Respiratory Flashcards
According to NICE guidelines, what recommendations should be given to those with COPD?
- Smoking cessation advice (NRT, varnicline, bupropion)
- Annual influenza vaccination
- One off pneumococcal vaccination
- Pulmonary rehab to those with MRC grade 3 and above
What is the 1st line treatment for COPD?
Short acting beta2 agonist (eg. salbutamol) or short acting muscarinic antagonist (eg. ipratropium or oxatroprium bromide)
If a pt remains symptomatic with short acting bronchodilators, what is the next step in management?
First, determine whether the patient has ‘asthmatic features/features suggesting steroid responsiveness’ - eg. previous dx asthma/atopy, eosinophilia, substantial (>400ml) variation in FEV1 over time, substantial diurnal variation in peak expiratory flow (>20%)
NO asthmatic features:
Add long-acting beta2 agonist (eg. tiotropium) and long actinic muscarinic antagonist (eg. -rol)
If taking SMA, discontinue and switch to SABA
Asthmatic features:
LABA + ICS
NICE recommend the use of combined inhalers where possible
If a pt with asthmatic features of COPD remains breathless on SABA + LABA + ICS, what is the next step in treatment?
Triple therapy ie. LAMA + LABA + ICS
(if taking SAMA, discontinue and switch to SABA)
If a pt remains symptomatic after trials of short and long acting bronchodilators, or cannot use inhaled therapy, what treatment is recommended in COPD?
Theophylline
In which circumstances should a reduced dose of theophylline be prescribed?
If a macrolide or fluoroquinolone is co-prescribed
What oral prophylactic antibiotic therapy is indicated in select COPD patients? What are the prerequisites for treatment?
Azithromycin
Its must not smoke, have optimised standard treatments, and continue to have exacerbations
Must have CT thorax to exclude bronchiectasis and sputum culture to exclude atypical infections and TB
Must have LDT and ECG to exclude QT prolongation (azithromycin can prolong QT)
When should mucolytics be prescribed in COPD?
Patient with a chronic productive cough - only continue if symptoms improve
When should oral phosphodiesterase-4 (PDE-4) inhibitors be used in COPD?
Patients must have:
- Severe COPD (FEB1 less than 50% of predicted normal after bronchodilator therapy)
- History of frequent COPD exacerbations (2 or more in last 12 months despite triple therapy)
What is an example of a PDE-4 inhibitor?
Roflumilast
What is cor pulmonale and how is it treated?
Cor pulmonale is abnormal right sided hypertrophy due to lung disease. Features include peripheral oedema, raised JVP, systolic parasternal heave and loud P2
Treatments include:
- Loop diuretic for oedema (eg furosemide, bumetanide)
- LTOT
Which treatments are not recommended in cor pulmonale that may be used in CCF?
ACEis, CCBs, alpha blockers
Which factors improve survival in patients with stable COPD?
Smoking cessation (most IMPORTANT)
LTOT (if fit criteria)
Lung volumer reduction surgery
What is CURB65?
Confusion (AMT <= 8)
Urea (>=7)
RR (>= 30)
BP (systolic <=90, diastolic <=60)
Age (>=65)
0/1 - low risk, treat at home
2 - intermediate risk, consider hospital
3 or more - high risk, urgent hospital admission
What are NICEs recommendation on abx treatment for pneumonia, when considering CRP?
CRP <20 - no routine abx
CRP 20-100 - consider or offer delayed abx
CRP >100 - abx
What investigations do NICE recommend for pneumonia?
CXR and CRP
Intermiediate/high risk patients should have blood and sputum cultures, pneumococal and legionella urinary antigens
What is 1st line therapy for low severity CAP?
Amoxicillin - 5d course
Penicillin allergy - macrolide (eg. clari/erythromycin) or tetracycline (eg. doxy)
What is 1st line therapy for moderate or high severity CAP?
