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
What is the management of acute COPD?
COSICAR
- Controlled oxygen
a. Sit patient up
b. 24% oxygen via Venturi mask, aiming for target sats 88-92%
c. Vary FiO2 and SpO2 target according to ABG
d. Aim for PaO2 > 8kPa and increase in PCO2 of <1.5kPa - Sal and ipatropium
a. Salbutamol 5mg/4h NEB
b. Ipratropium 0.5mg/6h NEB - Steroids
a. Hydrocortisone 200mg IV
b. Prednisolone 30mg PO for 7-14 days - Antibiotics is evidence of infection
- Consider aminophylline IV
- Consider BiPAP if pH < 7.35 and/or RR > 30
- Consider invasive ventilation if pH < 7.26
Chest Xray and refer
*If acidotic (blue bloater) – nebuliser should be driven by compressed air, not O2 (to avoid worsening hypercapnia)
What is the grading of COPD?
FEV1 %
> /= 80% - Stage 1 Mild
50-79% - Stage 2 Moderate
30-49% - Stage 3 Severe
<30% - Stage 4 Very Severe
What is bronchiectasis?
Bronchiectasis
- Permanent dilated bronchi (cavities for infected mucus to collect)
- It is an obstructive lung disease
- Vicious cycle of infection>inflammation> poor mucous clearing> obstruction> infection> airway damage/dilatation
What diseases can cause bronchiectasis?
Causes of bronchiectasis
POST INFECTION
-viral/bacterial/mycobacterial (e.g. TB-most common cause worldwide, whooping cough)
IMMUNE DEFFICIENCY
-primary (hypogammaglobuminaemia) or secondary (HIV, drugs)
INFLAMMATORY CONDITIONS
-Rheumatoid arthritis, IBD
STRUCTURAL
- Cystic fibrosis-most common cause in UK
- Primary Ciliary dyskinesia, kartageners syndrome
- COPD and fibrosis
- proximal obstruction (e.g. tumour) leads to distal widening
- Recurrent aspiration
- Asthma-ABPA
What is the cough like in bronchiectasis?
Bronchiectasis
- Chronic ‘wet’ cough
- Production of large amounts of foul smelling sputum
- Sputum may contain flecks of blood (heamoptysis)
- Worse in the mornings
- Can be brought on by changes in posture
What signs are seen in bronchiectasis?
Signs of bronchiectasis
- Clubbing
- Wheeze
- BILATERAL COURSE inspiratory crackles
- HYPEREXPANSION
- Reduced/absent breath sounds - at areas distal to places of obstruction
- May have signs of cor pulmonate (RHF)
- May have fertility problems (ask) due to cilia (PCD or youngs-chronic rhinosinusitis
What investigations would you do for bronchiectasis?
What would they show?
Bronchiectasis
Bedside
-sputum culture and sensitivity
Bloods
- rheumatoid factor
- immunglobulins
- HIV test
Imaging
- Chest X ray (tramline thick bronchial walls)
- High resolution CT (signet ring sign)
Special tests
- Spirometry (obstructive FEV/FVC <0.7)
- Bronchoscopy (proximal mass)
- CF (sweat test) or PCD testing
What is the management of bronchiectasis?
Management of bronchiectasis 1/ CONSERVATIVE -physiotherapy -treat underlying cause (HIV, IBD, Asthma) -stop smoking -pulmonary rehabilitation -specialist nurse and dietician
2/ MEDICAL
- antibiotics (look at past sputum sensitivities) (Psuedomonas=ciprofloxacin)
- mucolytics
- bronchodilators if COPD/asthma/abpa
- vaccines (influenza and pneumococcal)
3/ SURGICAL
-lobectomy, transplant
What is the pathophysiology of pulmonary fibrosis?
Alveolar walls become progressively thickened due to inflammatory cell infiltration with fibroblast proliferation
Loss of elasticity of lung parenchyma
Scarring is permanent
What are some environmental causes of pulmonary fibrosis?
Smoking Asbestos Radiation Antidepressant drugs Bird fancier's lung (extrinsic allergic alveolitis)
What are some symptoms and signs seen in pulmonary fibrosis?
Gradual onset of symptoms:
- Non-productive cough
- Breathlessness
- Haemoptysis
- Wheeze
- Anorexia
- Fatigue
Signs
- Clubbing in 50%
- Cyanosis
- Decreased chest expansion
- Fine inspiratory crackles (late)
What investigations would you order for pulmonary fibrosis and what would they show?
CXR - ground glass appearance
CT - honeycombing
FEV1/FVC spirometry - restrictive disease = >0.7 ratio
What is the treatment for pulmonary fibrosis?
