduced consciousness
Cyanosis
Increased peripheral oedema
Significant comorbidity
Unable to cope at home or lives alone
reduced ability to carry out ADL
O2 sats \< 90%
76
How should you manage a patient with an acute exacerbation of COPD in primary care?
Increase dose/frequency of inhalers (SABA or SAMA)
Suggest use of spacer (if severe or on inhaler)
PO corticosteroid: prednisilone 30mg OD for 7-14 days
PO ABX: Amoxicillin 500mg TDS for 5 days
Allergy to penicillin: doxycycline 200mg for one day, 100 mg for 4 days)
both contra-indicated: clarithromycin 500 mg BD for 5 days
Frequenct exacerbations/increased resistance: co-amoxiclav 500mg/125mg TDS for 5 days
77
When should you follow up someone who's had an acute exacerbation of COPD? What should it include?
When clinically stable (**about 6 weeks after symptom onset**)
Ask re. residual symptoms, consider referral to specialist or pulmonary rehab
review self-management plan (include rescue medication if not already)
?CXR if prolonged
78
What is pulmonary rehabilitation?
Programme of exercise and education
Run by respiratory nurse specialists, physios, OTs
6-8 weeks
2 sessions a week
Sessions usually 1.5-2 hours
In a group 8-16 people
Helps to improve muscle strength, general fitness to increase activity, methods to help cope with SOB and how to manage negative feelings eg. panic
79
What is stage one HTN?
Clinical BP 140/90 \<=
ABPM or HBPM 135/85 \<=
80
What is stage 2 HTN?
Clinical BP 160/100 \<=
ABPM/HBPM 150/95 \<=
81
What is classed as severe HTN?
Clinical systolic BP 180/110 \<=
82
What are the main causes of HTN?
Most cases = **ESSENTIAL HTN** (primary cause unknown)
Common causes of secondary HTN: renal disease (intrinsic or renovascular)
endocrine (Cushing's, Conn's, thyroid dysfunction, phaeochromocytoma)
Pregnancy
Coarctation of aorta
Sleep apnoea
Pharmacological - alcohol, amphetamines, cocaine, OCP, anti-depressants
83
What are the main RF for high BP?
Excess weight, salt, alcohol
Lack of physical activity
Stress
Age
FHx
Ethnicity (asian, afro-carribean)
Gender (up to 65 M\>W, after 65 W\>M)
84
How do you diagnose HTN?
measure BP in both arms
Diff \>20 = repeat reading in highest arm
Clinic BP \>140/90 = take a second reading
Second reading different, take third reading
**RECORD LOWER OF BP READINGS**
Follow up with ABPM/HBPM (unless v. high - just start anti-HTN)
(also investigate postural hypOtension)
85
What other investigations might you do for someone suspected to have HTN?
**Target organ damage** investigation:
LFTs
Kidney function tests (serum urea and creatinine, electrolytes), renal ultrasound, eGFR
Urine dip (looking for protein and blood)
Cardio exam, ECG,
**Cardiovascular disease prevention:** Lipids, blood glucose
**Investigating potential secondary causes:** 24-hour urinary metanephrines, Urinary free cortisol and/or dexamethasone suppression test, Renin/aldosterone levels, Plasma calcium, Magnetic resonance imaging of the renal arteries.
86
What is the tool used for assessing cardiovascular risk?
Q risk 2
87
What is inluded in the Qrisk2 calculations?
age
sex
ethnicity
postcode
smoking status
diabetes status
Fhx (1st degree relative) with angina/MI \<60 yrs
CKD
AF
BP treatment
RA
Cholesterol/HDL ratio
Systolic BP
BMI
88
When might you consider specialist referral for someone with HTN?
BP\>180/110 with papilloedemia and/or retinal haemorrhage OR
suspected phaeochromocytoma
Secondary causes suspected
89
What lifestyle interventions should you suggest to someone with HTN?
diet and exercise
alcohol and caffeine
salt intake
smokin cessation
stress management
groups/info to support and promote lifestyle changes (BP association website)
90
What is step one of HTN management?
A (\<55yrs) or C (\>55yrs)
Give anti-HTN to all people:
80\< with stage 1 HTN + target organ damage
with CV disease
diabetes
Qrisk2 \>=20%
Stage 2 HTN
91
What does A stand for in HTN management?