7-10d course dual antibiotic therapy with amoxicillin + macrolide
Consider co-amoxiclav/ceftriazxone/piptaz + clarithromycin in high severity
NICE would recommend that patients are not routinely discharged if they have had 2 or more of which findings in the last 24h?
- Temperature higher than 37.5°C
- Respiratory rate 24 breaths per minute or more
- Heart rate over 100 beats per minute
- Systolic blood pressure 90 mmHg or less
oxygen saturation under 90% on room air - Abnormal mental status
- Inability to eat without assistance.
How long should the following symptoms resolve after pneumonia?
a) fever
b) chest pain/sputum reduced
c) cough and SOB reduced
d) most symptoms except fatigue
e) back to normal
a) 1 week
b) 4 weeks
c) 6 weeks
d) 3 months
e) 6 months
What investigation should be done for all cases of pneumonia 6 weeks after clinical resolution?
CXR - if abnormal needs in detail imaging
What are the most common causes of an anterior mediastinal mass?
4 Ts - teratoma, terrible lymphadenopathy, thymic mass (thymoma/thymoid cancer) and thyroid mass
Why is a CT chest done in myasthenia graves?
To look for a thymoma - removal of thymoma may improve condition and helps prevent malignant transformation
What is the mediastinum?
The region between the pulmonary cavities, extending from the thoracic inlet superiorly to the diaphragm inferiorly.
Composed of 4 regions - superior/middle/posterior/anterior
The mediastinum contains the heart, great vessels, teaches and many essential nerves
What is the role of the thymus gland and where is it located?
Makes white blood cells ( T lymphocytes)
Located in the mediastinum
What are the most common infective causes of COPD exacerbations ?
Bacteria:
Haemophilus influenzae
Streptococcus pneumoniae
Moraxella catarrhalis
Virus (30%):
Rhinovirus
When should abx be given in an exacerbation of COPD?
Purulent sputum
Clinical features of pneumonia
How is an ECOPD managed?
- Increase frequency of bronchodilator +/- give via a nebuliser
- 5d course prednisolone 30mg
- Abx only if purulent sputum/clinical features of pneumonia (amoxicillin/clarithromycin/doxycycline)
What are the criteria for admission with an ECOPD?
- Severe SOB
- Acute confusion
- Cyanosis
- Sats<90%
- Social reasons
- Significant comorbidity (eg. cardiac disease or insulin dependent diabetes)
Prior to ABG analysis, what initial oxygen treatment should you give to patients with a COPD exacerbation ?
28% venturi mask at 4L/min - aim sats 88-92% (adjust to 94-98% if pC02 is normal)
How is a severe exacerbation of COPD managed in hospital?
- Oxygen therapy
- Nebulised bronchodilator (salbutamol, ipratropium)
- Steroid therapy (oral pred or IV hydrocortisone)
- IV theophylline (if not responding to bronchodilators)
May need NIV if:
- Resp acidosis (not necessarily T2RF)
- T2RF
Start biPaP with initial EPAP 4-5cm H20 and initial IPAP 10-25cm H20
How does CPAP work and when is it used?
Creates positive pressure by increasing gas exchange by recruitment of alveoli (uses PEEP and high flow)
Used in T1RF in:
- Cardiogenic pulmonary oedema
- Congestive heart failure
- Pneumonia
- Sleep apnoea
NB CPAP is not NIV!!!!!!
How does NIV work and when is it used?
Inspiratory push behind breath + PEEP to increase tidal volume and decrease C02
Used in T2RF:
- COPD
- Pneumonia
- Post extubation and to prevent intubation
- Cardiogenic pulmonary oedema
How is asthma diagnosed?
CLINICAL diagnosis - more than one of wheeze, SOB, chest tightness, cough + variable airflow obstruction (worse at night and early morning)
How do you manage a new diagnosis of high probability asthma?
Commence SABA ?check
Corroborate with lung function tests
If poor response to treatment - check inhaler technique and adherence, arrange further tests and consider alternative diagnoses
How do you manage a case of intermediate probability asthma?
