Respirology Flashcards
Emphysema etiology
Destruction of alveoli
Chronic bronchitis etiology
Inflammation of the bronchioles
Chronic bronchitis diagnosis
Clinical diagnosis
Chronic cough + sputum >3 months/year x 2 years
COPD risk factors
Smoke exposure/inhaled chemicals
Alpha 1 antitrypsin deficiency
Severe childhood respiratory disease/asthma
COPD epidemiology
4.4% Canadians
Female more common than male
4th leading cause of death
COPD screening
Spirometry if
- Smoker/ex smoker, >40 y/o and sx (persistent cough, phlegm, wheeze, recurrent URTI, exertional SOB)
- > 40 y/o with resp symptoms AND environmental exposure/frequent resp infections/family history of COPD
COPD diagnosis
- Spirometry
Fixed post bronchodilator FEV1/FVC < 0.7 - Alpha1 antritrypsin serum level if <65 y/o or smoking history of <20 pack years
COPD classifications
COPD Assessment Tool (CAT) or modified Medical Research Council (mMRC)
Mild - SOB with hurried walk, recurrent chest infections, FEV1>80%
Moderate - SOB requiring rest ~100m/few mins, limits in daily activities, exacerbations requiring corticosteroids +/- abx, FEV1 50-79%
Severe - Breathless after dressing, resp/cardiac failure, FEV1 30-49%
Routine management/prevention of AECOPD
Smoking cessation - single most effective intervention
Vaccines - annual influenza + pneumococcal (+booster @5 years)
Puffers - review technique + action plan
Activity - negative repercussions of inactivity (ESOB is not life threatening!!), stay indoors when air quality is poor
Which pharmocological agent slows progression of COPD
None
Pharmacotherapy evaluation follow up time frame
6 months or 12 months if it includes an ICS
Pharmacotherapy approach COPD
Mild
- Short acting bronchodilator (SABD) prn only
- LAMA (preferred) or LABA
Moderate/Severe and low risk of AECOPD 0-1 moderate AECOPD in last 12 months
- LAMA (preferred) or LABA
- LAMA/LABA
- LAMA/LABA/ICS
Moderate/Severe and high risk of AECOPD 2+ moderate AECOPD or 1+ severe AECOPD
- LAMA/LABA (preferred) or ICS/LABA (consider if blood eosinophil 300 uL+ or concomitant asthma)
- LAMA/LABA/ICS
- Oral therapies (macrolide, Raflumilast, N-acetylcysteine)
Examples of short acting bronchodilators
Short acting muscarinic antagonists
Ipratropium (Atrovent) 2 puffs QID
Short acting beta 2 agonists
Salbutamol (Ventolin) 1-2 puffs QID
Terbutaline (Bricanyl) 1 puff QID
SAMA/SABA
Ipratropium + salbutamol (Combivent) 1 puff QID
Examples of LAMAs
Long acting antimuscarinic antagonist
Tiotropium (Spiriva) 1 cap/2 puffs once daily
Aclidinium (Tudorza) 1 puff BID
Glycopyrronium (Seebri) 1 cap once daily
Umeclidinium (Incruse) 1 puff once daily
Examples of LABAs
Long acting beta2 agonists Salmeterol (Serevent) 1 puff BID Formoterol (Oxeze) 1 cap/6-12 ug BID Indacaterol (Onbrez) 1 cap inahled once daily Olodaterol 2 puffs once daily
Examples of LAMA/LABAs
Umeclidinium + vilanterol (Anoro) 1 puff once daily
Glycopyrronium + Indacaterol (Ultibro) 1 puff once daily
Tiotropium + Olodaterol (Inspiolto) 2 puffs once daily
Aclidinium + Formoterol (Duaklir) 1 puff BID
Examples of LABA/ICS
Formoterol + budesonide (Symbicort) 12/400 mcg BID
Salmeterol + fluticasone (Advair) 50/250 mcg BID
Vilanterol + fluticasone (Breo) 1 puff once daily
Role of ICS in COPD
No monotherapy!
