Respiratory disorders and their management Flashcards
Gain knowledge about the symptoms, signs and management of COPD Asthma Lung Cancer Fibrotic Lung Disease Obstructive Sleep Apnea Appreciate the action of different drugs used to manage patients with Asthma or COPD
Estimated prevalence of COPD UK
3M
Majority in 50s
Will rise by 30% over 10 next years
Prevalence of diagnosed/ undiagnosed COPD
0.9M diagnosed
2M undiagnosed
Survival rates of COPD
5 year survival in individuals with O2 or neb utilisation <30%
2005: 5% of all deaths globally
Diagnosis of COPD
Traditionally defined as emphysema (pathological diagnosis) or chronic bronchitis (clinical diagnosis with 3/12 of productive cough for >2 consecutive years)
- bronchial wall thickening
- airflow obstruction due to combination of airway and parenchymal damage
Diagnosis of COPD - spirometry CHART
FEV1/ FVC less than 70%
Suboptimal predictor of disability and QOL
Symptoms of chronic COPD
Shortness of breath on exertion
Wheeze
Cough
Weight loss
Symptoms of acute/ exacerbation of COPD
*worsening of the following* Acute sob/ wheeze Worsening sputum production Fever Drowsiness/ CO2 narcosis
Signs of COPD - general inspection
Cachexia - low body weight (severe disease) Use of accessory muscles Pursed lips Cyanosis (late disease) CO2 flap (severe disease) Drowsiness in CO2 narcosis
Signs of COPD - chest
Hyper-expanded chest (gross disease) Hyperesonant Reduced breath sounds Wheeze (acute disease) Elevated jugular venous pressure and peripheral oedema in late disease
Disease severity COPD - different clinical parameters
TABLE and CAT SCORE
Lung function
Symptoms (e.g. COPD assessment test)
Exacerbation frequency
BODE index
The MCR breathlessness scale
1 - not troubled by breathlessness except on strenuous exercise
2 - short of breath when hurrying on level or walking up slight hill
3 - walks slower than most people on level, stops after a mile or so, or stops after 15 minutes walking at own pace
4 - stops for breath after walking about 100 yds or after a few mins on level ground
5 - too breathless to leave the house, or breathless when undressing
less subjective than CAT scale
Disease severity comparisons COPD
- bringing all scores together
A - low risk, less symptoms (you want to be here) -risk 1-2 -mMRC 0-1 CAT< 10 B - low risk, more symptoms -risk 0-1 -mMRC >/2 -CAT>/10 C - high risk, less symptoms -risk 3-4 -mMRC 0-1 -CAT <10 D - high risk, more symptoms -risk >/2 -mMRC >/2 -CAT >/10
Inhaled treatment of COPD (FLOW CHART)
Aims are directed as trials to improve symptoms and < exacerbations
-not stepwise algorithm in contrast to asthma
S/LABA
Short/ long acting beta agonist
S/ LAMA
Short/ long acting muscarinic agonist
ICS
Inhaled corticosteroid
Management of stable COPD
Smoking cessation Oral Theophylline Oral mucolytic therapy Vaccination therapy Pulmonary rehabilitation Nutritional support Surgery Oxygen therapy
Management of stable COPD - smoking cessation
NRT
Bupropion
Varenicline
Management of stable COPD - Oral theophylline
Trial of therapy
Risk of side effects
Management of stable COPD - oral mucolytic therapy
Carbocisteine
Management of stable COPD - vaccination therapy
Annual influenza and 5 yearly pneumococcal vaccination
Management of stable COPD - pulomary rehabilitation
Addresses muscle deconditioning
Improves QoL, exercise tolerance
May have some impact on exacerbation
Non-pharmacological intervention
Management of stable COPD - nutritional support
BMI of 20-25
Management of stable COPD - surgery (very severe disease)
Transplant Lung volume reduction surgery Bullectomy -surgical removal of a bulla, which is a dilated air space in the lung parenchyma measuring more than 1 cm Placement of endobronchial valves
Management of stable COPD - oxygen therapy
Long term oxygen therapy
Ambulatory
Short burst oxygen therapy (SBOT)
Management of stable COPD - LTOT
Pts with persistant respiratory failure Min 14 hours per day of continuous O2 therapy delivered by concentrator -has prognostic benefit PO2 <7.3kPa persistently PO2 7.3-8kPa and secondary polycythaemia -+ nocte sPO2 <90% for >30% of night -+ peripheral oedema -+ pulmonary hypertension Not for symptomatic relief
