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3a - GP > Resp > Flashcards

Resp Flashcards

1
Q

What is asthma

A

chronic inflammatory disorder of the airways caused by type 1 hypersensitivity

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2
Q

What are some risk factors for developing asthma?

A
  • Personal or family history of atopy
  • Maternal smoking, viral infections during pregnancy, and low birth weight
  • Not being breastfed
  • Exposure to allergens (e.g., house dust mites) and air pollution
  • The ‘hygiene hypothesis’
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3
Q

What are common atopic conditions associated with asthma?

A

Atopic dermatitis (eczema)
Allergic rhinitis (hay fever)

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4
Q

What is occupational asthma and how is it diagnosed?

A
  • caused by allergens in the workplace, such as isocyanates or flour
  • diagnosed by observing reduced peak flow readings during workdays, with normal readings on days off.
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5
Q

What are the typical symptoms of asthma?

A

Cough (worse at night)
Dyspnoea (shortness of breath)
Wheeze
Chest tightness

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6
Q

What are the signs of asthma on examination?

A

Expiratory wheeze on auscultation
Reduced peak expiratory flow rate (PEFR)

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7
Q

What diagnostic tests are recommended for patients aged 17 years and older suspected of having asthma?

A

All patients should have:
* Spirometry with a bronchodilator reversibility (BDR) test
* Fractional exhaled nitric oxide (FeNO) test

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8
Q

What diagnostic tests should be performed on children aged 5-16 years suspected of having asthma?

A
  • All children should have spirometry with a bronchodilator reversibility (BDR) test.
  • If spirometry is normal or shows obstruction with a negative BDR test, a FeNO test should be requested.
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9
Q

How is asthma diagnosed in children under 5 years old?

A

Diagnosis should be made based on clinical judgment.

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10
Q

In asthmatics, what indicates a positive result on a bronchodilator reversibility (BDR) test?

A

An improvement in FEV1 of 12% or more

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11
Q

Typical spirometry results indicating asthma

A

Obstructive pattern:
* Reduced FEV1
* Normal FVC
* FEV1/FVC ratio < 70%

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12
Q

What is fractional exhaled nitric oxide (FeNO) used for in asthma?

A
  • FeNO levels correlate with inflammation, especially eosinophilic inflammation, in asthma
  • It helps assess the level of airway inflammation.
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13
Q

Describe the stepwise management of asthma in adults

A
  1. Short-acting beta agonist (SABA).
  2. SABA + low-dose inhaled corticosteroid (ICS).
  3. add Leukotriene receptor antagonist (LTRA).
  4. SABA + low-dose ICS + long-acting beta agonist (LABA); Continue LTRA depending on patient’s response to LTRA
  5. Switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a low-dose ICS
  6. Increase the inhaled corticosteroid to a moderate dose
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14
Q

How do short acting beta agonists work

A

relaxing the smooth muscle of airways

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15
Q

Give a side effect of Short-acting beta-agonists

A

tremor

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16
Q

In the management of asthma, when should inhaled corticosteroids and LABAs be taken

A

Taken everyday, regardless of whether the patient has symptom

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17
Q

Give 2 side effects of inhaled corticosteroids

A

oral candidiasis and stunted growth in children

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18
Q

What are common symptoms of acute asthma?

A

Worsening dyspnoea, wheeze, and cough

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19
Q

What are the signs of moderate acute asthma in adults?

A

PEFR 50-75% of best or predicted
Speech normal
Respiratory rate (RR) < 25/min
Pulse < 110 bpm

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20
Q

What are the signs of severe acute asthma in adults?

A

PEFR 33-50% of best or predicted
Unable to complete sentences
Respiratory rate (RR) > 25/min
Pulse > 110 bpm

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21
Q

What are the signs of life-threatening acute asthma?

A

PEFR < 33% of best or predicted
Oxygen saturations < 92%
‘Normal’ pC02 (4.6-6.0 kPa)
Silent chest, cyanosis, or feeble respiratory effort
Bradycardia, dysrhythmia, or hypotension
Exhaustion, confusion, or coma

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22
Q

What is the significance of a normal pCO2 during an acute asthma attack?

A

A normal pCO2 (4.6-6.0 kPa) indicates exhaustion, which classifies the asthma attack as life-threatening

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23
Q

What is the significance of a raised pCO2 during an acute asthma attack?

A

pC02 >6.0 kPa indicates near-fatal asthma

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24
Q

When is an ABG indicated in the management of an acute asthma attack

A

only if oxygen sats <92%

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25
Q

When is a chest Xray indicated in the management of an acute asthma attack

A

life-threatening asthma
suspected pneumothorax
failure to respond to treatment

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26
Q

Who should be admitted to the hospital for an acute asthma attack?

