Respiratory conditions Flashcards
What proportion of the UK population are affected by respiratory disease?
1 in 5
third biggest cause of death in England
Why are incidence and mortality rates from respiratory disease higher in disadvantaged groups and areas of social deprivation?
higher incidence of smoking
exposure to higher levels of air pollution
poor housing conditions
exposure to occupational hazards
What is the estimated cost of treating asthma and COPD in the UK?
asthma - £3 billion
COPD - £1.9 billion
What is the estimated direct cost to the NHS of all lung conditions in the UK per year?
£11 billion
partially due to a rise in hospital admissions in the UK over the past 7 years
most admissions are non-elective, due to exacerbation of their condition
admissions more than double in the winter period
List six types of respiratory disease.
asthma bronchitis emphysema cystic fibrosis mesothelioma lung cancer
What is the prevalence of asthma in the UK?
5.4 million (1.1 million children and 4.3 million adults)
What proportion of babies are born with cystic fibrosis in the UK?
1 in every 2500
What is the prevalence of mesothelioma in the UK?
1700 people
65,000 cases are expected to occur between 2020 and 2050
What is the prevalence of lung cancer in the UK?
over 46,000 diagnoses in 2015
What is chronic obstructive pulmonary disease (COPD)?
a chronic inflammatory lung disease that causes obstructed airflow from the lungs encompasses three respiratory conditions (1) chronic asthma (2) bronchitis (3) emphysema
How many people have a diagnosis of COPD in the UK?
1.2 million
115,000 new diagnoses per year
What are the most common risk factors for COPD?
age (more common >35 years)
smoking or history of smoking
List some of the common signs and symptoms of COPD.
exertional breathlessness chronic cough regular sputum production frequent winter 'bronchitis' wheeze
List some of the additional signs and symptoms of COPD.
weight loss reduced exercise tolerance waking at night with breathlessness ankle swelling fatigue occupational hazards (e.g. respiratory sensitisers) chest pain (uncommon) haemoptysis (uncommon)
What are the characteristics of asthma and COPD (ACO)?
persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD
the concept of asthma-COPD overlap was introduced in 2017 by the Global Initiative for Chronic Obstructive Lung Disease (GICOPD, 2017)
What is the prevalence of ACO in the general population?
0.9-11%
people with ACO have an increased burden of disease but are often misdiagnosed, so they may not receive the most appropriate therapy
What are the problems associated with ACO?
increased symptoms increased exacerbations increased hospitalisations increased comorbidities increased mortality lower quality of life higher healthcare costs greater prevalence of insomnia
Differences between COPD and asthma
Smoker or ex-smoker?
COPD - nearly all
asthma - possibly
Differences between COPD and asthma
Symptoms under age 35?
COPD - rare
asthma - often
Differences between COPD and asthma
Chronic productive cough?
COPD - common
asthma - uncommon
Differences between COPD and asthma
Breathlessness?
COPD - persistent and progressive
asthma - variable
Differences between COPD and asthma
Night time waking with breathlessness and/or weeze?
COPD - uncommon
asthma - common
Differences between COPD and asthma
Significant diurnal or day-to-day variability of symptoms?
COPD - uncommon
asthma - common
What is the Medical Research Council (MRC) dyspnoea scale?
tool to grade the degree of breathlessness related to activities
used alongside the presence of smoking history and one or more signs/symptoms
What is the MRC grade 1?
not troubled by breathlessness except on strenuous exercise
What is the MRC grade 2?
short of breath when hurrying or walking up a slight hill
What is the MRC grade 3?
walks slower than contemporaries on level ground due to breathlessness, or has to stop for breath when walking at own pace
What is the MRC grade 4?
stops for breath after walking about 100 metres or after a few minutes on level ground
What is the MRC grade 5?
too breathless to leave the house, or breathless when dressing or undressing
What is spirometry?
a test that is undertaken by trained and competent practitioners (e.g. GP nurses, occupational health nurses, respiratory physiologists in hospital)
their role is to perform the test and come to a diagnosis, or complete onward referral for further investigations
What is the purpose of a spirometry test?
to aid in the detection of a respiratory obstructive pattern which is seen in asthma
a restrictive airway pattern can be seen in many conditions (e.g. pulmonary fibrosis, cystic fibrosis)
obstructive patterns refer to difficulty exhaling
restrictive patterns refer to difficulty inhaling
shortness of breath can be seen in both cases
What is FEV1?