ACEi or ARB
92
What is the first-line A treatment for HTN? What is the alternative?
First line: ACEi
Not tolerated/refused = low cost ARB
93
Other than age, when might you consider a CCB first line?
Black/afro-carribean
94
What does C stand for in HTN management?
CCB
95
What might you use instead of CCB if it cannot be tolerated or if it causes s/e? what sort of s/e/cautions would you expect?
D (thiazide-like diuretic)
oedema/high-risk of cardiac failure
96
when in stage 1 might you want to refer a patient for specialist evaluation?
\<40 yrs of age + no evidence of:
target organ damage
CV
Renal disease
diabetes
97
What is step 2 of HTN management?
A+C
(if black = ARB instead of ACEi)
(CCB not tolerated/contra-indicated - thiazide diuretic)
\*Make sure drugs are at max. dose before changing
98
What is step 3 HTN?
A+C+D
If BP \>= 140/90 with optimal treatment = resistant hypertension, move on to step 4 OR specialist treatment
99
What is step 4 HTN management?
A+C+D+additional drug: diuretic or alpha/beta-blocker
Consider specialist advice
K \< 4.5 - spironolactone 25 mg OD (UNLICENSED)
K \> 4.5 higher-dose thiazide-like diuretic
unable to use diuretic: alpha/beta blocker
100
How do you monitor someone's BP and response to treatment?
Clinic BP
(ABPM/HBPM too, if white-coat HTN)
MONITOR SODIUM, POTASSIUM AND RENALFUNCTION IN PTS ON DIURETICS
101
What are the targets for clinic BP and ABPM/HBPM?
**Clinic**
\< 80 yrs: \<140/90
\> 80 yrs: \>150/90
**ABPM/HBPM**
\< 80yrs: \<135/85
\> 80yrs: \>145/85
102
What diuretic would you suggest for HTN?
Indapamide 1.5-2.5 mg OD
103
What diuretics might some people be on with HTN?
bendroflumethiazide or hydrochorothiazide
If they are working, continue them
104
when should spironolactone be used with caution? Why?
in pts with low eGFR
risk of hyperkalaemia
105
What other diuretic could you use in HTN (apart from indapamide and spironolacton)? Why isn't it commonly given?
Chlortalidone 12.5mg-25mg OD
Tablets come in 50mg - therefore they need to be halved. Not possible for pts with arthiritis AND don't always get right dose if tablet not split properly
106
When might beta blockers be used as a first line treatment for HTN? What drug would you combine with this second-line?
Young person who is unable to have ACEi or ARB
OR
Woman of child-bearing potential
Combine with CCB
107
What other drugs might you consider putting someone with HTN on?
anti-platlet eg. aspirin (or clopidogrel)
108
When might you consider giving anti-platelets as primary prevention for CV disease in HTN? What is the problem with this?
Qrisk2 \> 20% AND 50yrs=\<
BP must be 150/90
Target-organ damage
ASPIRIN AND CLOPIDOGREL ARE NOT LICENSE FOR 1o PREVENTION
109
What should you do if patient with HTN is on beta-blockers already?
Keep on if there is sufficient need (eg. other health problems)
If no need, try and change
110
When should you admit someone to hospital for their HTN?
Accelerated (malignant) HTN
HTN encephalopathy
Suspected phaeochromocytoma
severe HTN
Imoending vascular complication
111
When you follow up a patient with HTN, what should you ask/check?
s/e of treatment
BP
renal function
Cario health (incl. Qrisk 2)
Offer lifestyle advice
112
How often should you review a patient with HTN?
Lifestyle only: every 3-4 months until stable or drugs started
When starting treatment: after 4 wks (to recheck BP)
If on diuretic: U&Es at baseline and 4-6 weeks
If on ACEi: urea, electrolytes, eGFR at baseline and 1-2 weeks
If on CCB: no specific monitoring
Once controlled: annually
113
How would you describe asthma?