Pulmonary fibrosis
- Flu vaccination
- Smoking cessation
- Palliative care (oxygen, opiates for cough)
- Lung transplant or DMARD Pirfenidone (anti-fibrotic and immunosuppressant
What might be seen on an ECG in COPD?
P pulmonale = tall P waves (>2.5mm) in inferior leads showing RVH due to cor pulmonale
What are some contraindications of spirometry?
Recent MI/PE /stroke last 3 months Current ACS Recent thorax or eye surgery last 3 months Recent chest or ear infections Haemoptysis Pregnancy
what are the differentials of breathless patient?
Cardiovascular – Pericarditis, Heart failure, MI
Respiratory – PE, Pleural effusions, Pneumothorax, Asthma, COPD
Infection (LRTI/URTI)
Malignancy
Chest wall deformity
Severe anaemia
Anxiety
Anaphylaxis
Nueromuscular disease
Metabolic- Diabetic ketoacidosis, retrosternal goitre (pembertons)
Iatrogenic- Overdose – aspirin
What investigations would you do for COPD?
- Bloods FBC (Dd anaemia), BNP-heart failure blood test
- SPIROMETRY is diagnostic (reversibility helps with treatment options
- sputum analysis
- peak flow
- chest X ray
- ECG (Dd of AF, also for a baseline)
- BMI calculation
Things to ask in breathless history
RED FLAGS weight loss cough/coughing up blood night sweats chest pain breathlessness waking in the night? number of pillows? ankle swelling tiredness? reduced exercise tolerance/ADL affect
Tell patient how to use spirometry.
- check contraindications
- sit up straight
- breath in as deep as possible
- tight seal, do not purse
- pinch nose
- breath out as hard and fast as possible (until nothing left) ‘keep going keep going’
- repeat for 3 readings
How do you use spirometry to determine if its reversible lung disease?
- give 400mcg (4 puffs) salbutamol and remeasure after 15 mins
- FEV1 needs to increase by 400ml after bronchodilation to be classed as reversable
Explain an obstructive spirometry result and give example
OBSTRUCTIVE spirometry FEV1% :Reduced FVC%: Reduced FEV1/FEVC: <0.7 (FEV1 is more reduced than FVC) E.g. COPD/asthma/bronchiectasis
*also looks curved on peak flow
Explain a restrictive spirometry result and give example
RESTRICTIVE spirometry FEV1: Reduced FVC: Reduced FEV1/FEVC: >0.7 E.g. fibrosing alveolitis
What is the management of COPD
MANAGE RISK FACTORS
- smoking cessation
- pulmonary rehab (6-8 week course on nutrition, exercise. For patients 3+ on dyspnoea score)
MANAGE PROGRESSION (Dr job to reduce exacerbations)
-prescribe medication, check compliance and technique
-educate patients to take rescue packs if green sputum
(7 days antibiotics-amoxicillin, 7 days steroids-pred)
MANAGE/PREVENT COMPLICATIONS
- annual flu vaccine (influenza) and one off pnuemococcal
- look for cor pulmonale (RVHeave, oedema, raised JVP)
MANAGE COMORBIDITIES
MANAGE MENTAL HEALTH
-support at home and supporrt groups (pulmonary rehab)
FOLLOW UP
-annually to check spirometry and dyspnoea score.
-6 months if stage 4
SAFTEY NET-what to do if exacerbation
Things to ask in an asthma history?
ASTHMA triggers
- Cold air - drying of airways causes cell shrinkage which triggers an inflammatory response
- Exercise
- Emotion
- Allergens
- Smoking
- Infection
- Pollution
- Drugs (NSAIDs and Beta blockers)
what should you ask in an asthma review?
CURRENT SYMPTOMS
in the last month:
-how often you using inhaler? (3+ week is concerning)
-have you had any problems sleeping due to asthma?
-has breathless effected your daily life?
Check smoking cessation (inc housemates)
Look at peak flow diary and measure today
Check immunisations
Check inhaler technique
Check mental help (depression screen)
Next follow up
How do you make a diagnosis of asthma
Spirometry
-FEV1/FVC <0.7 (obstructive)
Peak flow
- Improvement with bronchiodilators of 12%
- dinural variation of 20%+ for 3 days a week and for 2 weeks
What is the management for Haematemesis
Haematemesis can kill quick
-dont panic, do ABCDE and CALL FOR HELP
then think about the following:
- Antibiotics
- Tranexamic acid
- CT
- Arterial embolisation
- Palliative care (morphine, benzo)
What bugs are important in bronchiectasis?
Bugs in bronchiectasis
-pseudomonas aeurginosa (prognostic indicator, give quinolone e.g. ciprofloxacin)
- aspergillus fumigatus (fungus) can cause allergic bronchopulmonary aspergillosis>bronchiectasis
- non tubercles mycobacterium
Risk factors for developing asthma?
