Respiratory Flashcards
COPD general management?
- Smoking cessation = NRT, varenicline or bupropion-often in combo with behavioural support.
- Annual influenza vaccination
- One-off pneumococcal vaccination
- Pulmonary rehab for functionally disabled (MRC >=3)
COPD medication management?
- SABA/SAMA 1st line
- Next determine if asthmatic features/steroid responsiveness
Asthmatic/steroid responsive features?
- Any previous, confirmed Dx of asthma or atopy (eczema allergic rhinitis)
- Raised eosinophils
- Substantial FEV1 variation (>400ml): A significant improvement in Forced Expiratory Volume in 1 second (FEV1) following bronchodilator therapy (e.g., >400 mL increase) suggests reversible airway obstruction typical of asthma.
- Substantial diurnal variation in PEF (at least 20%)
(Don’t recommend formal reversibility testing): implies that current guidelines may discourage the routine use of formal bronchodilator reversibility testing in certain populations, as other clinical and diagnostic criteria (e.g., eosinophils, FEV1, PEF variability) may suffice to establish the diagnosis.
No asthmatic features/steroid responsiveness?
- LABA + ICS
- Triple therapy = LAMA + LABA + ICS
Oral theophylline mushkies?
- Only after trials of SA and LAs or to people who cannot use inhaled therapy
- Dose reduced if macrolide or fluoroquinolone Abx co-prescribed
COPD oral prophylactic antibiotic therapy mushkies?
- Azithromycin in select patients
- Not smoke, optimised Rx, continue to have exacerbations
- Need CT thorax to exclude bronchiectasis ad sputum culture to rule out atypicals + TB
- LFT and ECG as azithromycin can prolong QT interval
COPD and mucolytics?
Considered in pts with chronic productive cough and continued if symptoms improve
Cor pulmonale mushkies?
- Features = peripheral oedema, raised JVP, systolic parasternal heave, loud P2
- Use loop diuretic for oedema, consider LTOT
- ACEi, CCB and alpha blocker not recommended
Factors which improve survival in stable COPD?
- Smoking cessation
- LTOT if fit criteria
- Lung volume reduction surgery in some
Acute bronchitis definition?
Self-limiting chest infection as a result of inflammation of the trachea and major bronchi and is therefore associated with oedematous large airways and the production of sputum. The disease course usually resolves before 3 weeks, however, 25% of patients will still have a cough beyond this time. Although there is uncertainty in the literature regarding the exact proportion of pathogens giving rise to acute bronchitis, it is accepted that viral infection is the leading cause. Around 80% of episodes occur in autumn or winter.
Acute bronchitis presentation?
- Cough = productive/non-productive
- Sore throat
- Rhinorrhoea
- Wheeze
- Some = low grade fever
Differentiating acute bronchitis from pneumonia?
- Hx = sputum, wheeze and breathlessness may be absent in bronchitis but is usually present in pneumonia
- Ex = No focal chest signs in acute bronchitis other than wheeze
Acute bronchitis Dx?
Clinical (but CRP also helpful)
Acute bronchitis Rx?
- Usually conservative
- Abx if = systemically very unwell, pre-existing co-morbidities, CRP 20-100 (delayed prescription) or CRP >100
Acute bronchitis Abx?
Doxycycline 1st line (Amoxicillin 2nd line)
Smoking cessation general points?
- NRT or Varenicline or Bupropion
- Target stop date –> 2 more weeks of NRT, 3-4 more weeks of V/B prescription given –> further prescription only given to those who have demonstrated their quit attempt is continuing
- If unsuccessful do not offer repeat prescription within 6 months unless special circumstances
- Do not offer combination of them
NRT s/e?
- N&V
- Headaches
- Flu-like symptoms
NRT for high level of dependence/have found single forms of NRT inadequate in the past?
Combination of nicotine patch and another form of NRT
Varenicline MOA?
Nicotinic receptor partial agonist
Varenicline mushkies?
- Should be started 1 week before the patients target date to stop
- Recommended course of Rx is 12 weeks
- More effective than bupropion
- Nausea is most common s/e, others = headache, insomnia, abnormal dreams
- Caution in pts with Hx of depression or self harm
- C/I in pregnancy and breastfeeding
Bupropion MOA?
Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
Bupropion mushkies?
- Start 1-2 weeks before target date to stop
- 1/1000 risk of seizures
- C/I in epilepsy, pregnancy and breast feeding
- Having an eating disorder is a relative contraindication
Pregnant women referral for smoking cessation crieteria?
- All women who smoke
- Stopped smoking in last 2 weeks
- CO reading of 7ppm or above (all pregnant women should be tested using carbon monoxide detectors)
Pregnant women smoking cessation interventions?
- CBT, motivational interviewing, structured self help and support
- NRT can be used if above measures fail, should remove patches before bed
- Varenicline and Bupropion are contraindicated