Management of stable COPD - ambulatory oxygen
Desaturation on exercise
> in exercise with supplemental O2
Delivered by cylinder
Management of stable COPD - SBOT
Short burst oxygen therapy
-not really advised for COPD
Palliative care
Prevention of exacerbation
Seasonal influenza vaccination (one-off pneumococcal vaccination)
Inhaled steroids (in conjunction with long acting bronchodilator)
Other agents
-anticholinergics - ipratropium/ tiotropium
-mucolytics (carbocysteine)
Pulmonary rehabilitation (used for symptom control as well)
Regulation of ventilation
GRAPHS
Respiratory failure type I
- PaO2
- PaCO2
- common causes
- O2
PaO2 <8KPa Low or normal PaCo2 Common causes -acute: pneumonia, asthma -chronic: fibrosing lung disease O2: yes, give them oxygen
Respiratory failure type II
- PaO2
- PaCO2
- common causes
- O2
PaO2 <8KPa PaCO2 >6.0KPa Common causes -acute: overdose, trauma -chronic: COPD, neuromuscular O2: yes but care in chronic -too much oxygen switches off hypoxic drive
Treatment for respiratory failure
Non-Invasive Ventilation (NIV)
- employed after optimum medical Rx
- cyclical non-invasive positive p delivered by face/ nasal mask
- supplemental O2 supply
- acute use for respiratory acidosis
- usually pt trigger with back-up respiratory rate
- delivered by trained nursing/ physio staff
- requires ABG/ transcutaneous CO2 monitoring
Contraindications to noninvasive positive pressure ventilation (relative not absolute)
Cardiac/ respiratory arrest Nonrespiratory organ failure Facial or neurological surgery, trauma, or deformity Upper airway obstruction Inability to cooperate/ protect airway Inability to clear secretions High risk for aspiration
Nonrespiratory organ failure as contraindications to NIV
Severe encepalopathy (e.g. GCS <10)
Supper upper GI bleeding
Haemodynamic instability or unstable cardiac arrhythmia
Prevalence of asthma in UK
5.4 million
1 adult in 12
1 child in 11
Airway during an asthma attack (DIAGRAM)
Narrowed Swollen submucosa Excess mucous Thickened smooth muscle layer Tightened bands of smooth muscle
Respiratory symptoms of asthma
Wheeze Cough Dyspnea (shortness of breath) Chest tightness Nocturnal duration
Structured clinical assessment for asthma (FLOW CHART and DIAGRAMS)
Recurrent episodes of symptoms
Symptom variability
Absence of symptoms of alternative diagnosis
Recorded observation of wheeze
Personal history of atopy (genetic tendency to develop allergy)
Historical record of variable PEF or FEV1
Possible triggers of asthma
Exertion Dust Change in T Emotional situations e.g. anxiety Occupation
Signs of asthma
Eczema Nasal polyps Cushingoid (excess cortisol) Wheeze Peripheral/ central cyanosis
Signs of asthma upon exacerbation
Elevated respiratory rate Elevated heart rate SpO2 Inability to complete sentences Audible wheeze
Treatment of asthma
Short acting beta2 agonists as required - consider moving up if using 3 doses a week or more
-refer pt for specialist care if using high dose therapies
Method of delivery of inhaled drugs - asthma
Metered dose inhaler
MDI via spacer
Breath actuated
Metered dose inhaler
(SABA/ LABA/ ipatropium/ ICS)
-inhale with simultaneous depression of canister with breath hold for 10s
MDI via spacer
10 puffs of salbutamol via spacer equivalent to nebuliser
Give 4 puffs initially then 2 puffs every 2 mins up to max of 10 puffs
-if not good with inhaler
Pts at risk of developing near-fatal or fatal asthma
A combination of severe asthma and adverse behavioural or psychosocial features
Severe asthma is recognised by one or more of:
Previous near-fatal asthma
-e.g. previous ventilation/ respiratory acidosis
Previous admission for asthma (especially if in last year)
Requiring 3 or more classes of asthma med
Heavy use of beta2 agonist
Repeated attendances at ED for asthma care (especially in last year)
“Brittle” asthma
Adverse behavioural or psychosocial features recognised by one or more of:
