Respiratory Flashcards
Asthma treatment
1st- Sabutamol (SABA)
2nd - SABA + low dose ICS
3rd - SABA + low dose ICS + Luekotriene receptor antagonist - lukast
4th - SABA + low dose ICS + LABA (Salmeterol Formoterol)
COPD treatment
if steroid responsive features (atophy, asthma history, high blood eosinophil count, variation in PEFR or FEV1) present - LABA + ICS
If absent - LABA + LAMA (glycopyrrolate, umeclidinium, , tiotropium)
Mechanism of action and SE of smoking cessation drugs
Nicotine SE
Varenicline
Bupropion
Nicotine - N &V, headache, flu-like symptoms
Varenicline - nicotine receptor partial agonist -CI in pregnancy, caution in depression, SE nausea
Bupropion - Norepinephrine and dopamine reuptake inhibitor and nicotinic antagonist, SE -small risk of seizure
features of severe acute asthma
PEF 33–50% best or predicted
Respiratory rate ≥25/min
Heart rate ≥110/min
Inability to complete sentences in one breath
As per NICE, when to give antibiotic to COPD exacerbation
‘if sputum is purulent or there are clinical signs of pneumonia’
Criteria for LTOT in COPD
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
Causes of clubbing
Cardiac causes
cyanotic congenital heart disease (Fallot’s, TGA)
bacterial endocarditis
atrial myxoma
Respiratory causes lung cancer pyogenic conditions: cystic fibrosis, bronchiectasis, abscess, empyema tuberculosis asbestosis, mesothelioma fibrosing alveolitis
Other causes Crohn's, to a lesser extent UC cirrhosis, primary biliary cirrhosis Graves' disease (thyroid acropachy) rare: Whipple's disease
how to step down inhaled corticosteriod in asthma
aim for a reduction of 25-50% in the dose of inhaled corticosteroids
Asthma diagnostic testing
Patients >= 17 years
spirometry + bronchodilator reversibility (BDR) test
FeNO test
Refer to specialist if concern about occupational asthma
Patients 5-16 years
spirometry + bronchodilator reversibility (BDR) test
request FeNO if above is normal
FeNo, Spirometry and reversibility test positive values
FeNO
in adults level of >= 40
in children a level of >= 35
Spirometry
FEV1/FVC ratio less than 70% (or below the lower limit of normal if this value is available) is considered obstructive
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
Obstructive vs Restrictive; values
Obstructive lung disease
FEV1 - significantly reduced
FVC - reduced or normal
FEV1% (FEV1/FVC) - reduced
Restrictive lung disease
FEV1 - reduced
FVC - significantly reduced
FEV1% (FEV1/FVC) - normal or increase
Obstructive lung conditions
Asthma
COPD
Bronchiectasis
Bronchiolitis obliterans
Restrictive lung conditions
Pulmonary fibrosis Asbestosis Sarcoidosis Acute respiratory distress syndrome Infant respiratory distress syndrome Kyphoscoliosis e.g. ankylosing spondylitis Neuromuscular disorders Severe obesity
CRB65
Confusion (abbreviated mental test score <= 8/10)
Respiration rate >= 30/min
Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg
Aged >= 65 years
COPD; 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 interva
Mountain sickness prevention
slow ascents <500m per day, rest days every third day and avoiding over-exertion
reason for using inhaled corticosteroids in COPD
reduced frequency of exacerbations
OSA and driving
The patient has a legal requirement to inform the DVLA and stop driving if:
They are diagnosed with OSA, and the symptoms include sufficient sleepiness to impair driving
COPD management
1st step. SABA or SAMA as required
2nd step: if asthmatic features present: add LABA + ICS
If asthmatic features absent: add LABA + LAMA
3rd step: LABA+LAMA+ICS
Goodpasture’s syndrome
Haemoptysis
Systemically unwell: fever, nausea
Glomerulonephritis
Granulomatosis with polyangiitis
Upper respiratory tract: epistaxis, sinusitis, nasal crusting
Lower respiratory tract: dyspnoea, haemoptysis
Glomerulonephritis
Saddle-shape nose deformity
Aspergilloma
Often past history of tuberculosis.
Haemoptysis may be severe
Chest x-ray shows rounded opacity
Mitral stenosis
Dyspnoea
Atrial fibrillation
Malar flush on cheeks
Mid-diastolic murmur
Pneumonia following flu
add flucloxacillin on top of amoxicillin
COPD diagnosis
FEV1/FVC < 70% + symptoms suggestive of COPD
Pulmonary fibrosis life expectancy
3-4 years
Smoking cessation in pregnancy
check all women with a carbon monoxide monitor
CBT/motivational interviewing before NRT
what to check before starting azithrymycin
ECG - to rule out long QT
Bronchiectasis
Affected patients may produce large amounts of purulent sputum
parallel lines on CXR
ex smoker, recurrent or slowly resolving chest infection
2WW
The most common organism causing infective exacerbations of COPD
H Influenzae
Vaccination for patients with COPD
Annual influenza + one-off pneumococcal
acute mountain sickness prevention
Acetazolamide
which is used for progression/severity of COPD
FEV1
occupational asthma, what to check
serious peak flow at work and home
How to prescribe LTOT
Oxygen concentrator supplied via home oxygen order form
Does LTOT improve survival in COPD?
Oh yes.
what number of courses of oral or intravenous steroids in the past 12 months should prompt referral to secondary care for optimisation of asthma treatment?
More than 2
End-stage COPD, management of dyspnoea
Opioids such as morphine
COPD Severity
post brochodilator FEV1/FVC < 0.7 FEV1 >80% Stage 1 50 - 79% Stage 2 30 - 49% Stage 3 < 30% Stage 4
Prednisolone dose in asthma and COPD
COPD exacerbation: 30mg for 5 days
adult asthma exacerbation: 40-50mg 5 days
