Respiratory - Asthma and COPD management

Question 1

You’ve taken a history from a 17 year old patient with SOB and wheeze which bothers her at night and when she wakes up. You suspect asthma but what investigations would you perform to confirm your diagnosis?

Answer 1

(Detailed history)
Peak flow
Peak flow diary
Trial of bronchodilator (expect reversibility) 
(Spirometry)

Question 2

A 20 year old man comes to the GP complaining of coughing and wheezing at night. You suspect asthma.
What is your first step?

a) Inhaled salbutamol
b) Oral prednisolone
c) Inhaled beclomethasone
d) Inhaled salmeterol
e) Nebulised salbutamol

Answer 2

a) Inhaled salbutamol

Step 1: inhaled SABA e.g. salbutamol

SABA = short acting B2 agonist

Question 3

A 20 year old man comes to the GP complaining of coughing and wheezing at night. You suspect asthma and give him an inhaler.
You send him home with a Peak Exp. Flow Rate monitor. However a few weeks later he is using the inhaler more often and his numbers are getting worse. What treatment is most appropriate to add ?

a) Inhaled salbutamol
b) Oral prednisolone
c) Inhaled beclomethasone
d) Inhaled salmeterol
e) Nebulised salbutamol

Answer 3

c) Inhaled beclomethasone

Step 1: inhaled SABA e.g. salbutamol
Step 2: Inhaled corticosteroid e.g. beclomethasone

SABA = short acting B2 agonist

Question 4

A 20 year old man comes to the GP complaining of coughing and wheezing at night. You’ve seen him before and already prescribed him two inhalers.
Despite new treatment, he comes after 2 months still coughing at night. What treatment could you add next?

a) Inhaled salmeterol
b) Oral prednisolone
c) Inhaled beclomethasone
d) Inhaled salmeterol
e) Nebulised salbutamol

Answer 4

a) Inhaled salmeterol

Step 1: inhaled SABA e.g. salbutamol
Step 2: Inhaled corticosteroid e.g. beclomethasone
Step 3: inhaled LABA e.g. salmeterol

SABA = short acting B2 agonist
LABA = long acting B2 agonist

Question 5

What are the British Thoracic Society guidelines on asthma management?

Answer 5

1. SABA PRN
2. SABA + inhaled corticosteroid
3. SABA + inhaled corticosteroid + LABA
   If control inadequate/no response LABA - ↑ steroid
   If control still inadequate – LRA or theophylline
4. ↑ steroid, LRA or theophylline
5. Oral steroid + refer

SABA = short acting B2 agonist
LABA = long acting B2 agonist 
LRA = leukotriene receptor antagonist 

NB: guidelines different in children!

Question 6

You suspect your patient, Mr Barker, has COPD. What is the most important diagnostic tool?

a) Peak flow
b) CT scan
c) Spirometry
d) Pulse oximetry
e) CXR

Answer 6

c) Spirometry - to see if obstructive

Other useful tests 
In their initial diagnostic evaluation all patients should have 
BMI
CXR - exclude other pathology 
FBC - anaemia or polycythaemia?

Also: peak flow to exclude asthma, a1-antitrypsin if early onset or minimal smoking, Transfer factor CO or CT to assess symptoms disproportionate to spirometric impairment, ECG/ECHO if signs of cor pulmonale, pulse oximetry to assess need for O2 therapy, sputum culture if recurrent infections.

Question 7

You have diagnosed Mr Barker with COPD. What is the first therapy you start? (2 correct options)

A) Long acting B2 agonist
B) Inhaled corticosteroid,
C) Short acting B2 agonist 
D) Short acting muscarinic antagonist
E) Long acting muscarinic antagonist
F) Long acting B2 agonist with inhaled corticosteroid

Answer 7

C) Short acting B2 agonist (SABA)
D) Short acting muscarinic antagonist (SAMA)

Steps:

1) Short acting bronchodilator
2) If remain SOB: LABA+/- ICS OR LAMA
3) If remain SOB: two (i.e. LABA + ICS OR LABA + LAMA)
4) If still SOB: three (i.e LABA + ICS + LAMA)
5) If still SOB despite max therapy consider nebuliser

Consider oral theophylline if uncontrolled with short and long acting therapy (must measure plasma levels)

Maintenance oral corticosteroid not usually recommended- use in advance if cannot be withdrawn following exacerbation

Question 8

You have diagnosed Mr Barker with COPD and started him on first line COPD treatment. 2 months later, he remains breathless, what could you try? (2 options)

A) Long acting B2 agonist
B) Inhaled corticosteroid,
C) Short acting B2 agonist 
D) Short acting muscarinic antagonist
E) Long acting muscarinic antagonist
F) Long acting B2 agonist with inhaled corticosteroid

Answer 8

E) Long acting muscarinic antagonist (LAMA)
F) Long acting B2 agonist with inhaled corticosteroid (LABA+ICS)

Steps:

1) Short acting bronchodilator
2) If remain SOB: LABA+/- ICS OR LAMA
3) If remain SOB: two (i.e. LABA + ICS OR LABA + LAMA)
4) If still SOB: three (i.e LABA + ICS + LAMA)
5) If still SOB despite max therapy consider nebuliser

Consider oral theophylline if uncontrolled with short and long acting therapy (must measure plasma levels)

Maintenance oral corticosteroid not usually recommended- use in advance if cannot be withdrawn following exacerbation

Question 9

Bonus question:
Mr Baker has COPD and takes a SABA/ SAMA + LAMA/LABA+ICS (second line treatment). Several years later, despite aggressive treatment his COPD is uncontrolled. The expert respiratory doctor decides he needs to start a drug and asks you to monitor the blood levels. What is it?

Answer 9

Oral theophylline - if COPD uncontrolled with short and long acting therapy (must measure plasma levels)

Question 10

When is long term oxygen therapy indicated in COPD?

Answer 10

1. PaO2 <7.3kPa or

2. 7.3-8kPa + 2’ polycythaemia/nocturnal hypoxaemia/peripheral oedema/pulmonary HTN

Question 11

What is the risk of oxygen therapy in COPD?

Answer 11

Respiratory depression

Question 12

What other types of further COPD therapy are there beyond long term O2 therapy?

Answer 12

ambulatory O2 therapy, Non-invasive ventilation (NIV)

If very severe: Surgery e.g. bullectomy, lung transplant