Respiratory Flashcards
What methods can be used for smoking cessation? how are these prescribed?
patients should be offered nicotine replacement therapy (NRT), varenicline or bupropion - NICE state that clinicians should not favour one medication over another
NRT, varenicline or bupropion should normally be prescribed as part of a commitment to stop smoking on or before a particular date (target stop date)
prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after the target stop date. Normally, this will be after 2 weeks of NRT therapy, and 3-4 weeks for varenicline and bupropion, to allow for the different methods of administration and mode of action. Further prescriptions should be given only to people who have demonstrated that their quit attempt is continuing
if unsuccessful using NRT, varenicline or bupropion, do not offer a repeat prescription within 6 months unless special circumstances have intervened
do not offer NRT, varenicline or bupropion in any combination
What are the adverse effects of NRT?
Nicotine replacement therapy
adverse effects include nausea & vomiting, headaches and flu-like symptoms NICE recommend offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge or nasal spray) to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past
What is varenicline? When should this be started?
a nicotinic receptor partial agonist
should be started 1 week before the patients target date to stop
the recommended course of treatment is 12 weeks (but patients should be monitored regularly and treatment only continued if not smoking)
IS varenicline effective? what are the side effects? when is this contraindicated?
has been shown in studies to be more effective than bupropion
nausea is the most common adverse effect. Other common problems include headache, insomnia, abnormal dreams
varenicline should be used with caution in patients with a history of depression or self-harm. There are ongoing studies looking at the risk of suicidal behaviour in patients taking varenicline
contraindicated in pregnancy and breast feeding
What is bupropion? when should this be started? what are the risks (1) and contraindications (4)?
a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
should be started 1 to 2 weeks before the patients target date to stop
small risk of seizures (1 in 1,000)
contraindicated in epilepsy, pregnancy and breast feeding. Having an eating disorder is a relative contraindication
Are pregnant women tested for smoking? who is referred to smoking cessation?
NICE recommended in 2010 that all pregnant women should be tested for smoking using carbon monoxide detectors, partly because ‘some women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense.’. All women who smoke, or have stopped smoking within the last 2 weeks, or those with a CO reading of 7 ppm or above should be referred to NHS Stop Smoking Services.
What can be used for smoking cessation in pregnancy?
Interventions
the first-line interventions in pregnancy should be cognitive behaviour therapy, motivational interviewing or structured self-help and support from NHS Stop Smoking Services the evidence for the use of NRT in pregnancy is mixed but it is often used if the above measures failure. There is no evidence that it affects the child's birthweight. Pregnant women should remove the patches before going to bed as mentioned above, varenicline and bupropion are contraindicated
COPD
-What lifestyle help is offered? (2)
-what vaccinations are offered?
General management
>smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion annual influenza vaccination one-off pneumococcal vaccination pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)
what is the first line treatment of COPD? what is the next step determined by?
Bronchodilator therapy
a short-acting beta2-agonist (SABA) i.e. salbutamol or short-acting muscarinic antagonist (SAMA) i.e. ipratropium is first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by whether the patient has 'asthmatic features/features suggesting steroid responsiveness'
How do you determine whether a patient had asthmatic/steroid responsive features? (4)
There are a number of criteria NICE suggest to determine whether a patient has asthmatic/steroid responsive features:
any previous, secure diagnosis of asthma or of atopy a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up substantial variation in FEV1 over time (at least 400 ml) substantial diurnal variation in peak expiratory flow (at least 20%)
What is the second line therapy for COPD if there is no asthmatic features?
No asthmatic features/features suggesting steroid responsiveness
add a long-acting beta2-agonist (LABA) i.e. salmeterol + long-acting muscarinic antagonist (LAMA) e.g. tioptropium
if already taking a SAMA, discontinue and switch to a SABA
What is the second line therapy for COPD if there is asthmatic features?
Asthmatic features/features suggesting steroid responsiveness
LABA + inhaled corticosteroid (ICS)
if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS
if already taking a SAMA, discontinue and switch to a SABA
NICE recommend the use of combined inhalers where possible
When is oral theophylline used in COPD?
