Respiratory Disease Flashcards
What is Asthma
- Hyper reactivity response which results in reversible airway obstruction
- Most commonly tiggered by an allergen- dust, pet dander, pollen, viral infection, exercise
- Results in a cascade which releases histamine, leukotrienes and prostaglandins from mast cells
These, along with eosinophils, then cause airway inflammation and respiratory
Asthma symptoms
- Breathlessness
- Tight chest
- Wheezing
- Cough
Asthma Diagnosis
- Diagnosis is based on the pattern of symptoms, patient history, peak flow readings and reversibility testing (spirometry). NICE also recommend the use of FeNO test
- Need variable airflow obstruction and >1 of the following symptoms
- Cough
- Shortness of breath
- Wheeze
-Chest tightness
Patient history Asthma
- History of atopy
- Recurrent symptoms
- Symptom variability
- Peak flow readings are monitored to look for variability during the day
- Serial peak flow measurements showing 20% or greater diurnal/day-to-day variability
- Wheeze heard on auscultation
- Bronchodilator reversibility test
- An improvement of 12% or more, with an increase in volume of at least 200ml=positive result
- An improvement in lung volume of greater than 400ml is strongly suggestive of asthma
- A large (>400ml) response to 2 weeks, 30mg a day of oral prednisolone
FeNo levels of 40ppb or greater in adults (17+) with either positive bronchodilator reversibility or positive peak flow variability
Peak flow readings
A measure of how quickly you can blow air out of your lungs. If you have asthma, you may sometimes have narrow airways . This will make it more difficult to blow the air out of your lungs quickly and can change your peak flow score.
Used to diagnose and monitor asthma
Bronchodilator reversibility testing
Monitors how well patient responds to bronchodilator medicine
1. A healthcare professional performs a spirometry test to measure how much and how fast you can exhale.
2. You take a bronchodilator medicine, such as a reliever inhaler.
3. You wait 15–20 minutes.
4. The healthcare professional performs another spirometry test to measure how your airways have responded to the bronchodilator
Goals of Asthma treatment
The aim of asthma management is control of the disease
* No daytime symptoms
* No night time awakening due to asthma
* No need for rescue medication
* No asthma attacks
* No limitations on activity including exercise
* Normal lung function (FEV1 and or PEF >80% predicted or best)
Minimal side effects from medication
Assessing symptom control
ACT test
* Series of FIVE questions where the patient can rate the severity of their asthma over the past 4 weeks
C ACT for children 4-11years
The first 4 questions relate to symptom control and the final question is about how well the patient feels their asthma is controlled
Spacer counselling
- Rinse mouth after using inhaler
- Appropriate inhaler technique
- Check expiry dates of SABA if used infrequently
- Return finished/unused inhalers to pharmacy for correct disposal
Aerochamber will whistle if breathing is too quick
Stepping down treatment
Recommended once asthma is controlled
Consider reductions at 3 month intervals with 25-50% dose decreases each time
Aim is to get to lowest dose while still controlling symptoms
Considerations
* Asthma severity
* Side effects to medication
* Duration of current treatment
* Patient preference
* Achieved benefits
* Slow reductions in ICS
Regular review
Treatment of acute exacerbation of asthma
- Supplemental o2 if hypoxamia, titrate to spo2 94-98%
- Steroids: prednisolone 40-50mg OD (minimum 5 days)
- High dose inhaled beta agonist (bronchodilator)
- Ipratropium nebs (severe/life threatening or poor response to SABA alone)
IV Magnesium sulfate 1.2g-2g acute severe asthma
COPD
- chronic bronchitis
- emphysema
chronic bronchitis
recurrent inflammation causes:
- Ciliary dysfunction
- An increase in the presence and size of goblet cells causing excessive mucus production
emphysema
destruction of alveolar wall, less surface area for gaseous exchange
different to asthma
In contrast to asthma, eosinophils have a smaller role in the inflammatory process in COPD, where neutrophilic inflammation is more prominent- why ICS are not used
Risk factors for COPD
- Smoking
- Past history of smoking
- Older age