Non-compliance with treatment/ monitoring Failure to attend Fewer GP contacts Frequent home visits Self discharge from hospital Psychosis, depression, other psychiatric illness or deliberate self harm Current or recent major tranquiliser use Denial Alcohol/ drug abuse Obesity Learning difficulties Employment problems Income problems Social isolation Childhood abuse Severe domestic, marital or legal stress
Acute asthma severity (KNOW THIS)
Mild (routine): -75% PEF % best -pt should bewell Moderate (semi urgent): -50-75% PEF % best Severe (urgent): -33-49% best PEF -RR > 25/min -HR > 110/min -not talking LT (urgent): -<33% best PEF -bradycardia -SaO2 <92, silent chest
Acute asthma management
O2 40-60%: drive nebulisers with O2
B2 agonists are mainstay
Oral steroids should be given within an hour (asap)
B2 agonists and anticholinergics in those who fail to progress
IV beta2 agonists (very rare) reserved for those where inhaled route cannot be relied upon
Lung cancer epidemiology
Main cause of cancer related death in UK 2nd most common cancer in UK 2nd most common cancer in males (14%) and females (12%) 69 new cases for every 100,000 persons 85% NSCLC/ 15% SCLC
Lung cancer % operable at diagnosis
10%
Risk of spread lung cancer
From primary tumours to nodes and distal organs
-bone, liver, lung pleura cavity
What predicts survival of lung cancer
T N M1A/1B
Symptoms can be dependent upon stage of disease
-some pts can present late with widespread metastatic disease (and still be feeling well)
Major subtypes of NSCLC (non-small-cell)
Squamous cell
Adenocarcinoma
Adenocarcinoma in situ (aka bronchoalveolar carcinoma)
Lung cancer - chest symptoms
Sob - lobar collapse, effusion, lymphangitis
Chest pain - rib involvement, chest wall invasion
Cough
Haemoptysis - usually due to endobronchial involvement
Lung cancer - constitutional symptoms
Weight loss
Low appetite
Low energy levels
Lung cancer - paraneoplastic syndromes (uncommon)
High Ca (PTH release or bone involvement)
SIADH
Hypertrophic pulmonary osteoarthropathy
Lambert Eaton Syndrome
High calcium syndrome
PTH release (hold on to water) or bone involvement Nausea, confusion, abdominal pain and constipation
SIADH
Confusion, fits, lethargy
Lambert Eaton Syndrome
Neuromuscular weakness
Lung cancer - metastatic disease
SVC obstruction (SVCO) due to mediastinal disease
Brain metastasis - confusion, nausea, headache
Bone metastasis - pathological fracture, pain
Liver metastasis - abdominal pain
Signs of lung cancer
Finger nail clubbing Cachexia Horner's syndrome (tumour in apex of lung, chomps through brachial plexus --> drooping eyelid and miosis) Neck nodes Chest signs Palpable liver SVCO
Diagnosis of lung cancer
Chest X-ray
CT
PET scan for radical treatable disease
Tissue biopsy
Diagnosis of lung cancer - tissue biopsy
Bronchoscopy
Thoracoscopy for pleural disease
Surgical
Diagnosis of lung cancer - Chest x-ray
Cheap Good screening tool Won't detect mediastinal disease necessarily Won't detect small nodules Not a staging tool
Diagnosis of lung cancer - CT
Staging tool
Detailed info
Requires IV contrast
Contrast not allowed in pts with chronic kidney disease
Cannot detect microscopic disease e.g. in med nodes
Diagnosis of lung cancer - PET scan for radical treatable disease
Infusion of FD glucose Detects cancer, infection and vasculitis Very sensitive Expensive False positive rate Care needed in DM
WHO performance status
0: able to carry out all normal activity w/o restriction
1: restricted in strenuous activity but ambulatory and able to carry out light work
2: ambulatory and capable of self-care but unable to carry out any work activities; up and about >50% of waking hours
3: symptomatic and in chair/ bed for >50% of day but not bedridden
4: completely disabled; cannot carry out any self-care; totally confined to bed/ chair
Treatment of lung cancer for NSCLC
Dependent upon stage and WHO performance status
Radiation therapy/ surgery for limited disease WHO PSo-1/2
Chemo (platinum + 3rd gen drug) for extensive disease
Immunotherapy
Oral EGFR mAb for EGFR +ve disease WHO PS 0-3