forced expiratory volume in one second - the volume of breath exhaled with effort in that time frame
What is FVC?
forced vital capacity - the full amount of air that can be exhaled with effort in a complete breath
According to NICE guideline CG12 (2004), what are the values related to a diagnosis of COPD?
mild - post-bronchodilator FEV1/FVC <0.7; FEV1% predicted 50-79%
moderate - post-bronchodilator FEV1/FVC <0.7; FEV1% predicted 30-49%
severe - post-bronchodilator FEV1/FVC <0.7; FEV1% predicted <30%
According to ATS/ERS 2004, what are the values related to the diagnosis of COPD?
mild - post-bronchodilator FEV1/FVC <0.7; FEV1% predicted ≥80%
moderate - post-bronchodilator FEV1/FVC <0.7; FEV1% predicted 50-79%
severe - post-bronchodilator FEV1/FVC <0.7; FEV1% predicted 30-49%
very severe - post-bronchodilator FEV1/FVC <0.7; FEV1% predicted <30%
According to GOLD 2008 and NICE guideline CG101 (2010), what are the values related to the diagnosis of COPD?
stage 1 (mild) - post-bronchodilator FEV1/FVC <0.7; FEV1% predicted ≥80% stage 2 (moderate) - post-bronchodilator FEV1/FVC <0.7; FEV1% predicted 50-79% stage 3 (severe) - post-bronchodilator FEV1/FVC <0.7; FEV1% predicted 30-49% stage 4 (very severe) - post-bronchodilator FEV1/FVC <0.7; FEV1% predicted <30%
What does yellow/green sputum indicate?
likely infection
What does pink/red/bloody sputum indicate?
could be related to an infection or cancer, in some cases
What does white sputum indicate?
allergies, asthma or viral infections
What does charcoal/grey sputum indicate?
environmental, common in people who work in coal mines and factories or heavy smokers
What does brown sputum indicate?
chronic lung disease, cystic fibrosis or bronchiectasis
How can a chest X-ray detect hyperinflation?
hyperinflation occurs when air gets trapped in the lungs and causes them to overinflate
diaphragm appears flattened
enlarged retrosternal air space
What is a limitation of chest X-rays for the diagnosis of COPD?
may only detect severe and progressive COPD
What is the purpose of a sputum culture in the diagnosis of COPD?
to identify organisms if sputum is persistently present and purulent
What is the purpose of serial home peak flow measurements in the diagnosis of COPD?
to exclude asthma if diagnostic doubt remains
What is the purpose of an ECG and serial natriuretic peptides in the diagnosis of COPD?
to assess cardiac status if cardiac disease or pulmonary hypertension are suspected because of:
(1) a history of CVD, hypertension or hypoxia, or
(2) clinical signs such as tachycardia, oedema, cyanosis or features of cor pulmonale
What is the purpose of an echocardiogram in the diagnosis of COPD?
to assess cardiac status if cardiac disease or pulmonary hypertension are suspected
What is the purpose of a CT scan of the thorax in the diagnosis of COPD?
to investigate symptoms that seem disproportionate to the spirometric impairment
to investigate signs that may suggest another lung diagnosis (e.g. fibrosis or bronchiectasis)
to investigate abnormalities seen on a chest X-ray
to assess suitability for lung volume reduction procedures
What is the purpose of a serum alpha-1 antitrypsin test in the diagnosis of COPD?
to assess for alpha-1 antitrypsin deficiency if early onset, minimal smoking history or family history
What is the purpose of a transfer factor for carbon monoxide (TLCO) test in the diagnosis of COPD?
to investigate symptoms that seem disproportionate to the spirometric impairment
to assess suitability for lung volume reduction procedures
What factors influence the treatment of respiratory diseases?
severity of disease
tolerance of medication
ability to adhere to treatment protocols
What are the inhaled treatment options for asthma?
initial therapy - ICS
advanced therapy - ICS + LABA
uncontrolled symptoms or frequent exacerbations - referral to specialist respiratory care
What are the inhaled treatment options for COPD?
initial therapy - SABA
advanced therapy - LABA + LAMA → ICS + LABA + LAMA
What are the inhaled treatment options for ACO?
initial therapy - ICS
advanced therapy - ICS + LABA → ICS + LABA + LAMA
uncontrolled symptoms or frequent exacerbations - referral to specialist respiratory care
List some examples of long acting beta antagonists (LABAs).
formoterol
indacaterol
List some examples of long acting muscarinic antagonists (LAMAs).
glycopyrronium
tiotropium
List some examples of LABAs and LAMAs combined.
