Primary Care - Respiratory Flashcards
What kind of reaction occurs in atopic asthma?
Type 1 hypersensitivity reaction IgE-mediated release of histamine
What 3 things cause reversible airway obstruction in asthma?
1) Bronchial muscle contraction
2) Inflammation - mast cell + basophil degranulation
3) Increased mucus secretion
What drugs trigger asthma?
Beta-blockers - vasodilation + bronchoconstriction
NSAIDs
What is the clinical triad of asthma?
Cough (worse at night)
Shortness of breath
Wheeze
Diurnal variation in all symptoms (worse at night and morning)
**HAVE TO BE AVOVE 5 YEARS TO GET A DIAGNOSIS
What are signs on examination asthma?
ASTHMA
- Tachypnoea
- Bilateral widespread polyphonic wheeze
- Hyperinflated chest (i.e. hyper-resonant percussion)
- Accessory muscles
- Reduced air entry
What are signs on examination of severe asthma attack?
SEVERE = 50STaR
- 33%-50% PEFR
- Sentences-Inability to complete full sentences
- Tachycardia >110/min
- RR >25/mi
What are signs on examination of life-threatening asthma attack?
LIFE-THREATENING = 33 92, NO CHEST
- <33% PEFR
- 92% Sats
- Normal CO2 (4.6-6kPa)
- Oxygen (<8kPa)
- Cyanosis
- Hypotensive
- Exhaustion/confusion
- Silent chest
- Tachycardia (can get arrhythmia)
How do you differentiate between life-threatening and near-fatal attack?
Normal Co2 in life-threatening
Raised CO2 in near fatal
What investigations do you do for asthma? bedside, bloods, imaging, special
ASTHMA
Bedside
-PEFR (low and reversible with salbutamol)
Bloods
-ABG (Respiratory alkalosis)
Imaging
-Chest X-Ray
Special
- Spirometry
- low FEV1
- FEV1/FVC <0.7 (obstructive)
- Increased residual volume (after expiration)
*20% improvement after beta2 agonists/steroids
What is the management of acute severe asthma?
GO TO A AND E IF NO IMPROVEMENT AFTER 10 PUFFS
Management of acute asthma:
• ABCDE
• Oxygen -15L/min via non-rebreathe mask(maintain sats of 94-98% can also add nasal O2)
• Salbutamol 5mg NEB with oxygen (back to back-THREE IN A ROW)
• If severe or life threatening (PEFR<50%) add ipatropium bromide 0.5mg NEB (cant repeat as often 4-6 hours)
• Early treatment with Oral Pred (40mg) or IV hydrocortisone 100mg if can’t tolerate
Reassess every 15 mins
• If still <75% repeat salbutamol nebs every 15-30 mins
CALL SENIOR - Magnesium sulphate (with cardiac monitoring), theophylline, or IV salbutamol
(in reality you would just get nurses to mix ipratropium bromide and salbutamol for nebs-takes longer to run through but its good to get both going)
What is STEP 1 of chronic asthma management in ADULTS?
When would you progress to step 2?
Step 1: mild intermittent asthma (100% PEFR)
- Inhaled SABA as required
- If used more than 3 times a week or being woken up at night go to step 2
What is STEP 2 of chronic asthma management in ADULTS
Step 2: daily symptoms (< 80% PEFR)
- Add ICS e.g. SABA+ beclomethasone (max 2 puffs twice a day)
What is STEP 3 of chronic asthma management in ADULTS
Step 3: severe symptoms (50-80% PEFR)
- SABA + ICS + LABA
e.g. salbutamol, beclomethasone, salmeterol
(fixed dose or MART)
What is STEP 4 of chronic asthma management in ADULTS
Step 4:
- increase ICS
or
-add LTRA (if you haven’t already before)
** if LABA helped keep it, if not bin it
What other drugs can you add to control asthma (speicalist)
Additional drugs can be added to control asthma:
- muscarinic receptor antagonist (ipatropium bromide)
- theophylline
What conditions should you be cautious with beta-2 agonists?