BSC for pts not fit for active treatment
Immunotherapy
Inhibition of PDL suppression by tumours on T-cells
- allows them to fight malignancy
- pts must have sufficient PDL1
Treatment of lung cancer for SCLC
Systemic Cisplatin based Chemotherapy
-disease extensive at presentation
Treat within 7/7 of diagnosis to due speed of deterioration
If localised disease - f/u radiation therapy
Interstitial lung disease names (FLOW CHART)
Interstitial lung disease
Diffuse parenchymal lung disease
Lung fibrosis
Classification of interstitial lung disease
Idiopathic
Drug reaction
Extrinsic allergic alveolitis/ hypersensitivity pneumonitis
Associated with rheumatological disease
Symptoms of intersititial lung disease
Dysnpea
Cough
Consitutional symptoms
Onset of symptoms may identify aetiology
Extrinsic allergic alveolitis - post exposure
Idiopathic pulmonary fibrosis - chronic
Acute intersitial pneumonia - rapid onset
Signs of intersitial lung disease
Signs associated with CT diseases/ rheumatoid arthritis
Nail clubbing
Sclerodactyly (associated with systemic sclerosis)
Signs of steroid use
Chest - audible crackles; distribution may influence diagnosis
Chest - squeaks - suggest small airways disease
Idiopathic pulmonary fibrosis aka cryptogenic fibrosis
Male Older population Median survival 3yrs Associated with clubbing Mainly lower zone preponderance Classically restrictive spirometry and < transfer factor Diagnosis can be made from CT FEV1/FVC ratio >70%
Idiopathic pulmonary fibrosis treatment
Supportive Pulm rehab Pirenidone (anti-fibroblast activity with effect on survival and lung function) when FVC<80% Nintenadib (anti-fibroblast FVC 50-80%) Opiates/ palliative care in later stages Role of steroids controversial
Extrinsic allergic alveolitis
Trigger may not identifiable
Classical triggers occupation- baker, farmer, moulds
Disease has predominant upper zone predominance
Treatment for extrinsic allergic alveolitis
Antigen avoidance
Trial of corticosteroid therapy
Calcium and vitamin D supplementation
Possible bisphosphonate
Sleep apnea
Excessive daytime sleepiness with disordered nocturnal irregular breathing
0.5-4% population prevalence cf Type 1 DM
Severity defined by Apnea-Hypopnea Index
Apnea-Hypopnea Index
Mild: AHI 5-14/hr
Moderate: AHI 15-30/hr
Severe: AHI >30/hr
Apnea definition
Cessation of flow for 10s
Hypopnea definition
< of flow for 10s by >30%
Types of sleep apnea
3
- obstructive sleep apnea (OSA)
- central sleep apnea
- mixed apnea
Risk factors for OSA
Obesity >17 inch collar Men x2-3 likely Age Cranio-facial and upper airway abnormalities e.g. short mandible, tonsillar/ adenoid hypertrophy, wide craniofacial base
CAT score
Number of different symptoms and pt subjectively scores themselves 0-5
Ranked out of 40
BODE index
Number of different parameters
- BMI
- dyspnea scale score
- distance walked in 6 mins
Sleep apnea symptoms
Excessive daytime sleepiness Impaired concentration Snoring Unrefreshing sleep Choking episodes during sleep Witnessed apnoeas Restless sleep Irritability/ personality change Nucturia (waking up to urinate at night) < libido
Obstructive sleep apnea
Snoring and apnoeas observed when upper airway collapses
Epworth sleepiness scale
Questionnaire with 0-24 scale 11-14 mild sleepiness 15-18 moderate sleepiness >18 severe sleepiness -screening tool when assessing daytime somnolence
Other tests for sleepiness
Sleep latency test and maintenance of wakefulness
Some potential causes of excessive daytime sleepiness in adults
Fragmented sleep (quality of sleep) Sleep deprivation (quantity of sleep) Shift work Depression Narcolepsy Hypothyroidism Restless leg syndrome/ periodic limb movement disorder Drugs -sedatives -stimulants (caffeine, theophyllines, amphetamines) -beta-blockers -selective serotonin reuptake inhibitors (SSRIs) Idiopathic hypersomnolence Excess alcohol Neurological conditions
Neurological conditions as potential causes of excessive daytime sleepiness in adults
Dystrophica myotonica
Previous encephalitis
Previous head injury
Parkinsonism
Diagnosis of sleeping disorders??