Spirometry with bronchodilator reversibility +/- monitored initiation of treatment
+/- challenge tests, measure FeNO (eosinophils)
If unable to perform spirometry, consider watchful waiting if asymptomatic, or start trial
Describe some primary prevention initiatives to reduce asthma occurrence
Breast feeding
Weight loss in obese children
Smoking cessation (parents)
Allergen avoidance is NOT recommended
Describe some secondary prevention initiatives to prevent asthma xacerbations
Weight loss in obese children
Smoking cessation
Breathing exercise programmes
Dust mite reduction is NOT recommended
How do you define complete control of asthma?
- No daytime symptoms
- No nighttime awakening
- No need for rescue medication
- No asthma attacks
- No limitations of activity
- Normal lung function (>80% predicted/best)
- Minimal side effects from medications
What is the 1st step in pharmacological asthma treatment?
Prescribe an inhaled SABA as short term deliver therapy
What is the 2nd step in pharmacological asthma treatment?
SABA + ICS (give twice daily except for ciclesonide which is given OD)
NB - Smokers may need higher doses
What is the 3rd step in pharmacological asthma treatment?
SABA + ICS + LRTA (give LRTA before increasing ICS)
Note LRTA is an oral therapy taken at night so if you think unlikely to be adherent give LABA instead
What is the 4th step in pharmacological asthma treatment?
Increase dose of ICS or consider adding LABA
What is the 5th step in pharmacological asthma treatment?
Refer to specialist care where they may start theophyllines/sodium cromoglicate
How often should asthma patients be reviewed?
3 monthly to consider reducing treatment
ICS - reduce by 25-50% at a time
What device is preferred for delivery of medication in asthma?
If in doubt, pMDI +/- spacer in children
Face mask required until child can breathe reproducibly using spacer
What are the features of a moderate acute asthma attack?
Increasing symptoms
PEF>50-75% best or predicted
No features of acute severe asthma
What are the features of an acute severe asthma attack?
PEF 33-50% best or predicted
RR >= 25 (>40 in 1-5y, >30 in over 5 yrs)
HR >= 110 (>140 in 1-5y, >125 in over 5 yrs)
Inability to complete sentences
What are the features of a life threatening asthma attack?
PEF <33%
sP02 <92%
pa02 <8 kpa
Altered consciousness
Exhaustion
Arrhythmia
Hypotension
Cyanosis
Silent chest
Poor respiratory effort
How is an acute asthma attack managed in adults?
- Oxygen
- Beta agonist bronchodilators (high dose >nebs/IV)
- Steroid therapy (prednisolone 40-50mg daily until recovered)
- Ipratropium bromide nebs (if severe/life threatening or poor response to beta agonists)
Consider single dose IV Mg (1.2-2g over 20 minutes) if severe or poor response to above therapies
Consider IV aminophylline/salbutamol if still refractory (caution and may require ICU admission for cardiac monitoring)
What is the follow up for adults after an acute severe asthma attack?
Inform primary care physician within 24h
Respiratory specialist for at least 1 year
How is an acute asthma attack managed in children OOH?
Increase SABA by giving one puff every 30-60s up to a maximum of 10
If not controlled - seek urgent medication attention
If severe symptoms, given additional doses of SABA whilst awaiting ambulance
Nebulised salbutamol to be given in ambulance if severe
How is an acute asthma attack managed in children?
- Beta agonist treatment + oral steroids is 1st line
- Give nebuliser ipratropium bromide if refractory
- Consider adding Mg to each nebuliser if sp02 <92%
- Consider IV salbutamol if treatment refractory
- Consider aminophylline if severe/lifre threatening
- Consider IV Mg if treatment refractory
Oral steroids - 10mg pred if child under 2 years old, 20mg pred if child 2-5 years old, 30-40mg pred if child >5 years old
If on maintenance oral steroids can have a max of 60mg OD
Treatment for 3 days is usually sufficient