Oral theophylline
NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy the dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed
When are oral prophylactic antibiotics used for COPD? What are prerequisites? what tests are required before prescribing?
Oral prophylactic antibiotic therapy
azithromycin prophylaxis is recommended in select patients patients should not smoke, have optimised standard treatments and continue to have exacerbations other prerequisites include a CT thorax (to exclude bronchiectasis) and sputum culture (to exclude atypical infections and tuberculosis) LFTs and an ECG to exclude QT prolongation should also be done as azithromycin can prolong the QT interval
When are mucolytics considered for COPD?
Mucolytics
should be 'considered' in patients with a chronic productive cough and continued if symptoms improve
When are oral PDE-4 inhibitors used in COPD?
Phosphodiesterase-4 (PDE-4) inhibitors NICE
oral PDE-4 inhibitors such as roflumilast reduce the risk of COPD exacerbations in patients with severe COPD and a history of frequent COPD exacerbations
NICE recommend if:
the disease is severe, defined as a forced expiratory volume in 1 second (FEV1) after a bronchodilator of less than 50% of predicted normal, and
the person has had 2 or more exacerbations in the previous 12 months despite triple inhaled therapy with a long-acting muscarinic antagonist, a long-acting beta-2 agonist and an inhaled corticosteroid
What are the features of cor pulmonale? what treatments can be used?
Cor pulmonale
features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2 use a loop diuretic for oedema, consider long-term oxygen therapy ACE-inhibitors, calcium channel blockers and alpha blockers are not recommended by NICE
What 3 factors may improve survival in COPD?
Factors which may improve survival in patients with stable COPD
smoking cessation - the single most important intervention in patients who are still smoking long term oxygen therapy in patients who fit criteria lung volume reduction surgery in selected patients
What 3 bacteria are the most common in COPD exacerbations? what viral causes is common?
bacteria
Haemophilus influenzae (most common cause)
Streptococcus pneumoniae
Moraxella catarrhalis
respiratory viruses
account for around 30% of exacerbations
human rhinovirus is the most important pathogen
What is the treatment of exac CCOPD?
NICE guidelines from 2010 recommend the following:
increase the frequency of bronchodilator use and consider giving via a nebuliser give prednisolone 30 mg daily for 5 days it is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE do not support this approach. They recommend giving oral antibiotics 'if sputum is purulent or there are clinical signs of pneumonia' the BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.
What oxygen therapy do you give oxygen therapy?
Oxygen therapy
COPD patients are at risk of hypercapnia - therefore an initial oxygen saturation target of 88-92% should be used prior to the availability of blood gases, use a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis adjust target range to 94-98% if the pCO2 is normal
What nebs/steroids or additional therapy would you give for acute COPD?
Nebulised bronchodilator
beta adrenergic agonist: e.g. salbutamol muscarinic antagonists: e.g. ipratropium
Steroid therapy as above
IV hydrocortisone may sometimes be considered instead of oral prednisolone
IV theophylline
may be considered for patients not responding to nebulised bronchodilators
when is NIV used for COPD patients? When is BiPaP used?
Patients with COPD are prone to develop type 2 respiratory failure. If this develops then non-invasive ventilation may be used
typically used for COPD with respiratory acidosis pH 7.25-7.35
the BTS guidelines state that NIV can be used in patients who are more acidotic (i.e. pH < 7.25) but that a greater degree of monitoring is required (e.g. HDU) and a lower threshold for intubation and ventilation should be used
bilevel positive airway pressure (BiPaP) is typically used with initial settings:
Expiratory Positive Airway Pressure (EPAP): 4-5 cm H2O
Inspiratory Positive Airway Pressure (IPAP): RCP advocate 10 cm H20 whilst BTS suggest 12-15 cm H2O
What is A1AT caused by?
Alpha-1 antitrypsin (A1AT) deficiency is a common inherited condition caused by a lack of a protease inhibitor (Pi) normally produced by the liver. The role of A1AT is to protect cells from enzymes such as neutrophil elastase. It classically causes emphysema (i.e. chronic obstructive pulmonary disease) in patients who are young and non-smokers.