Anoro
Ultibro
What is the first-line treatment with steroids for respiratory exacerbations?
prednisolone 30mg PD for 5 days
this can be stored in the patient’s home and commenced when symptoms appear
What are the most common infections in patients with respiratory diseases.
Hemophilus influenza
Moraxella catharralis
Streptococcus pneumonia
Pseudomonas
When is the use of antibiotics most beneficial in patients with respiratory diseases?
during a severe acute exacerbation
What are the first-choice oral antibiotics for respiratory diseases?
amoxicillin
doxycycline
clarithromycin
What is the dosage and course length of amoxicillin?
500mg TD for 5 days
What is the dosage and course length of doxycycline?
200mg on first day, then 100mg OD for 5-day course in total
What is the dosage and course length of clarithromycin?
500mg BD for 5 days
BETA-LACTAM ANTIBIOTICS
Penicillins: amoxicillin - actions
bactericidal
interfere with cell wall synthesis in dividing bacteria
BETA-LACTAM ANTIBIOTICS
Penicillins: amoxicillin - MOA
bind to and inhibit the enzyme that cross-links the peptide chain of the newly formed ‘building block’ to the peptidoglycan cell wall backbone
BETA-LACTAM ANTIBIOTICS
Penicillins: amoxicillin - abs/distrib/elim
rapid oral absorption
can also be given IM or IV
pass into all body fluids
cross the placenta but not the blood-brain barrier unless the meninges are inflamed
half-life 61.3 mins
excreted in the urine (blocked by probenecid)
BETA-LACTAM ANTIBIOTICS
Penicillins: amoxicillin - clinical use
otitis media
bronchitis
pneumonia
BETA-LACTAM ANTIBIOTICS
Penicillins: amoxicillin - adverse effects
hypersensitivity reactions (rashes, urticaria, angioedema, fever, arthralgia, anaphylaxis)
What is the difference between oral and IV amoxicillin in terms of dosage and frequency of administration (acute exacerbation of COPD)?
oral - 500 mg 3 times a day for 5 days, increased if necessary to 1 g 3 times a day, increased dose used in severe infections
IV - 500 mg every 8 hours, increased to 1 g every 6 hours, increased dose used in severe infections
BACTERIAL PROTEIN SYNTHESIS BLOCKERS
Tetracyclines: doxycycline, tetracycline, oxytetracycline - actions & MOA
interfere with bacterial protein synthesis by competing with tRNA for the A site of the ribosome and reversibly inhibiting its binding to the mRNA codons in the 30s subunit
BACTERIAL PROTEIN SYNTHESIS BLOCKERS
Tetracyclines: doxycycline, tetracycline, oxytetracycline - abs/distrib/elim
given orally, absorption impaired by milk and by calcium, magnesium and iron preparations
BACTERIAL PROTEIN SYNTHESIS BLOCKERS
Tetracyclines: doxycycline, tetracycline, oxytetracycline - clinical use
doxycycline is drug of choice for chlamydial, rickettsial and brucella infections
effective in most chest infections, including mycoplasma and Haemophilus influenzae
used in acne, sinusitis, prostatitis, syphilis, Lyme disease and in treatment/prevention of malaria
demeclocycline used in inappropriate secretion of antidiuretic hormone causing hyponatraemia (different action from its antibacterial effect)
BACTERIAL PROTEIN SYNTHESIS BLOCKERS
Tetracyclines: doxycycline, tetracycline, oxytetracycline - adverse effects
staining of the teeth, GIT disturbances, anorexia, flushing, tinnitus
eare: hepatotoxicity pancreatitis, hypersensitivity reactions
BACTERIAL PROTEIN SYNTHESIS BLOCKERS
Tetracyclines: doxycycline, tetracycline, oxytetracycline - special points
tetracyclines should not be given to children or pregnant or breastfeeding women
What is the difference between oral and IV doxycycline in terms of dosage and frequency of administration (acute exacerbation of COPD)?