Hyperthyroid (SE tremor)
CVD
Arrhythmias (SE palpitations)
Hypertension (SE headache)
Explain COPD to patient
-chronic inflammation which long term has lead to narrowed airways and secretions which makes you breathless
Chronic bronchitis = productive cough most days for 3 months per year for 2 years
AND
Emphysema = enlarged air spaces with destruction of alveolar walls
What does airway obstruction in COPD lead to ?
Type 2 respiratory failure (inadequate ventilation-build up of CO2)
What are blue bloaters?
V/Q?
What are the O2/CO2 like?
Blue bloaters=bronchitis
- chronic narrowing
- air that is expelled is 1st in lungs, therefore CO2 gets left in the alveoli>CO2 RETENTION
- rely on hypoxic drive to breathe = type 2 respiratory failure
- so there is decreased ventilation but normal perfusion
- cyanosed but not breathless (hypoventilate)
- Low O2 (rely on this hypodermic drive for reparation)
- High CO2
what are pink puffers?
Classic signs on X ray?
V/Q?
What are the O2/CO2 like?
Pink puffers = emphysema
- decreased perfusion due to emphysema
- increased ventilation to compensate for lack of surface area for gas exchange (puffers)
- breathless but not cyanosed
- HYPEREXPANSION (flattened diagphrams)
↑ ventilation and ↓perfusion = VQ mismatch
Normal/low CO2
Normal O2
What is the main cause of COPD?
Smoking - 10-20% heavy smokers
What else can cause COPD?
Alpha 1-antitrypsin deficiency (alpha-1-antitrypsin inhibits the destruction of alveolar wall). Also effects liver
Pollution/Recurrent infections
What symptoms define chronic bronchitis?
Productive cough most days of 3 months per year for 2 years
What signs would you see on examination of COPD?
COPD
- Tachypnoea
- Flapping tremor
- Sitting in tripod position
- Pursed lip breathing for prolonged expiration
- Use of accessory muscles
- Hyperinflated barrel chest - decreased cricosternal distance
- Decreased lung expansion
- Cyanosis
- Ankle oedema
listening
- Hyper-resonant percussion
- Quiet breath sounds over bullae (areas with no gas exchange can increase over time-put valve to fix)
What are some complications of COPD? (4)
COMPLICATIONS OF COPD - Acute infective exacerbations - Hypertension - Polycythaemia - Cor pulmonale (blue bloaters) • RHF secondary to lung disease •↑pulm pressure→ R ventricular failure → HF • Peripheral oedema/↑JVP
How do we measure the severity of breathlessness? 5 stages
MRC dyspnoea scale
- Not troubled by breathlessness except on strenuous exercise
- Short of breath when hurrying or walking up a slight incline
- Walks slower than most people on the level
- Stops after a mile or so
- Or stops after 15 minutes walking at own pace
- Stops for breath after walk about 100m or after a few minutes on level ground
- Too breathless to leave the house or breathless on dressing/undressing
What is the only intervention shown to improve life-expectancy in COPD?
Smoking cessation
What index assesses the severity of COPD?
BODE index
- BMI
- Obstruction to airflow - FEV1 < 80%
- Dyspnoea
- Exercise tolerance
What is the first line drug treatment of COPD?
SABA (salbutamol) or SAMA (ipratropium)
What is the second line drug treatment of COPD?
Asthmatic features:
add LABA (salmetorol) and ICS (budenoside)
or in combo inhaler e.g. seretide
(esionophils, dinurial variation or reversible FEV1)
No asthmatic features: add LABA (salmetorol) and LAMA (tiotropium) (stop if on SAMA cant take 2 muscarinics at the same time)
Remember salbutamol and salmeterol can go together, but ipratropium and tiotropium (SAMA and LAMA) can’t !
When would you consider third line treatment in COPD?
What is the third line drug treatment of COPD?
TRIPLE THERAPY LABA + LAMA + ICS (trilogy)
Consider if:
- affecting Q of Life
- if they have 1 severe or 2 moderate episodes in one year
What are some examples of ‘asthmatic features’ you need to consider in COPD?
- asthmatic features include:
- previous diagnosis of asthma or atopy
- high blood eosinophils
- variatoin of FEV1 overtime (400ml)
- 20% diurnal variation in peak flow