ASTHMA
- Atopy/family history of atopy
- Pollution i.e. living in an inner-city environment
- Prematurity and low birth weight
- Viral infections in childhood e.g. bronchiolitis
What is cardiac asthma?
Pulmonary oedema (due to heart failure)
What diseases are associated with asthma?
- Atopic diseases
- GORD
- Churg-Strauss aka eosinophilic granulomatosis - first presents with asthma
- Allergic bronchopulmonary aspergillosis
What would ABG show in asthma
Respiratory alkalosis
Low PaO2
Sometimes low PaCO2 due to hyperventilation
If PaCO2 is normal/raised = failing respiratory effort
What would you see on an Xray for COPD?
X RAY COPD
- Hyperinflated chest = more than 6 anterior ribs seen
- Flat hemidiaphragms
- Narrow heart
- Large pulmonary arteries
- Reduced vascular markings
What AB do you give to acute exacerbation of COPD?
Acute exacerbation of COPD
-Amoxicillin, tetracycline (Doxycycline) or macrolide (Erythromycin)
How can you differentiate between asthma and COPD?
Asthma: following findings are used to help identify asthma:
- Large (>400ml) response to Broncodilators
- Large (>400ml) response to 30mg PO Pred (2 wks)
- Serial PEFR > 20% diurnal variation
- COPD not present if FEV1 or FEV1/FVC ratio returns to normal (or > 15%) w/ drug therapy
pneumonic for remembering venturi masks?
Blue whales yell really good
- Blue 2L (24%)
- White 4L (28%)
- Yellow 8L (35%)
- Red 10L (40%)
- Green 15L (60%)
Contraindications for spirometry
Recent MI
Current ACS
Recent thorax surgery
Haemoptysis
Whats the treatment for ABPA
Allergic bronchopulmonary aspergillosis (ABPA)
-treatment: corticosteroids (e.g. pred) and anti fungal
What type of COPD gets Cor pulmonale?
BLUE BLOATERS (bronchitis) get cor pulmonale
Management of acute breathlessness in COPD?
- 15L nrb mask
- then get gas to see if they are chronic CO2 retainers
- if they are then reduce oxygen and titrate
What is the GOLD criteria
GOLD criteria
- takes into account MRC dysnoea score and questionnaire
- to determine impact of COPD on daily living
In order to start a COPD patient on long-term oxygen therapy, what criteria must they fulfil?
LONG TERM OXYGEN THERAPY
One of:
PaO2 <7.3kPa on two readings more than 3 weeks apart (hypoxaemia whilst breathing room air and are clinically stable), and are non-smokers
PaO2 of 7.3-8kPa + one of evidence of end-organ damage due to hypoxia:
- Nocturnal hypoxia
- Polycythemia
- Peripheral oedema (right sided heart failure)
- Pulmonary hypertension
Terminal illness
Asthma vs COPD
- asthma unproductive cough vs COPD productive
- asthma worse at night/early morning vs COPD progressive breathlessness
- asthma spirometry improves with bronchodilator (COPD does not)
- asthma has NITROGEN FROM EOSINOPHILS vs copd does not
- both get inspiritory wheeze
- both have obstructive picture FEV1<0.7
What is the diagnostic test for asthma diagnosis?
When would you NOT do this?
GOLD STANDARD diagnostic test for asthma is the challenge test (give histamine/manitol)
- dont do for frail/heart condition
- dont do for <4 years (can only be diagnosed from 5yrs)
- good for 45 year old work induced asthma for example
What chest X ray findings do you find in Pink puffers?
Pink puffers/emphesyma causes HYPER INFLATION and FLATTENED DIAGRAMS
(blue bloaters on the other hand cause cor pulmonale)
If an asthmatic has been previously admitted to ICU, what category of asthma is this?
Previous ICU admission is severe asthma! (also want to ask if they have been intubated)
If someone has an acute exacerbation of asthma in the community, what should you give?
Asthma exacerbation in community
Oral steroids 40mg for 5-7 days
+/- antibiotics if infective
What are the indications for admission of a child with bronchiolitis?
Bronchiolitis. Admit if:
<50% feeds
<92% oxygen
-worried parent or parents who wont be able to recognise red flags (its worse at night and around day 3)
When would you consider prophylactic antibiotics for COPD?
Consider prophylactic antibiotics if:
3 courses of steroid treatment AND hospital admission in 1 year
Indication for Bipap in COPD?
Indication for invasive ventilation in COPD?
Consider BiPAP if pH < 7.35 and/or RR > 30
Consider invasive ventilation if pH < 7.26