Where is A1AT gene located? how is this inherited?
Genetics
located on chromosome 14 inherited in an autosomal recessive / co-dominant fashion*
How are alleles for A1AT classifed?
alleles classified by their electrophoretic mobility - M for normal, S for slow, and Z for very slow
normal: PiMM
heterozygous: PiMZ
evidence base is conflicting re: risk of emphsema
however, if non-smoker low risk of developing emphsema but may pass on A1AT gene to children
homozygous PiSS: 50% normal A1AT levels
homozygous PiZZ: 10% normal A1AT levels
Features A1AT, what genotype do most patients who present have? what is seen in the lungs? what is seen in the liver?
Features
patients who manifest disease usually have PiZZ genotype lungs: panacinar emphysema, most marked in lower lobes liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children
What are the investigations for A1AT?
Investigations
A1AT concentrations spirometry: obstructive picture
What is the management of A1AT?
Management
no smoking supportive: bronchodilators, physiotherapy intravenous alpha1-antitrypsin protein concentrates surgery: lung volume reduction surgery, lung transplantation
What are some causes of COPD?
Smoking!
Alpha-1 antitrypsin deficiency
Other causes
cadmium (used in smelting) coal cotton cement grain
what are the investigations for suspected COPD?
The following investigations are recommended in patients with suspected COPD:
post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70%
chest x-ray
hyperinflation
bullae: if large, may sometimes mimic a pneumothorax
flat hemidiaphragm
also important to exclude lung cancer
full blood count: exclude secondary polycythaemia
body mass index (BMI) calculation
HOw is COPD classified?
Post-bronchodilator FEV1/FVC FEV1 (of predicted) Severity
< 0.7 > 80% Stage 1 - Mild**
< 0.7 50-79% Stage 2 - Moderate
< 0.7 30-49% Stage 3 - Severe
< 0.7 < 30% Stage 4 - Very severe
Which patients should be assessed for LTOT?
Assess patients if any of the following:
very severe airflow obstruction (FEV1 < 30% predicted). Assessment should be 'considered' for patients with severe airflow obstruction (FEV1 30-49% predicted) cyanosis polycythaemia peripheral oedema raised jugular venous pressure oxygen saturations less than or equal to 92% on room air
How is assessment for LTOT done? who is offered LTOT?
Assessment is done by measuring arterial blood gases on 2 occasions at least 3 weeks apart in patients with stable COPD on optimal management.
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia peripheral oedema pulmonary hypertension
What is seen in moderate asthma exac.
-PEFR
-Speech
-RR
-Pulse
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
What is seen in severe asthma exac.
-PEFR
-Speech
-RR
-Pulse
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
What is seen in lifethreatening asthma exac?
PEFR
O2 sats
HR
Chest exam
PEFR < 33% best or predicted
Oxygen sats < 92%
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
n addition, a normal pCO2 in an acute asthma attack indicates exhaustion and should, therefore, be classified as life-threatening.
when is a chest xr indicated in asthma exac?
a chest x-ray is not routinely recommended, unless:
life-threatening asthma suspected pneumothorax failure to respond to treatment
who is offered admission for asthma exac?
admission
all patients with life-threatening should be admitted in hospital patients with features of severe acute asthma should also be admitted if they fail to respond to initial treatment. other admission criteria include a previous near-fatal asthma attack, pregnancy, an attack occurring despite already using oral corticosteroid and presentation at night
How is oxygen therapy managed in asthma exac?
oxygen
if patients are hypoxaemic, it is important to start them on supplemental oxygen therapy if patients are acutely unwell they should be started on 15L of supplemental via a non-rebreathe mask, which can then be titrated down to a flow rate where they are able to maintain a SpO₂ 94-98%.
SABA therapy in asthma
-what is given?
