Respiratory symptoms Flashcards
Asthma first presentation - education
- Disease prevalence
- Ages at which may appear/disappear
- Association with other atopic disorders in that person or family
- Use of diagram to explain basic pathophysiology - bronchospasm, inflammation and mucus production
- Commonly seen sx
- Range of possible severities
- Episodic vs. continuous sx
- Determine if known precipitants of attack
Asthma first presentation - mx
a. Immediate
1. Organise spirometry and record measurements
2. Prescribe short acting B2 agonist (reliever) medication - salbutamol
3. Go through dose, technique, duration of use, use of spacer if appropriate
4. Prescribe inhaled corticosteroids (most pts) - beclomethasone or budesonide
5. Mention common side effects of medications used
6. Importance of seeking medical advice if sx not improving
7. F/U in 2-7d time to check PFTs, sx and proper use of medications, then review regularly after that
b. Long-term
1. Advise on appropriate use of medications for recurrent attacks with regards to timing and duration
2. Advise importance of review with PFTs and appropriate control
Asthma first presentation - prevention
- Discuss probable need for relieving medication prior to exercise and also impacting agents including fixed dose combination medication (?)
COPD - education
- Smoking, exposure to particulate matter/dusts /gases as causative factors
- Decreased surface area for respiratory exchange
- Irreversible nature of condition. Can cease progression if stop smoking
- Seriousness of problem. Slow recovery from pneumonia. Propensity to URTIs/LRTIs. SOB at night and on exertion. Potential underlying asthma. Night heart failure
COPD - mx
a. Immediate
1. Measure PEFR (peak expiratory flow rate) before and after bronchodilatory - airflow limitation is irreversible or only partially reversible (spirometry preferable)
2. Review puffer technique (if coexisting asthma)
3. Short acting beta-2 agonists - salbutamol or terbutaline (why do you use these if they do not reverse airflow limitation?)
4. Add tiotropium (Spiriva) or ipratropium bromide (Atrovent) to regimen
5. Add inhaled corticosteroids, e.g. budesonide (consider it as a trial for 6 weeks and continue only if beneficial)
6. Consider possibility of home oxygen if arterial PO2
7. F/U in 2-7d time to check PFTs, sx and proper use of medications, then review regularly after that
COPD - prevention/reinforcement
- Influenza and pneumococcal vaccine
- Early treatment of intercurrent respiratory infections
- Regular surveillance of medication needs by doctor
- Avoid places with polluted air and other irritants such as smoke, paint fumes and fine dust
- Go for walks in clean, fresh air
- Course of abx to have on hand as soon as an infection develops (recommended = amoxycillin or doxycycline)
Other preventive measures
- Reduction in alcohol intake
- Weight control
Reinforcement - help pt to accept chronicity of problem
- Living within functional limits
- Offer to explain/discuss problems with partner
- Support and ongoing care by doctor
Hayfever - explanation
- Allergic etiology (oversensitive rx in upper respiratory tract)
- Association with patient’s hx of asthma/eczema
- Seasonal problem - role of grasses, pollens, etc. (October and November are the worst months in Australia)
- Not an infection
Hayfever - mx
a. Immediate (several alternatives)
1. Prescribing antihistamine tablets - preferably non-sedating variety, e.g. fexofenadine (Telfast) 180mg daily, loratadine (Claratyne) 10mg daily
i. Trial over weekend, when not driving
ii. Possibly use only at night
iii. Explain that there is still a possibility of some sedation
2. Intranasal steroid spray
i. Warn that it will not give immediate relief (takes 7-10d for symptom control)
ii. Must be used throughout hayfever season
3. Intranasal sodium chromoglycate
i. Compliance may be a problem - required 4-6x/d
4. Tx conjunctivitis
i. Sodium chromoglycate (preferred) or hydrocortisone drops for symptomatic relief
5. Arrange F/U if sx not adequately controlled with proposed regime
b. Long-term
1. Avoid allergens wherever possible
2. Early tx of symptoms in future seasons
3. Discuss role of allergy testing and desensitisation only if symptoms are severe in long term and not adequately controlled by other available methods
Hayfever - prevention
Driving and accident avoidance
Influenza in returned traveller with RF - explanation
- Presentation typical of viral influenza but other infectious diseases have to be kept in mind
- Infection probably acquired through contact with infected person while overseas
- Explain that it is unlikely to be Avian influenza or SARS because it is uncommon and more likely to be acquired in SE Asia
- At risk of complications if pre-existing respiratory problems (e.g. bronchiectasis)
- Good outcome likely but will be improved by taking anti-influenza medication within 48h of symptom onset. Insufficient time to get confirmatory influenza tests
Influenza in returned traveller with RF - mx
a. Immediate
1. Bed rest with good nursing care is essential
2. Antiviral medication, immediately and continue for 5d (indicated). Oseltamivir (Tamiflu) 75mg orally BD for 5d. Avoid zanamivir if pre-existing lung disease
3. High fluid intake
4. Analgesics - e.g. paracetamol + NSAIDs
5. Cease smoking
6. Review initially within a few days
Ix
- CXR
- If abx to be started, get sputum specimen to laboratory. Ciprofloxacillin orally. If no response, need IV antibiotics guided by sensitivities
Other
9. Pt can be mx at home but may require hospital admission
b. Intermediate
1. Close monitoring - domiciliary follow-up visit may be required
2. Referral for physiotherapy
Influenza in returned traveller with RF - prevention
- Reinforce smoking cessation
- Reduce alcohol
- Regular F/U
- Annual influenza vaccine
- Pneumococcal vaccine - one initial dose, then one booster 5y later
OSA - explanation
- Snoring results from obstruction of upper airway
- Sleep apnoea = cyclical brief interruptions of ventilation. Results in hypoxaemia and arousal from sleep (often not recognised by pt). Interruption then followed by resumption of normal breathing, a return to sleep and then further interruptions of ventilation
- OSA = cessation of airflow >10s with intermittent occlusion of upper airway. Results in snoring + hypoxaemia
OSA - mx
a. Immediate
1. Lifestyle modification
i. Weight reduction
ii. Reducing alcohol intake
iii. Reducing nasal stuffiness, with nasal sprays or occasionally nasal surgery
iv. Stopping or reducing sleeping or sedating tablets
v. Improving lung function (increasing asthma tx, ceasing smoking)
2. Refer to a sleep disorder centre for sleep polysomnography (sleep study)
b. Long-term
1. For pts with moderate to severe OSA, ongoing GP mx and support as they begin long-term tx with:
i. Continuous positive airway pressure devices (CPAP machine), or
ii. Mandibular advancement splints, or
iii. Corrective ENT surgery
2. F/U every 2 weeks (initially) to reinforce lifestyle changes and check compliance regarding long-term tx for OSA
OSA - prevention
- Follow guidelines RE smoking, alcohol, weight reduction
- Screening blood tests -fasting BSL, lipids
- Other screening opportunities - mammogram, pap smear, colon cancer screening
