Respiratory Health Flashcards
Features of acute severe asthma?
RR>25
HR>110
PEFR 33-50% of best or predicted
inability to complete sentences in 1 breath
Objective tests for asthma used in making a diagnosis?
Peak flow variability Spirometry FeNO (fractional exhaled nitric oxide) (results of 40 ppb or more is a positive test)-note levels can be lowered by patient's current smoking status
Use of skin prick tests in diagnosing asthma?
NOT used in diagnosis
however once diagnosis made, can be used to identify triggers.
Management of suspected occupational asthma in primary care?
refer to an occupational asthma specialist
When should a FeNO test be considered in children with suspected asthma?
in those aged 5 to 16, FeNO should be offered if there is diagnostic uncertainty after initial assessment AND either normal spirometry or obstructive spirometry with negative bronchodilator reversibility test.
(FeNO 35 or greater in children is positive)
What is the criteria for an obstructive spirometry result?
FEV1/FVC ratio of <70%
What is a positive bronchodilator reversibility test in the assessment of asthma in adults?
an improvement in FEV1 of 12% or more, together with an increase in volume of 200ml or more
When should peak flow variability be monitored in adults to help diagnose asthma?
in those where diagnostic uncertainty after clinical assessment and FeNO and either normal spirometry or obstructive spirometry, reversible airways obstruction but FeNO 39 or less. Consider offering if irreversible obstruction and FeNO 25-39.
What is a positive peak flow variability test in asthma diagnosis?
more than 20% variability
What is a positive result in direct bronchial challenge test for adults in testing for asthma?
20% fall in FEV1 of 8mg/ml or less
When should patients be reviewed if starting or having medication adjusted for asthma?
in 4-8 weeks
Next management step in adults with uncontrolled asthma on SABA+low dose ICS (equal to or less than 400 micrograms of budesonide or equivalent?
Add LTRA in addition (montelukast 10mg ON), if sx remain uncontrolled add LABA and consider whether or not to continue LTRA.
If on low dose ICS and LABA +/- LTRA and sx not controlled offer switch to MART-reliever and preventor 1 inhaler (LABA and low dose ICS).
Next management step in adults on MART (low dose ICS+LABA-fast acting, maintenance and reliever) with uncontrolled sx?
consider increasing ICS to a moderate maintenance dose (400-800 mcg budesonide or equivalent)
if still not controlled consider increasing ICS to high dose (only as fixed dose regimen with SABA as reliever) OR trial additional drug e.g. montelukast or theophylline OR seek advice from asthma healthcare professional
How to manage children under 5 suspected of having asthma and requiring maintenance therapy?
SABA plus 8/52 trial of moderate paediatric dose ICS, stop at 8/52 and review-if sx resolved then reoccurred within 4/52 of stopping ICS then restart ICS at low dose maintenance therapy.
if sx resolved and reoccurred beyond 4/52 of stopping ICS then rpt 8/52 trial.
Management of child under 5 with suspected asthma and uncontrolled sx on low dose ICS (less than or equal to 200mcg budesonide) and LTRA?
stop LTRA and refer child to expert
Advice in self management programme for adults with asthma using an ICS as a single inhlaer and asthma control deteriorated?
increase ICS for 7 days-consider quadrupling the regular ICS dose
When should a patient’s asthma maintenance therapy be considered to be decreased?
when their asthma has been controlled with their current maintenance therapy for at least 3 months.
Objective test to monitor asthma control?
spirometry and peak flow (NOT FeNO)
Organisms most commonly implicated in recurrent pulmonary infection in CF patients?
Children and early teenagers-staph aureus
(2nd most common is H.influenza)
Late teenagers and adults-P.aeruginosa
PO pred dose for asthma exacerbation in children?
<2 years, 10mg pred
2-5 years, 20mg pred
>5 years, 30-40mg pred
When to admit a patient with an asthma attack?
- Any life threatening features
- If severe asthma attack with any persistent severe sx post bronchodilator therapy
- If moderate asthma attack with worsening sx post bronchodilator therapy and/or previous near fatal asthma attack
Features that should prompt consideration of admission in a moderate exacerbation of asthma?
age under 18 years poor treatment adherence living alone/social isolation psych problems e.g. alcohol/drug misuse, depression physical or learning disability previous severe asthma attack pregnancy recent hosp admission recent nocturnal sx px in afternoon/evening exacerbation despite adequate dose of PO steroids prior to presentation
When to f/u patient in GP after asthma attack?
within 2 days after attack or admission
What HR defines an acute severe asthma attack in children aged >5-12 years?
125 or greater
What HR defines an acute severe asthma attack in children aged 1-5 years?
140 or greater
What RR defines an acute severe asthma attack in children aged >5-12 years?
RR 30 or more
What RR defines an acute severe asthma attack in children aged 1-5 years?
RR 40 or more
Next pharmacological step in managing stable COPD patient who remains breathless despite using PRN short acting bronchodilators (SABA or SAMA) e.g. salbutamol or ipratropium?
- Add combination therapy with inhaled LAMA and LABA if no features of steroid responsiveness.
- If they have asthmatic features or features of steroid responsiveness e.g. PEFR variability, eosinophilia, consider LABA+ICS instead.
If COPD patient is on LABA+ICS, when would you offer a LAMA?
- day to day sx continue to adversely impact their QOL or
- severe exacerbation (req hosp admission) or
- 2 moderate exacerbations within a year
If pt on LABA+LAMA for COPD when would you consider adding ICS?
severe exacerbation (req hosp admission) or 2 moderate exacerbations within a year
if sx adversely impacting daily life on LABA+LAMA but not meeting above criteria consider 3/12 trial of ICS.