Polysomnography
Pulse oximetry
Pulse oximetry pros
Cheap
Easy to use
Can be used at home
Pulse oximetry cons
Can show false negative
Less sensitive in thin pts/ issues with tissue perfusion
How does pulse oximetry work
Measure 4% desaturation rate (ODI)
- >10 events per hour suspicious
Pursed lips meaning
Pt coping strategy to allow symptomatic improvement
Lips brought together
Working hard to breath out
Creates “auto-PEEP” to allow prolonged opening of distal airways to allow emptying of lungs
> p within windpipes/ bronchioles which splits them open
Taking history of COPD
Duration of onset of symptoms
Change in vol and character of sputum
Severity of chronic illness - use of supplemental oxygen
Smoking occupational (e.g. coal mining) history
PYH = (cigs consumption/day) x no. of years smoked divided by 20
>10 PYH - significant
Treatment for COPD
Visit GP for assessment of infective exacerbation of COPD Antibiotics given if 2 of -increasing dyspnoea -sputum vol -sputum purulence Oral prednisolone -7-10 days (0.6mg/kg/day) = 30-40mg/day -more rapid improvement in physiology -shortens hospital discharge -must weigh severity against side effects
How NIV works
Pushes in pressure to expand the lungs, helping them inflate/ deflate
Lowers CO2 level?
Tight fitting mask
Diagnosis of asthma
PEF A%M (peak flow) -fluctuation of 20% indicates asthma -poorly sensitive, around 20% would be diagnosed Bronchodilatory response -salbutamol via spacer -20-50% increase indicates asthma -only diagnoses about 50% FEV1/FVC ratio -around 80% of pts would be diagnosed
Taking history of asthma
Duration of onset of symptom
Any infective features/triggers-dust/pets/exercise/anxiety
Severity of illness – previous hospital/ED/ITU admissions
Other medications
Bedside test for asthma
Peak flow meter
Treatment of suspected asthma
Consider monitored initiation of treatment with low dose ICS
-if they get better through this they have asthma
5 step ladder of asthma treatment (DIAGRAM)
Regular preventer - low dose ICS
Initial add-on therapy - add inhaled LABA to low-dose ICS (normally as combination inhaler)
Additional add-on therapies
High dose therapies
Continuous or frequent use of oral steroids
Polysomnography pros
Limited vs full
-full considered gold standard
Polysomnography cons
Full PSG requires hospital admission
How polysomnography works
Measurement of EEG, eye and limb movements, nasal flow, thoraco-abdo movement, ECG and oxygen saturation
Morbidity associated with OSA
Untreated x2-3 risk of RTA (DVLA)
Associated with CHD, CCF, PAH & Hypertension & CVD
Insulin resistance (Metabolic syndrome) & T2 DM
Concurrent obesity is a confounding factor in studies
> risk of post-operative complications
Treatment of sleep apnea
FUNDAMENTAL TREATMENT: Weight loss/lifestyle change
Continuous Positive Airway Pressure (CPAP)
Mandibular Advancement Device (MAD)
Pharmocotherapy & surgery?
CPAP
(Continuous positive airway pressure)
Delivery of constant pressure by face/nasal mask
Abolition of apneas/hypopneas with improvement in oxygen saturation
Very effective
Adherence variable
Essential to maintain licence validity
Mandibular advancement device role
Role when CPAP not tolerated
Mild-Moderate OSA
Adherence is key to success
Manndibular advancement device mechanism
Anterior displacement of the mandible -variable results of trials MAD better than no-MAD -CPAP better than MAD for -< of AHI/ODI -sleep fragmentation MAD better than CPAP for patient preference MAD better than UPPP for AHI/ODI but snoring same for both.