- Genetic pre disposition
- Occupational exposure to dust or chemicals
- Infection: history of childhood respiratory infections and tuberculosis
- Asthma
Poor socioeconomic status
COPD should be considered in adults over 35 with risk factors presenting with
- Exertional breathlessness
- Dyspnoea
- Chronic cough or sputum production
- History of recurrent LRTI
History of exposure to risk factors
COPD clinical signs on examination
- Cyanosis
- Raised jugular pressure
- Cachexia
- Hyperinflated chest
- Use of accessory muscles
- Pursed lip breathing
- Wheeze
Peripheral oedem
COPD non pharmacological interventions
- Exercise and physical fitness
- Smoking cessation
- Vaccinations
- Dietary input
- Breathing techniques
Referral for LTOT
bronchodilators
- Help open up the airways to relieve SOB and wheeze by reducing resistance in the lungs
- Provide symptomatic relief without curing the underlying pathology
- Cause relaxation of the smooth muscle within the airways
Can work on sympathetic nervous system or parasympathetic nervous system
s/e of bronchodilators
- Palpitations
- Headaches
Tremor
- Headaches
LABA/LAMA combo
- Generally superior to either constituent ingredient given alone when looking at FEV1 and symptom control
- Choice of combination inhaler should be based on cost, dosing regime and patient preference
- More cost effective and adherence likely to be better vs LAMA plus LABA in separate inhalers
E.g Duaklir
ICS
- Use is controversial
- ICS have been associated with an increased risk of non fatal pneumonia
Only given to patients with frequent exacerbations >2 a year
- ICS have been associated with an increased risk of non fatal pneumonia
triple therapy
- Beclometasone/Formoterol/Glycopyrronium- Trimbow
- Fluticasone/umeclidinium/vilanterol- Trelegy
Budesonide/formoterol/glycopyrronium- Trixeo
- Fluticasone/umeclidinium/vilanterol- Trelegy
s/e ICS
- Oral candidiasis
- Pneumonia
- Bronchospasm
Adrenal suppression
mucolytics
Role of these drugs are to disrupt mucus production in the airways, making it easier to breakdown and clear. E.g. carbocisteine
Prednisolone
- Long term treatment with oral prednisolone is generally not recommended
Consider bone protection in patient on long term steroids due to the risk of developing osteoporosis
prednisolone s/e
- Cushing’s syndrome
- Electrolyte imbalance
- Fluid retention
- Increased risk of infection
Osteoporosis
theophylline
A xanthine bronchodilator in asthma and COPD. It is generally not effective for exacerbations of COPD. It may have an additive effect when used in combination with small doses of beta agonists
Narrow therapeutic window
prophylactic antibiotics
- Azithromycin 250mg 3 times a week is generally used for prophylaxis
Antibiotics should only be used during an exacerbation if sputum is purulent
rescue packs
- These may contain oral prednisolone, antibiotics and a salbutamol inhaler
- Education is vital
- Patients need to inform their GP practice so they can be reviewed before further packs are issued
Recurrent rescue pack use may be indicative of poor management
cor pulmonale
Right sided heart failure- remodelling around the pulmonary vasculature. Causes pulmonary vasoconstriction, which leads to pulmonary hypertension, increases right ventricular pressure and therefore ultimately can result in right sided heart failure.
pneumonia
Pneumonia is an infection of the lower respiratory ling tissue
Caused by bacterial/viral or fungal pathogens causing migration of inflammatory cells
Consolidation results as the alveoli fill with inflammatory fluid, bacteria and white blood cells
CAP
CAP occurs when bacteria breaches the natural defenses of the lung to reach the usually sterile levels below the larynx
HAP
Acute LRTI acquired after at least 48h of hospital admission and not incubating at time of admission
Pulmonary embolism
- PE is defined as a clinically significant obstruction of part or all the pulmonary vascular tree, usually caused by clots from a distant site
- There are several risk factors for developing a PE
There are usually identified as part of the patient history
- There are several risk factors for developing a PE
PE S/e
- Sudden onset breathlessness
- Pleuritic chest pain
- Haemoptysis
- Haemodynamic disturbances
Circulatory failure, pulmonary artery necrosis, lung ischaemia
