Respiratory Flashcards
Features severe asthma exacerbation
Peak flow 33-50% predicted
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RR>25
HR>110
Sats>92%
Features life threatening asthma exacerbation
Peak flow <33% predicted
Sats<92%
Silent chest, cyanosis, or poor respiratory effort
Arrhythmia or hypotension
Exhaustion, altered consciousness
Risk factors severe asthma
Prev ICU/admissions
3+ classes of medication
High use SABA?3x per week
Non compliance/psychosis
Smoking
Management acute exacerbation asthma
O2, salbutamol nebs, admit
If mild:
5-10 puffs salbutamol using tidal breathing + aerochamber
prednisolone 40mg OD 5 days
+/- amoxicillin 500mg TDS 5 days
Quadruple inhaler ICS dose until recovered
How do you diagnose asthma in adults with spirometry?
If pre BD spirometry shows obstruction (FEV1/FVC ratio <0.7) perform reversibility with SABA
12% (and >200mls) increase in FEV1
How do you diagnose asthma in adults with peak flow diary?
Complete 2-4 week peak flow diary
Evidence of 20% peak flow variability supports asthma diagnosis.
Once on treatment with ICS expect peak flow to increase and variability reduce
How do you diagnose asthma in adults with FeNO?
FeNO >40 consistent with
asthma (steroid naive)
Triggers for asthma exacerbation
Allergens- hayfever, rhinitis
Exercise
Cold air
Medications, e.g. aspirin and beta blockers
Occupational
Viral infections
6 questions to assess asthma control
Nocturnal disturbance- woken with coughing and wheezing?
Impact on ADLs
Cough, wheeze, chest tightness, breathlessness, during the day?
Reliever therapy use
Concordance with preventer use
Use of PO corticosteroids
1st step asthma management in adults
ICS+immediate acting LABA as MART regime
Symbicort Turbohaler 200/6
1 dose PRN up to 8 doses/day
Step 2 asthma management adults
MART regime:
Symbicort Turbohaler
200/6, 1 puff BD
Max doses/day: 12
Fostair NEXThaler
100/6, 1 puff BD
Max doses/day: 8
Trial montelukast 10mg at night 6 weeks
Step 3 asthma management adults
MART regime:
Symbicort Turbohaler
200/6, 2 puff BD
Max doses/day: 12
Fostair NEXThaler
100/6 2 puffs BD
Max doses/day: 8
Trial montelukast 10mg at night 6 weeks
Step 4 asthma management in adults
Continue MART regime + LAMA
Add on Spiriva Respimat
2.5mcg 2 doses OD
Step 5 asthma management adults
Referral ?biologics
Symbicort Turbohaler
400/12, 2 doses BD + spiriva respimat 2.5mcg 2 doses OD
When would you refer adults with asthma?
-Diagnostic uncertainty
* Complex comorbidity
* Suspected occupational asthma
* Poor control following treatment at Step 4
* ≥2 courses of oral steroids/ year
Step 1 children with asthma
Age<6
Clenil 100mcg 1 dose BD + SABA PRN (with spacer)
Age 6-11
Budesonide100mcg Turbohaler 1 dose BD + SABA PRN (Terbutaline 500mcg Turbohaler)
Age>12
Budesonide 100mcg Turbohaler 1-2 doses BD + SABA PRN (Terbutaline 500mcg Turbohaler)
Step 2 children with asthma
Age<6
6 week trial montelukast 4mg ON
Age 6-11
6 week trial montelukast 5mg ON
Age>12
6 week trial montelukast 5mg ON or 10mg if age>15
Step 3 children with asthma
Age<6 refer, mod dose ICS + SABA Clenil modulite 100 mcg
2 doses BD via spacer
Age 6-11
ICS/LABA plus PRN SABA
Symbicort 100/6 Turbohaler 1 dose BD
Age>12
Adult MART Symbicort 100/6 Turbohaler 1 dose BD
(max 8 doses/24 hrs) + emergency SABA
Step 4 children with asthma
Age<6 Refer
Age 6-11
Refer
ICS/LABA Mod Symbicort 100/6
Turbohaler 2 doses BD
Age>12
MART Symbicort 200/6
Turbohaler 1-2 doses BD
(max 8 doses/24 hrs)
Diagnosis asthma in children
Peak flow diary (1-2 week) age 5-17
Skin prick test, Allergen-specific IgE, Blood eosinophils age 3-17
Spirometry with reversibly testing age ≥ 12
Fractional exhaled Nitric Oxide (FeNO) age ≥ 12
If no objective evidence but strong clinical suspicion asthma in children?