A
  • All patients with life-threatening asthma
  • Patients with severe asthma who fail to respond to initial treatment
  • Patients with a previous near-fatal asthma attack
  • Pregnant patients with a severe attack even if they initially improve with treatment
  • experience an attack despite using oral corticosteroids
  • Patients presenting at night
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27
Q

How should oxygen be administered in acute asthma management?

A
  • If hypoxaemic, start supplemental oxygen.
  • For acutely unwell patients: give 15L via a non-rebreather mask, then titrate to maintain SpO2 at 94-98%.
28
Q

How is bronchodilation used to manage acute asthma?

A
  • High-dose inhaled SABA (e.g. salbutamol, terbutaline).
  • For non-life-threatening asthma: can be given via pMDI or oxygen-driven nebulizer.
  • For life-threatening asthma: nebulised SABA
29
Q

What corticosteroid treatment is recommended for acute asthma?

A
  • Prednisolone 40-50mg orally daily for at least 5 days or until recovery.
  • IV hydrocortisone if they can’t tolerate oral meds
  • Continue regular inhaled corticosteroid therapy during the acute attack.
30
Q

When is ipratropium bromide used in acute asthma?

A

*should be given to all patients with severe or life-threatening asthma or those who haven’t responded to SABA and corticosteroids.
* Administer nebulised ipratropium bromide, a short-acting muscarinic antagonist.

31
Q

What additional treatments may be considered for severe/life-threatening asthma?

A
  • IV magnesium sulphate (evidence mixed but commonly used in severe cases).
  • IV aminophylline (considered after consulting senior staff).
  • Senior critical care support may be needed for unresponsive patients, including:
    Intubation and ventilation
    Extracorporeal membrane oxygenation (ECMO)
32
Q

What criteria should be met before discharging an acute asthma patient?

A
  • Stable on discharge medication (no nebulizers or oxygen) for 12-24 hours.
  • Inhaler technique checked and recorded.
  • PEF > 75% of best or predicted.
33
Q

What is Chronic obstructive pulmonary disease (COPD)

A

Progressive condition involving airway obstruction, chronic bronchitis and emphysema

34
Q

What is chronic bronchitis

A

long-term symptoms of cough and sputum production due to inflammation in the bronchi

35
Q

What is emphysema

A

damage and dilatation of the alveolar sacs and alveoli, decreasing the surface area for gas exchange

36
Q

Give 3 causes of COPD

A
  • smoking
  • Alpha-1 antitrypsin deficiency
  • coal
37
Q

Describe a typical presentation of COPD

A
  • cough: often productive
  • dyspnoea
  • wheeze
  • recurrent resp infections
38
Q

What investigations should be done when diagnosing COPD

A
  • post-bronchodilator spirometry to demonstrate airflow obstruction and minimal reversibilty
  • chest x-ray: exclude lung cancer
  • FBC: exclude secondary polycythaemia
  • BMI
39
Q

What may be seen on a chest Xray of COPD

A
  • hyperinflation
  • bullae: if large, can mimic a pneumothorax
  • flat hemidiaphragm
40
Q

How is COPD severity graded based on FEV1?

A

Stage 1 (Mild): FEV1 > 80% of predicted
Stage 2 (Moderate): FEV1 50-79% of predicted
Stage 3 (Severe): FEV1 30-49% of predicted
Stage 4 (Very Severe): FEV1 < 30% of predicted

41
Q

What are the general management strategies for stable COPD?

A
  • Smoking cessation advice, including nicotine replacement therapy
  • Annual influenza vaccination
  • One-off pneumococcal vaccination
  • Pulmonary rehabilitation for those functionally disabled by COPD (usually MRC grade 3 and above)
42
Q

What is the first-line bronchodilator therapy for stable COPD?

A

Short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA).

43
Q

What step is taken if a COPD patient remains breathless or has exacerbations despite using short-acting bronchodilators?

A

The next step depends on whether the patient has ‘asthmatic features/features suggesting steroid responsiveness.’

44
Q

What are the NICE criteria to determine whether a COPD patient has asthmatic/steroid-responsive features?

A
  • Previous diagnosis of asthma or atopy
  • Higher blood eosinophil count
  • Substantial variation in FEV1 over time (at least 400 ml)
  • Substantial diurnal variation in peak expiratory flow (at least 20%)
45
Q

What is the treatment for COPD if there are no asthmatic features or features suggesting steroid responsiveness?

A
  • add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA)
  • if already taking a SAMA, discontinue and switch to a SABA
46
Q

What is the treatment for COPD if asthmatic features or steroid responsiveness are present?

