Respiratory GP Flashcards
Sore throat -
criteria to decide whether antibiotics are indicated?
FeverPain score
- Fever during previous 24 hours
- Purulence
- Attended rapidly (3 days or less)
- very Inflamed tonsils
- No cough/coryza
0-1 criteria: 13-18% streptococci, no antibiotic
2-3 criteria: 34-40% streptococci, 3 day back-up antibiotic
4 or more: 62-65% streptococci, immediate antibiotic if severe, or 2d back-up antibiotic
Guidance on treating common infections in primary care?
“Managing common infections: guidance for primary care”
by Public Health England, evidence based and regularly updated
https://www.gov.uk/government/publications/managing-common-infections-guidance-for-primary-care
Guidance on diagnosing and managing Asthma?
British Thoracic Society (BTS) and SIGN guideline of 2016
Diagnosing Asthma -
what is involved in a ‘structured clinical assessment’?
Structured clinical assessment
- a characteristic pattern of respiratory symptoms, signs and test results
- the absence of any alternative explanation for these
- grading the probability of asthma as high, intermediate or low
- a trial of treatment to confirm thye diagnosis, with investigations reserved to resolve diagnostic doubt
Diagnosing Asthma -
what features suggest asthma?
Episodic symptoms - more than one of: wheeze, breathlessness, chest tightness and cough, occurring in episodes with periods of no (or minimal) symptoms between episodes. For example:
- a documented history of acute attacks of wheeze, triggered by viral infection or allergen exposure with symptomatic and objective improvement with time and/or treatment
- recurrent intermittent episodes of symptoms triggered by allergen exposure as well as viral infections and exacerbated by exercise and cold air, and emotion or laughter in children
- in adults, symptoms triggered by taking NSAIDs or beta blockers.
Wheeze confirmed by a healthcare professional on auscultation - distinguish wheezing from other respiratory noises, such as stridor or rattly breathing. Repeatedly normal examination of chest when symptomatic reduces the probability of asthma.
Evidence of diurnal variability - symptoms which are worse at night or in the early morning.
Atopic history - personal history of an atopic disorder (ie eczema or allergic rhinitis) or a family history of asthma and/or atopic disorders, potentially corroborated by a previous record of raised allergen-specific IgE levels, positive skin prick tests to aeroallergens or blood eosinophilia.
Absence of symptoms, signs or clinical history to suggest alternative diagnoses (including but not limited to COPD, dysfunctional breathing, obesity)
Compare peak flows or FEV1 undertaken whilst a patient is asymptomatic with those undertaken when symptomatic to detect variation over time.
Diagnosing Asthma -
when is asthma highly probably,
what steps should you take?
High probability of asthma:
- typical clinical assessment including recurrent episodes of symptoms (attacks)
- wheeze heard on auscultation by a healthcare professional
- a historical record of variable airflow obstruction
- a positive history of atopy
- without any features to suggest an alternative diagnosis.
Next steps
- Code as ‘suspected asthma’
- Trial of treatment, inhaled corticosteroids for typically 6 weeks
- Reassess with symptom questionnaire +/- serial home peak flows or clinic FEV1
If response is good, symptomatic and objectively: asthma diagnosis confirmed, record on which basis diagnosis is made
If response is poor or equivocal: check adherence and inhaler technique, arrange further tests and consider alternative diagnoses
Diagnosing asthma -
intermediate probability of asthma?
Intermediate probability of asthma:
- some, but not all, of the typical features of asthma on an initial structured clinical assessment, or
- did not respond well to a monitored initiation of treatment.
Next steps
- In adults and children with an intermediate probability of asthma and airway obstruction on spirometry, undertake reversibility tests and/or a monitored initiation of treatment assessing response to treatment by repeating lung function and objective measures of asthma control.
- In children with an intermediate probability of asthma who cannot perform spirometry:
- consider watchful waiting if the child is asymptomatic
- monitored trial of treatment if symptomatic.
- In adults and children with an intermediate probability of asthma and normal spirometry results, refer for challenge tests and/or measurement of FeNO to identify eosinophilic inflammation.
Diagnosing asthma -
low probability of asthma?
Low probability
- do not have any of the typical features on initial structured clinical assessment
- have symptoms suggestive of an alternative diagnosis
Next steps
- investigate for the alternative diagnosis, and/or
- undertake or refer for further tests of asthma
What are the aims of asthma management?
The aim is control of asthma, defined as:
- no daytime symptoms
- no night time waking due to asthma
- no need for reliever inhalers
- no asthma attacks
- no limitations on activity including exercise
What matters is that the patient is and feels in control of their asthma. Validated symptom questionnaires like the ‘asthma control test’ (see below) ask these questions and should be used to assess effective management.
Other aspects:
- normal lung function (FEV1 and/or PEF >80% of predicted or best values)
- minimal side effects from medication.
Primary prevention of asthma -
what is recommended?
- Breast feeding is encouraged for its protective effect
- Obese and overweight children should be offered weight-loss programmes
- No exposure to smoking which increases the risk of wheezing and asthma
- Measures to reduce in utero or early life exposure to single aeroallergens, such as house dust mites or pets, or single food allergens, are not recommended.
Secondary prevention of asthma?