When to consider prophylactic Abx therapy in COPD? (azithromycin 250mg 3 times a week)?
if don’t smoke AND
have optimised non-pharm management+inhaled therapies, vaccinations (influenza+pneumococcal) and pulm rehab referral AND
1 or more of:
-4 or more exacerbations with sputum production in 1 year
-prolonged exacerbations with sputum production
-exacerbations resulting in hospitalisation
Baseline tests before starting prophylactic azithromycin in COPD?
ECG to rule out QT prolongation
LFTs
- when starting, must advise patients about risk of hearing loss and tinnitus
- must also have a CT chest to exclude bronchiectasis
Tx for latent TB infection (dx with mantoux or interferon gamma release assay) ?
3 months of isoniazid (+ pyridoxine) and rifampicin or
6months of isoniazid
Tx for active TB?
6 months of Abx
Rifampicin, isoniazid (+pyridoxine), pyrazinamide and ethambutol for 2 months then continue rifampicin and isoniazid for a further 4 months
When should LT O2 therapy be considered for patients with COPD?
if don't smoke and: -either PaO2 <7.3 when stable (2 or more ABGs 3 weeks apart) OR -PaO2 7.3-<8 and either 1 of: secondary polycythaemia peripheral oedema pulmonary HTN
Which people despite meeting MRC criteria would be unsuitable for pulmonary rehab?
- unable to walk
- unstable angina
- recent MI
Initial examination/investigations recommended in suspected COPD?
post bronchodilator spirometry (WITHOUT reversibility testing)
CXR
FBC
BMI
2ww referral criteria for suspected lung cancer?
age 40 and over with unexplained haemoptysis
CXR findings that suggest lung cancer
When should an urgent (within 2wks) CXR be requested to assess for lung cancer?
if age 40 and over with 2 or more of the below unexplained sx or 1 or more of the below unexplained sx if have ever smoked:
- SOB
- cough
- CP
- fatigue
- weight loss
- loss of appetite
consider requesting if 40 and over with persistent/recurrent chest infection/cervical or SC lymphadenopathy/thrombocytosis/chest signs consistent with lung ca/clubbing.
What is the definition of abnormal neck circumference in the assessment of sleep-disordered breathing?
> 43cm in males
40cm in females
this is an idea of fat in the neck
Investigations for sleep apnoea?
sleep study (polysomnography)-gold standard overnight pulse oximetry
How is the severity of sleep apnoea graded?
Apnoea hypopnoea index (AHI)-number of apnoea and hypopnoea in 1 hr of sleep
mild: 5-15
moderate: 15-30
severe: more than 30
What can be offered by a sleep clinic for moderate or severe sleep apnoea?
CPAP or BiPAP
Tx of mild sleep apnoea?
lifestyle modifications:
weight reduction
regular exercise, healthy diet, reduce smoking and alcohol
sleep in lateral position
Who should receive antiviral tx for influenza?
‘at risk’ patients
give oseltamivir 75mg BD for 5/7 ideally within 48hr of sx onset
1st line Abx for acute exacerbation of bronchiectasis?
amoxicillin OR doxycycline OR clarithromycin for 7-14 days
Abx for CAP with CURB-65 score of 2 (moderate severity)?
amoxicillin + clarithromycin/erythromycin (if atypicals suspected)
From what age should patients be tested for CF related diabetes?
age 10, yearly OGTTs
note HbA1c often low in CF patients so not used for screening
1st choice of mucoactive agent for patients with CF who have clinical features of lung disease?
rhDNase
reduces frequency of exacerbations and rates of decline in lung function
can combine with hypertonic saline nebulisers
if above ineffective or not suitable can use mannitol dry powder
What is the blood spot at day 5 neonatal screening tested for to screen for cystic fibrosis?
level of immunoreactive trypsin (enzyme produced in the pancreas)
if significantly raised, sample is then tested for the most common CF mutations in caucasians.
Microbiological management of CF patients who are colonised with pseudomonas aeruginosa?
long term nebulised or inhaled antibiotics e.g. colistimethate (Colistin) or tobramycin.
Azithromycin used at specific immunomodulating doses can improve lung function and reduce hosp admissions in patients colonised with pseudomonas.
Management of CF patients with positive sputum cultures but asymptomatic?
aggressive management with antibiotics
For which complications following asbestos exposure can patients claim?
mesothelioma
lung cancer caused by asbestos
pleural thickening causing disability
asbestosis
Indications for hosp admission in exacerbation of COPD?
- SpO2 <90%
- severe SOB
- inability to cope at home
- poor or deteriorating general condition including significant co-morbidity e.g. insulin dependent diabetes, cardiac disease
- rapid onset of sx
- acute confusion or impaired consciousness
- cyanosis
- worsening peripheral oedema
- new arrhythmia
- failure to respond to initial tx
- already receiving LTOT
- changes on CXR
When might you consider co-amoxiclav to treat an infective exacerbation of COPD rather than amoxicllin/doxy/clarithromycin?
if person is at higher risk of tx failure e.g. frequent Abx use, previous or current sputum culture with resistant bacteria, or high risk of developing complications
note if pt not responding to 1st line Abx after 2-3 days then sputum culture should be sent
all patients should receive PO prednisolone 30mg for 5/7
When should patients be f/u after an exacerbation of COPD?
once condition stable e.g. around 6 weeks
When is Abx therapy considered in acute bronchitis?
- systemically very unwell
- pre existing comorbidities e.g. asthma
- raised CRP-20-100-delayed px, >100-immediate px
PO doxycycline 1st line, if CI then amoxicillin