Paroxysmal and REVERSIBLE OBSTRUCTION of airways
INFLAMMATORY response and bronchial and hyperresponsiveness - triggers inflammatory cascade = Sx
Treatment: aims to prevent persistent inflammation
114
Why is it important to treat asthma?
under treatment = chronic low levels of inflammation = remodelling of airways = fixed airways disease = NO LONGER RESPONDS TO THERAPY
115
What are some common risk factors for asthma?
Hx/FHx of asthma or atopy
Inner city environment or low SES
Obesity
Prematurity or low-birth weight
Viral infections in early childhood
Smoking (incl. maternal smoking)
Early exposure to broad-spectrum ABX
116
What are some protective factors for asthma?
Breast feeding
Vaginal birth
Farming environment
117
What are some clinical features that increase the probability of asthma (in children)?
More than one of: wheeze, (dry) cough, difficulty breathing, chest tightness - recurrent/worse at night/triggered by exercise, pets, cold, damp, emotions
Sx occur separately to colds
FHx of atopy
Widespread (mostly) expiratory wheeze on auscultation
Sx improve/lung function improves with therapy
118
What are some clinical features that reduce the probability of asthma (in children)?
Other Sx of a cold, no interval Sx
Cough WITHOUT wheeze or difficulty breathing
Moist cough
Dizziness, light-headedness, peripheral tingling
Normal chest exam (repeatedly) when Sxmatic
Normal PEFR/spirometry when Sxmatic
No response to trial therapy
119
How do you determine what management path to send a patient down in asthma?
Split pt. into:
High probability of asthma
Intermediate probability of asthma
Low probability of asthma
120
What would you find on examination in a patient with asthma?
tachypnoea
tachycardia
hyperinflated chest or Harrison's sulci
reduced O2 sats
increased work of breathing
reduced PEFR
121
How would you manage a child with high probability asthma?
start a trial of treatment
review and assess response in 2-3 mths
Good response: continue with treatment, try and reduce down to minimal effective dose
Poor response: check inhaler technique, further tests
122
How would you manage a child with intermediate probability asthma?
(can do watchful waiting, with review)
PEFR and reversible spirometry (if possible, usually 5yrs\<)
Trial treatment - assess response after a period of time.
Response OR reversibility = probable asthma - continue to treat but attempt to find minimum effective dose of therapy
NO response or reversibility = check technique, consider tests for alternative condition, consider specialist referral
STOP treatment
123
How would youmanage a child with low probability asthma?
Do more investigations and possibly suggest specialist referral
124
How would you investigate for asthma in a child?
Spirometry (\>PEFR) - usually in children over 5
NOT CXR
ASTHMA IN CHILDREN IS A CLINICAL DIAGNOSIS (PATTERN OF Sx IN ABSENCE OF ALTERNATIVE EXPLANATION)
125
What are some clinical features that increase the probability of asthma (in adults)?
More than one of: wheeze, breathlessness, chest tightness, (dry) cough
Worse at night or early morning, occurs in response to exercise/allergens/cold air/aspirin/beta-blockers
Hx/FHx of atopic disorders
Widespread (mostly) expiratory wheeze
unexplained reduced PEFR or FEV1
unexplained periopheral blood eosinophilia
126
What are some clinical features the decrease the probability of asthma?
Dizziness, light-headedness, peripheral tingling
Chronic productive cough in absence of wheeze/SOB
Repeatedly normal CXR/PEFR/Spirometry when Sxmatic
Voice disturbance
Sx with cold
Smoking Hx
Heart disease
127
How would you manage a child with high probability asthma?
start a trial of treatment
review and assess response in 2-3 mths
Good response: continue with treatment, try and reduce down to minimal effective dose
Poor response: check inhaler technique, further tests
128
How would you manage a child with intermediate probability asthma?
(can do watchful waiting, with review)
```
PEFR and reversible spirometry
(possible CXR)
Trial treatment (if FEV1/FVC \< 0.7) - assess response after a period of time.
```
Response OR reversibility = probable asthma - continue to treat but attempt to find minimum effective dose of therapy
NO response or reversibility = check technique, consider tests for alternative condition, consider specialist referral
STOP treatment
129
How would you manage a child with low probability asthma?
Investigate alternate cause for Sx
Spirometry (for COPD)
CXR (for infection, Ca etc.)