- Parental smoking cessation
- Weight loss if overweight or obese
- Breathing exercise programmes (including physiotherapist-taught methods) can be offered to people with asthma as an adjuvant to pharmacological treatment to improve quality of life and reduce symptoms.
Inhaled corticosteroids - categories of doses?
Doses of ICS are expressed as
- very low (paediatric)
- low (adult starting dose)
- medium
- high
ICS and doses are listed on page 9 of the quick reference guide:
Should we use combination inhalers?
In efficacy studies, where there is generally good adherence, there is no difference in efficacy in giving inhaled corticosteriod and a long-acting β2 agonist in combination or in separate inhalers.
In clinical practice, however, it is generally considered that combination inhalers aid adherence and also have the advantage of guaranteeing that the long-acting β2 agonist is not taken without the inhaled corticosteroid.
The relevance of exercise-induced asthma?
For most patients, exercise-induced asthma is an expression of poorly controlled asthma and regular treatment including inhaled corticosteroids should be reviewed.
Rules for inhaler devices?
- Choice of device may depend on choice of drug.
- If patient is unable to use a device satisfactorily, try a different one.
- Practise and reassess inhaler technique as part of structured clinical review.
- Medication needs to be titrated against clinical response.
- Generic prescribing of inhalers should be avoided so people don’t receive unfamiliar devices.
- Use the same type of device to deliver preventer and reliever treatments.
- In children, a pMDI and spacer are preferred. A face mask is required until the child can breathe reproducibly using the spacer mouthpiece. Where this is ineffective a nebuliser may be required.
What do SABA, LABA, ICS, LRA and pMDI stand for?
SABA = short-acting beta agonist
LABA = Long-acting beta agonist
ICS = Inhaled corticosteroid, doses expressed as very low (paediatric), low (usual adult starting dose), medium and high
LRA = leukotriene receptor antagonist
pMDI = pressurised metered dose inhaler
Asthma treatment - what are the steps?
Steps of asthma treatment:
- Trial of treatment / Regular preventer = ICS low dose
- Initial add-on therapy = ICS low dose + LABA in combination inhaler
- Additional add-on therapies = ICS medium dose + LABA, consider adding other treatments (LRA, LAMA, Theophylllin)
- High dose therapies = ICS high dose + LABA, a fourth drug, + Referral
- Add daily oral steroids at lowest possible dose, + Referral
SABA as required at all steps, move up a step if more than 3 doses/week.
Move up to improve control as needed
Move down to maintain lowest effective dose
What would make you think of the possibility of an occupational cause of asthma?
Occupational asthma
- Adult onset or reappearance of childhood asthma
- Are you better on days away from work?
- Are you better on holiday?
Those with positive answers should be investigated for occupational asthma.
Asthma in pregnancy - what should we advise?
Importance of maintaining good control of asthma during pregnancy to avoid problems for mother and baby.
Importance and safety of continuing asthma medications during pregnancy to ensure good asthma control.
Acute asthma (asthma attack) is categorised as moderate, severe and life-theatening -
when is it moderately severe?
Moderately severe asthma attack adults
- Increasing symptoms
- PEF >50-75% of best or predicted values
- No features of severe asthma
Children
- Able to talk in sentences
- SpO2 >92%
- PEF >50% of predicted or best
- HR <140 age 1-5, or <125 age >5
- RR <40 age 1-5, or <30 age >5
When is it a severe asthma attack?
Severe asthma attack adults
- PEF 33-50% best or predicted
- Respiratory rate >25/min
- Heart rate > 110/min
- Inability to complete sentences in one breath
Children
- Cannot complete sentences in one breath
- SpO2 <92%
- PEF 33-50% best or predicted
- HR >140 age 1-5, or >125 age >5
- RR >40 age 1-5, or >30 age >5
When is it a life-threatening asthma attack?
Life-threatening asthma, adults
- Severe asthma plus any one of
- PEF <33% best or predicted
- SpO2 <92%
- Silent chest
- Cyanosis
- Poor respiratory effort
- Arrhythmia
- Exhaustion, altered conscious level
Children
- Severe asthma plus any of:
- Silent chest
- Cyanosis
- Poor respiratory effort
- Hypotension
- Exhaustion
- Confusion
- SpO2 <92%
- PEF <33%
Principles of treating an asthma attack
999 if any feature of life-threatening or near-fatal asthma attack, or
any feature of severe asthma persisting after initial treatment
Oxygen to maintain SpO2 between 94-98%
Salbutamol high dose as first-line as early as possible. Nebulisers preferrably driven by oxygen. If poorly responsive to an initial dose of β2 agonist, consider continuous nebulization.
Ipratropium bromide (0.5mg 4–6 hourly) added to Salbutamol in severe or lifethreatening asthma or poor initial response to Salbutamol.
Steroids – Prednisolone (40–50 mg daily) continued for at least five days or until recovery.
Routine prescription of antibiotics is not indicated for patients with acute asthma.
Asthma treatment - when and how to step down
Patients should be maintained at the lowest possible dose of inhaled corticosteroid.
Reduction in inhaled corticosteroid dose should be slow as patients deteriorate at different rates.
Reductions should be considered every three months, decreasing the dose by approximately 25-50% each time.
Regular review as treatment is decreased is important. When deciding which drug to decrease first and at what rate, the severity of asthma, side effects of the treatment, time on current dose, beneficial effect achieved, and patient’s preference should all be taken into account.