-how is this given?
bronchodilation with short-acting beta₂-agonists (SABA)
high-dose inhaled SABA e.g. salbutamol, terbutaline in patients without features of life-threatening or near-fatal asthma, this can be given by a standard pressurised metered-dose inhaler (pMDI) or by an oxygen-driven nebulizer in patients with features of a life-threatening exacerbation of asthma, nebulised SABA is recommended
What steroids are given in asthma exac?
corticosteroid
all patients should be given 40-50mg of prednisolone orally (PO) daily, which should be continued for at least five days or until the patient recovers from the attack during this time, patients should continue their normal medication routine including inhaled corticosteroids.
When and what SAMA is given in asthma exac?
ipratropium bromide: in patients with severe or life-threatening asthma, or in patients who have not responded to beta₂-agonist and corticosteroid treatment, nebulised ipratropium bromide, a short-acting muscarinic antagonist
When is iv magnesium / iv aminophylline given in asthma exac?
IV magnesium sulphate
the BTS notes that the evidence base is mixed for this treatment that is now commonly given for severe/life-threatening asthma
IV aminophylline may be considered following consultation with senior medical staff
patients who fail to respond require senior critical care support and should be treated in an appropriate ITU/HDU setting. Treatment options include:
intubation and ventilation extracorporeal membrane oxygenation (ECMO)
What is the criteria for discharge of patients after acute exac asthma?
Criteria for discharge
been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours inhaler technique checked and recorded PEF >75% of best or predicted
who should get objective tests for asthma diagnosis?
All patients >= 5 years should have objective tests. Once a child with suspected asthma reaches the age of 5 years objective tests should be performed to confirm the diagnosis
What objective tests are used in diagnosing asthma in patients 17 years or older?
Patients >= 17 years
patients should be asked if their symptoms are better on days away from work/during holidays. If so, patients should be referred to a specialist as possible occupational asthma all patients should have spirometry with a bronchodilator reversibility (BDR) test all patients should have a FeNO test
What objective tests are used in the diagnosis of asthma in children between 5-16 years? what if they are younger than 5?
Children 5-16 years
all children should have spirometry with a bronchodilator reversibility (BDR) test a FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative bronchodilator reversibility (BDR) test
Patients < 5 years
- diagnosis should be made on clinical judgement
When is a FeNO test considered positive?
FeNO
in adults level of >= 40 parts per billion (ppb) is considered positive in children a level of >= 35 parts per billion (ppb) is considered positive
When is spirometry considered obstructive?
Spirometry
FEV1/FVC ratio less than 70% (or below the lower limit of normal if this value is available) is considered obstructive
When is reversibility testing considered positive?
Reversibility testing
in adults, a positive test is indicated by an improvement in FEV1 of 12% or more and increase in volume of 200 ml or more in children, a positive test is indicated by an improvement in FEV1 of 12% or more
What is the first line treatment of asthma?
1
Newly-diagnosed asthma Short-acting beta agonist (SABA)
2
Not controlled on previous step
OR
Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking SABA + low-dose inhaled corticosteroid (ICS)
What is the third line treatment of asthma?
3 SABA + low-dose ICS + leukotriene receptor antagonist (LTRA)
What is the fourth line treatment asthma?
SABA + low-dose ICS + long-acting beta agonist (LABA)
Continue LTRA depending on patient’s response to LTRA
What is the fifth line treatment of asthma?
SABA +/- LTRA
Switch ICS/LABA for a maintenance and reliever therapy (MART), that includes a low-dose ICS
What is the 6th line therapy of asthma?
SABA +/- LTRA + medium-dose ICS MART
OR consider changing back to a fixed-dose of a moderate-dose ICS and a separate LABA
What is the 7th line therapy in asthma?
SABA +/- LTRA + one of the following options:
increase ICS to high-dose (only as part of a fixed-dose regime, not as a MART) a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline) seeking advice from a healthcare professional with expertise in asthma
What is maintenance and reliever therapy?
Maintenance and reliever therapy (MART)
a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol)
what is a low / medium / high dose ICS?
Frustratingly, the definitions of what constitutes a low, moderate or high-dose ICS have also changed. For adults:
<= 400 micrograms budesonide or equivalent = low dose 400 micrograms - 800 micrograms budesonide or equivalent = moderate dose > 800 micrograms budesonide or equivalent= high dose.