130
How would you treat asthma using lifestyle?
obesity
smoking cessation
breast-feeding babies (recommended)
reduce dust
131
What is considered complete control of asthma?
No:
Daytime Sx
Night-time waking (because of Sx)
Need for rescue meds
Exacerbations
Limitations on activity (incl. exercise)
Normal lung function (FEV1 or PEFR \>80% of predicted)
Minimal s/e of drugs
132
How is asthma managed pharmacologically?
Step-wise approach to inhaled treatment:
Start treatment at most appropriate step
Achieve control
Maintain control by increasing as necessary/decreasing when control is good
Check compliance before making medication changes
133
What differentials might you consider an adult with suspected asthma?
Airway obstruction:
COPD
Bronchiectasis
Inhaled foreign body
Bronchiolitis
Airway stenosis
Lung Ca
Sarcoidosis
Without airway obstruction:
Chronic cough
Hyperventilation
Vocal cord dysfunction
Rhinitis
GORD
Heart failure
Pulmonary fibrosis
134
What differentials might you consider in a child with suspected asthma?
Viral-induced wheeze
Aspergillosis, alveolitis, pneumonitis
CF
Laryngeal or tracheal disorder
GORD
Heart failure
Tumour
Psychogenic
Inhaled foreign body
CROUP
Pertussis
Sinusitis
Post-nasal drip
Bronchiectasis
TB
135
How often should you review a pt. with asthma?
at least once a year
More often in: new diagnosis, drug alteration, severe asthma/poor lung function, recurrent exacerbations
136
What should be included in an asthma review?
Ask re. Sx management - royal college of physicians' 3 Qs:
In last week/month:
- Difficulty sleeping due to Sx (including cough)
- Usual Sx during day (cough, wheeze, tightness, SOB)
- Have Sx interfered with usual activities (eg. housework, work, school)
PEF/Spirometry (compare to predicted and previous)
Any exacerbations, frequency or use of PO steroids. How often using reliever.
s/e/health conditions
If well managed, stay same or see if able to 'step down'
Update 'action plan'
Lifestyle management advice (incl. vaccination)
CHILDREN: GROWTH, WEIGHT
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What kinds of things should be included on an asthma action plan?
What to do in the case of an acute exacerbation - when to increase treatment, when to seek medical help
Increase in Sx od reduction in PEFR for a couple of days: implement action plan.
PEFR \> 75%: regular use of SABA for 1-2 days until Sx improve
PEFR 50-75%: oral prednisilone + regular use of SABA (seek help after 1-2 days if no improvement)
PEFR \< 50%: oral prednisilone + regular use of SABA and seek medical help
138
When might you consider using spirometry?
Asthma
COPD
CF
Airway malformations
139
What does spirometry measure?
How quickly and effectively lungs can be filled and EMPTIED
140
How long should patients' condition be stable before undertaking spirometry
141
What are the three criteria for satisfactory blows in spirometry?
Blow continues until volume plateau in reached
FVC and FEV1 should be WITHIN 5% OR 100ML of each other
Graph should be smooth and free from irregularities
142
What is administered to pts. before testing reversibility in spirometry? How long is the patient left before trying spirometry again?
400 mg \<= of salbutamol
15 mins
143
What is it important to tell pts. about their medication before they undergo reversibility spirometry?
STOP:
SABA for 6 hrs
LA bronchodilators for 12 hrs
theophyllines for 24 hrs
144
What pattern of spirometry results would you expect from a restrictive lung disease?
FVC and FEV1 = reduced proportionately
FVC reduced by \< 80%
FEV1 reduced by \< 80%
FEV1/FVC = normal
145
What pattern of spirometry results would you expect with obstructive lung disease?
FVC and FEV1 reduce disproportionately
FVC normal or reduced (reduction less extreme than that of FEV1)
FEV1 reduced \< 80% of predicted
FEV1/FVC \< 70% (0.7)
146
What would be considered as reversibility in spirometry? What would this indicate?
\> 400ml increase in FEV1
Would indicate obstruction is reversible = asthma
147
What lung capacities can spirometry measure?
Vital capacity (slow and forced)
Forced expiratory volume in one sec
Forced expiratory ratio
Forced expiratory flow