Perform treatment trial
Including in children age 3-5 years
with “episodic wheeze”:
* Commence ICS for 8 weeks: Clenil
modulite 200mcg BD
* Review response at 8 weeks
No response
- Discontinue treatment
- Consider alternative diagnosis
Positive response
- Discontinue treatment
- If symptoms recur, restart low dose
ICS as maintenance therapy
How to differentiate asthma from COPD
Asthma: response to SABA>200 mL and >12% improvement of FEV1.
Completely reversible airway obstruction do not have COPD
If a patient with a high clinical suspicion of asthma, consider a trial of 40 mg of prednisolone OD for 2 weeks, then repeat spirometry.
Features bronchiectasis
Permanent abnormal dilatation of the airways
Impaired mucociliary clearance
Excessive inflammation of airways, mucus production, and bacterial colonisation.
chronic productive cough.
unexplained haemoptysis
Exertional dyspnoea
Recurrent chest infections
Signs of over-inflation of chest
Finger clubbing (now rare)
Pseudomonas on sputum culture
Underlying causes bronchiectasis
Post TB, Measles, pertussis, pneumonia
Cystic fibrosis
COPD
IBD, RA
Diagnosis of bronchiectasis
CXR to exclude other causes
Spirometry
Sputum
High resolution CT when well
Referral criteria bronchiectasis
first isolate of Pseudomonas aeruginosa, or atypical mycobacteria.
persistent haemoptysis.
spirometry shows moderate to severe airflow obstruction or declining lung function over time.
recurrent exacerbations (>3 per year)
known immune deficiency, IBD, RA, or allergic bronchopulmonary aspergillosis (ABPA).
considering long‑term antibiotic therapy.
CRB-65
Confusion
RR>30
BP: Systolic <90 or Diastolic <60
Aged 65 years or older
If >1 then admit
Ix for LRTI
Treat empirically/based on prev sputum for 72 hrs
If no improvement: CXR, bloods, sputum culture, consider admission
Features COPD
airflow obstruction on spirometry, and
a history of smoking, or exposure to other noxious agents.
cough up phlegm or mucus most days.
lose breath more easily than others their age.
suffer recurrent episodes of winter chest infections.
COPD findings on spirometry
Reduced FEV1 (<80% predicted)
Reduced FVC (but to a lesser extent than FEV1)
FEV1/FVC ratio reduced (<0.7)
Mild – FEV1 more than 80% predicted
Moderate – FEV1 50 to 80% predicted
Severe – FEV1 30 to 50% predicted
Very severe – FEV1 less than 30% predicted
Non inhaler management COPD
Vaccination (flu, COVID, pnuemococcal)
Exercise + pulmonary rehab
Smoking cessation
Referral for oxygen assessment if SpO2 is <93% and not smoking
Mucolytic – carbocisteine 750 mg twice a day.
COPD management
Phenotype 1- Dyspnoea with less than 2 exacerbations per year
LABA + LAMA (Anoro Ellipta 55/22 T OD)
Phenotype 2- Two or more exacerbations per year
Prescribe Triple therapy (trelegy OD, trimbow BD)
Phenotype 3- asthma overlap Significant symptomatic or lung function response to steroids. Blood eosinophil counts >0.3
MART plus LAMA (symbicort turbohaler 200/6 TT BD + spiriva respimat TT OD)
COPD exacerbation management
SABA PRN
Prednisolone (30mg OD 5 days)
Abx if increased sputum purulence, volume + breathlessness
Referral criteria COPD
diagnostic uncertainty.
patient younger than 40 years, or younger than 55 years with severe disease.
>2 exacerbations a year.
considering pulmonary rehabilitation.
considering nebulised therapy
Differential diagnoses for cough
Asthma
Gastro‑oesophageal reflux –worse lying down to sleep, after meals, dysphonia.
Postnasal drip
Malignancy – weight loss, dysphonia, dysphagia
ACEi
Cardiac – dyspnoea, palpitations, ankle swelling.
Cough>8 weeks
USC referral if unexplained haemoptysis or weight loss/hoarseness
CXR
Consider sputum culture x3 (MC+S, acid‑fast bacilli, and fungi)
Consider spirometry
Treat underlying cause (eg trial nasal steroid, asthma treatment, PPI)
Causes haemoptysis
lung cancer.
TB
bronchiectasis
pulmonary abscess.
Minor haemoptysis:
LRTI
PE
anticoagulant or antiplatelet treatment.
CCF/ mitral stenosis – pink frothy
Risk factors for TB
Close contacts active TB
Migrants
Age<5/Elderly
Immunosuppressed, HIV, diabetes
Misusing drugs or alcohol
Homeless or in overcrowded housing
Prison leavers
ILD causes
Idiopathic
RA/Sarcoid
Asbestosis/silica
Chemo, nitrofurantoin
Features OSA
STOP BANG
Snore loudly
Tired/fatigued
Stopping breathing during sleep
HTN
BMI>35
Age>50
Neck circumference>40cm
Male