oral - initially 200 mg daily for 1 dose, then maintenance 100 mg once daily for 5 days in total, increased if necessary to 200 mg once daily, increased dose used in severe infections
IV - 200 mg first day in one or two infusions, subsequent daily dosage 100-200 mg based on severity of infection (IV not recommended)
BACTERIAL PROTEIN SYNTHESIS BLOCKERS
Macrolides: erythromycin, clarithromycin, azithromycin - actions
inhibit bacterial protein synthesis
BACTERIAL PROTEIN SYNTHESIS BLOCKERS
Macrolides: erythromycin, clarithromycin, azithromycin - MOA
macrolides inhibit bacterial protein synthesis by an effect on ribosomal translocation
they bind to same 50s subunit of bacterial ribosome as chloramphenicol and clindamycin and any of these drugs may compete if given concurrently
BACTERIAL PROTEIN SYNTHESIS BLOCKERS
Macrolides: erythromycin, clarithromycin, azithromycin - abs/distrib/elim
given orally or by IV infusion (IV injection can cause thrombophlebitis)
erythromycin half-life 1.5h
distributed widely but does not enter brain or CSF
BACTERIAL PROTEIN SYNTHESIS BLOCKERS
Macrolides: erythromycin, clarithromycin, azithromycin - clinical use
for pneumococcal and streptococcal infections in patients allergic to penicillin
for chlamydial and mycoplasma infections
for infections of the skin and the respiratory tract (for syphilis, diphtheria, prostatitis, whooping cough, campylobacter enteritis)
azithromycin more effective against Haemophilus influenzae and may be more active against Legionella
clarithromycin effective against H. influenzae and Mycobacterium avium-intracellulare and may also be useful in leprosy and against Helicobacter pylori
BACTERIAL PROTEIN SYNTHESIS BLOCKERS
Macrolides: erythromycin, clarithromycin, azithromycin - adverse effects
GIT disturbances
less frequent: allergic reactions, cholestatic jaundice
BACTERIAL PROTEIN SYNTHESIS BLOCKERS
Macrolides: erythromycin, clarithromycin, azithromycin - special notes
concomitant use of statins with clarithromycin is contraindicated
statins are extensively metabolized by CYP3A4 and concomitant treatment with clarithromycin increases their plasma concentration, which increases the risk of myopathy, including rhabdomyolysis
What is the difference between oral and IV clarithromycin in terms of dosage and frequency of administration (acute exacerbation of COPD)?
oral - 500 mg twice daily for 5 days
IV - 500 mg every 12 hours, to be administered into a large proximal vein
Which patient groups are more likely to use an inhaler or nebuliser incorrectly?
children and the elderly
What is pulmonary rehabilitation?
this is considered appropriate patients with COPD who have an exacerbation that led to hospitalisation, or who have a MRC grade 3 or above
limited benefit for patients unable to walk
the program is determined on the patient’s ability to engage and continue within the home environment
What is involved in the treatment of depression and/or anxiety in patients with COPD?
appropriate identification and discussion with patients
consideration of the guidelines that relate to this area as provided by NICE (2009)
What is the ‘expert patient programme’ (EPP) initiative?
began in 1999 following the development of National Service Frameworks
the aim was to empower patients through peer-led and supportive groups to offer patient education via a different platform
What did Law et al. (2019) conclude about the parental administration of asthma inhalers to their young children?
online discussions show parents’ distress, lack of preparedness, and understanding of administering inhalers to their children
health professionals must review their own knowledge and skills in administration of inhalers to younger patients, and their provision of patient- and family-centred care
What did Granados-Santiago et al. (2019) conclude about the effectiveness of a shared decision-making and patient engagement (SDM-PE) program following acute exacerbation of COPD?
SDM-PE program significantly improved perceived health status, COPD knowledge, medicines adherence, general functionality, and healthy lifestyle measures at discharge and 3-month follow-up
COPD patients and professionals must work together to select the best care and treatment model for patients, taking into account individual values and preferences
What did Peckham et al. (2019) conclude about the effectiveness of a bespoke smoking cessation service compared with treatment as usual for people with severe mental ill health?
people with SMI are more ready to engage with a bespoke intervention that results in increased 6-month quit rates
health professionals should ask all patients about their smoking status and offer referrals to effective smoking cessation services
health professionals can be confident that smoking cessation is likely to either be beneficial to mental health or not harm mental health