Pharmacotherapy in obstructive airways disease
Short acting bronchodilators -salbutamol (ventolin), terbutaline (bricanyl turbohaler) Long acting bronchodilators -salmeterol (severent) -formoterol (oxis turbohaler) -formoterol (atimos MDI) Anticholinergic agents -ipatropium (Atrovent) -tiotropium (Spiriva) -glycoporronium (Seebri) -aclidinium (Elkira) Inhaled steroids -beclometasone (Clenil, Qvar) -budesonide (Pulmicort) -fluticasone (Flixotide) -ciclesonide (Alvesco) Oral steroids -prednisolone -deflazacort Theophyllines -nuelin SA -slophyllin Antileukotrienes -montelukast -zafilukast
Short acting bronchodilators
Relief of symptoms For PRN use Use in COPD & Asthma Immediate bronchodilation 4-6hour duration Increase in cAMP with reduction in cell Ca2+ leading to relaxation of smooth muscle
Short acting bronchodilators side effects
Increased HR & palpitations Tremor Hypokalaemia Headache Nervousness
Long acting bronchodilators
Alternative to increasing dose of steroids
Given by inhaled route
Not to be used in monotherapy in Asthma
High selectivity for B2 adenoceptor in pulmonary tissue
Can increase glucocorticord receptor availability
Long acting bronchodilators side effects
Concern of sudden cardiac death when used in monotherapy
Anticholinergic agents (block action of ACh)
Relief of symptoms
Primarily for COPD
Reduction in exacerbation frequency in COPD
Improvement in FEV1
Mode of action Blockade of muscarinic receptors M1-3
Systemic absorption low
Side effects of anticholinergic agents
Possible effect on urinary retention
Dry mouth
Possible adverse cardiovascular effects (seen in severe cardiac disease)
Inhaled steroids
Mainstay of asthma medication
Prevent symptoms
< risk of exacerbations and death
Usually 2x daily medication
Not useful in acute attack
Binds to cytosolic GR with reduction in cytokines
< bronchoconstriction and airway inflammation
Side effects of inhaled steroids
Oral candida
Voice change
Risk of skin bruising, bone mineral density change and cataracts with high dose
Oral steroids
Given in acute asthma or chronically in severe asthma
Avoid if possible as long term therapy but essential if asthma worsens
Clearer role in eosinophilic asthma
Time to efficacy 4hours for IV & PO routes
Side effects of oral steroids
Weight gain Hyperglycaemia Skin change Hypertension Eye change (cataracts) Mood change < bone mineral density
Theophyllines (help to relieve breathlessness by relaxing muscles in your airways so they open up, and the air can flow through them more easily)
Tablets and intravenous Useful in acute and chronic asthma Method of action unclear Possibly acting upon cAMP via PDE inhibition Possibly acting upon HDAC pathway Requires serum level monitoring Drug interactions
Side effects of theophyllines
Nausea Vomiting Palpitations Headaches Dyspepsia Arrhythmias Confusion
Antileukotrienes
Oral
Useful in chronic asthma
Not useful in acute asthma and not used in COPD
Role in exercise induced asthma & patients with aspirin hypersensitivity
Leukotrienes within phospholipid cell membranes and derived from inflammatory cells
Can promote smooth muscle contraction and inflammatory changes in airway wall
Side effects of antileukotrienes
Headache N&V Sleep disturbance Sore throat GI disturbance
1st line pharmacotherapy for Obstructive Airways (FOR REST SEE TABLE)
Asthma and COPD: short-acting B2 agonists PRN
Oxygen therapy
O2 is potentially dangerous drug Delivered by mask, nasal cannulae or ET tube Controlled i.e. concentration known -venturi systems, e.g. 24,28,35,60…% Uncontrolled i.e. concentration guessed -full face masks -cannulae – highly dependent on RR
Aim for acutely unwell pts on oxygen therapy
In majority of acutely unwell pts aim for SpO294-98% unless concern of hypercapnea
Aim for COPD and oxygen therapy
In COPD (or other conditions prone to type 2 RF e.g. OSA) – aim for SpO2>88-92% until ABG taken
Combination treatments
Used for COPD not asthma
Hypoxic drive
Form of respiratory drive in which the body uses oxygen chemoreceptors instead of carbon dioxide receptors to regulate the respiratory cycle
-typical of COPD