A
  • LABA + inhaled corticosteroid (e.g. fostair, seretide)
  • If symptoms persist, offer triple therapy (LAMA + LABA + ICS)
  • Discontinue SAMA and switch to SABA if commencing LABA
47
Q

In severe cases of COPD that are unresponsive to bronchodilators/steroids, what additional management options should be considered

A
  • nebulisers
  • oral theophylline
  • Oral prophylactic antibiotic therapy: azithromycin
  • Standby medication: short course of oral corticosteroids and oral antibiotics to keep at home
  • Mucolytics
  • Phosphodiesterase-4 (PDE-4) inhibitors (e.g. roflumilast)
48
Q

When should oral prophylactic antibiotic therapy be considered for COPD patients?

A

In patients with frequent exacerbations who meet specific prerequisites:
* No smoking
* Optimised standard treatments
* CT thorax to exclude bronchiectasis
* Sputum culture to exclude atypical infections and TB
* LFTs and ECG - exclude QT prolongation

49
Q

What are NICE’s recommendations for standby medication in COPD?

A

Offer a short course of oral corticosteroids and oral antibiotics to keep at home for patients who:
* Had an exacerbation within the last year
* Understand how to use the medication and when to seek help

50
Q

What factors may improve survival in patients with stable COPD?

A
  • Smoking cessation (most important if the patient still smokes)
  • Long-term oxygen therapy (if criteria are met)
  • Lung volume reduction surgery in selected patients
51
Q

What is cor pulmonale

A

right sided heart failure caused by respiratory failure

52
Q

Give 3 causes of cor pulmonale

A
  • COPD (mc)
  • PE
  • Interstitial lung disease
53
Q

What are some features of cor pulomale

A
  • peripheral oedema
  • raised jugular venous pressure
  • systolic parasternal heave
  • loud P2
54
Q

What are the most common infective causes of COPD exacerbations?

A

Bacteria:
* Haemophilus influenzae (most common cause)
* Streptococcus pneumoniae
* Moraxella catarrhalis
Respiratory viruses
* human rhinovirus

55
Q

What are the typical features of a COPD exacerbation?

A
  • Increase in dyspnoea, cough, and wheeze
  • Possible increase in sputum, suggestive of an infective cause
  • Patients may be hypoxic and, in some cases, experience acute confusion
56
Q

Management of acute exacerbation of COPD

A
  • Increase the frequency of bronchodilator use and consider nebuliser therapy.
  • Give prednisolone 30 mg daily for 5 days.
  • oral Antibiotics only if sputum is purulent or there are clinical signs of pneumonia
57
Q

What are the first-line oral antibiotics for COPD exacerbations?

A

Amoxicillin
Clarithromycin
Doxycycline

58
Q

When is admission recommended for a COPD exacerbation?

A
  • Severe breathlessness
  • Acute confusion or impaired consciousness
  • Cyanosis
  • Oxygen saturation < 90% on pulse oximetry
  • Social reasons (e.g., inability to cope at home)
  • Significant comorbidity (e.g., cardiac disease, insulin-dependent diabetes)
59
Q

What type of respiratory failure can COPD patients develop during exacerbations?

A

type 2 respiratory failure (respiratory acidosis)

60
Q

When is non-invasive ventilation (NIV) used for COPD patients?

A

BiPaP typically used for COPD with respiratory acidosis (pH 7.25-7.35) despite maximal medical treatment

61
Q

When should a COPD patient be assessed for long-term oxygen therapy ?

A
  • Very severe airflow obstruction (FEV1 < 30% predicted)
  • Cyanosis
  • Polycythaemia
  • Peripheral oedema
  • Raised jugular venous pressure
  • Oxygen saturations ≤ 92% on room air
62
Q

How is assessment for long-term oxygen therapy done in COPD patients?

A

Assessment is done by measuring arterial blood gases on two occasions, at least 3 weeks apart, in stable COPD patients on optimal management.

63
Q

When should long-term oxygen therapy be offered to COPD patients?

A
  • pO2 < 7.3 kPa
  • pO2 between 7.3 - 8 kPa and one of the following:
    Secondary polycythaemia
    Peripheral oedema
    Pulmonary hypertension
64
Q

What is the recommended duration of oxygen use for patients receiving long-term oxygen therapy?

A

Patients should breathe supplementary oxygen for at least 15 hours a day.

65
Q

What is the target oxygen saturation range for COPD patients at risk of hypercapnia during an exacerbation?

A

The target oxygen saturation is 88-92%.
* Use a 28% Venturi mask at 4 l/min before blood gas availability.

66
Q

Why are COPD patients at high risk of hypercapnia

A

they retain CO2 when treated with O2

67
Q

What is the target oxygen saturation range for COPD patients with normal pCO2

A

94-98%

3a - GP (13 decks)

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