Blood eosinophil 300 uL+ predicts response to ICS (unlikely to respond if 0-100)
Note increase risk of pneumonia with ICS use but no change in mortality
AECOPD definition
Sustained >48h worsening of symptoms (dyspnea, cough, sputum volume/purulence)
Classification of AECOPD severity
Mild - change in sx but no abx or steroids needed
Moderate - abx +/- steroids
Severe - hospitalization/ER visit
AECOPD causes
Infection (50%)
H. influenza, S. pneumonia, M. catarrhalis
CHF
Irritants
PE
MI
Anemia
AECOPD management
- Ventolin + LAAC (Spiriva)
- For moderate to severe give 30-40 mg prednisone/day x 5 days with no taper. Usually must persist >48h before starting oral steroids or abx
- Increased purulence (or moderate to severe symptoms) - antibiotics
If point of care CRP <40 then patient likely does not need abx
Simple - 5 days (FEV1>50%, mild-mod, 0-3 exacerbations/year, no cardiac disease)
First line
a) Amoxicillin 500 mg TID
b) Doxycycline 100 mg BID x 1 day then 100 mg once daily
c) Tetracycline 250-500 mg QID
d) TMP/SMX 2 tabs BID or 1 DS tab BID
Second line
a) Clarithromycin 500 mg BID OR 1000 mg extended release once daily
b) Azithromycin 500 mg x 1 then 250 mg once daily x 4 days OR 500 mg once daily x 3 days
c) Cefuroxime 500 mg BID
d) Cefprozil 500 mg BID
Complicated/high risk 7-10 days (FEV1 <50%, 4+ exacerbations/year, cardiac disease)
First line
a) Amoxicillin/Clavulanate 500 mg TID or 875 mg BID
Second line
a) Levofloxacin 500 mg once daily x 7 days or 750 mg once daily x 5 days
b) Moxifloxacin 400 mg once daily
At risk of Pseudomonas (FEV1<35% predicted, chronic steroids, constant purulent sputum)
1. Ciprofloxacin 500-750 mg BID
Indication for pulmonary rehabilitation in COPD
Remains dyspneic despite dual therapy LAMA/LABA
What is the target oxygenation level in COPD
Goal sats >90%
Survival advantage if arterial oxygen <55 mm Hg
When to refer COPD cases
Diagnosis uncertain Symptoms severe/unproportionate to spirometry Failure to respond to therapy Accelerated decrease of lung function Onset 0-40 y/o Complex co-morbidities Assessment for pulmonary rehabilitation Home oxygen Surgical therapy
Indications for continuous long-term oxygen therapy (LTOT) for patients with chronic lung disease include
●Arterial oxygen tension (PaO2) less than or equal to 55 mmHg (7.32 kPa), or a pulse oxygen saturation (SpO2) less than or equal to 88 percent
●PaO2 less than or equal to 59 mmHg (7.85 kPa), or an SpO2 less than or equal to 89 percent, if there is evidence of cor pulmonale, right heart failure, or erythrocytosis (hematocrit >55 percent)
For patients with normal awake oxygenation, oxygen may be prescribed during sleep if any of the following occur during sleep:
the PaO2 is 55 mmHg or less
the SpO2 is 88 percent or less
the PaO2 decreases more than 10 mmHg (1.33 kPa), and/or the SpO2 decreases more than 5 percent with signs or symptoms of nocturnal hypoxemia (eg, impaired cognitive function, morning headaches, restlessness, or insomnia). In this setting, portable oxygen would not be covered.
Oxygen may be prescribed during exercise if there is a reduction of
PaO2 to 55 mmHg or less
or SpO2 to 88 percent or less during exercise.
Additionally, oxygen may be warranted during exercise even in those patients who do not significantly desaturate during exercise, if they have dyspnea and ventilatory abnormalities during exercise that suggest supplemental oxygen may permit greater exertion. This is supported by studies that found that hyperoxia increases exercise endurance in a dose-dependent manner, up to an inspired oxygen fraction of 50 percent or a flow rate of 6 L/min.
The use of supplemental oxygen in the palliative treatment of dyspnea in non-hypoxemic patients is not well supported by the literature. Pharmacological management is first line for this
Asthma triggers
Cold air Exercise Viral illness Allergen Irritant Food (sulphites, MSG, cold drinks) Meds (beta blockers, NSAIDs, aspirin) Strong emotion
Asthma aggravating comorbidities
Rhinitis/rhinosinusitis Sleep apnea GERD Obesity Stress/depression/anxiety Psychosocial issues
Asthma prevention
Primary
Conflicting evidence for avoiding early life exposure to pets, unless both parents are atopic then stronger evidence
Secondary
Avoid tobacco
Tertiary
Allergens that patients are sensitive to should be identified and systematically removed
Diagnosis <6 years old
Patient and family history
If refractory to tx exclude other pathology
Assess for atopy which predicts persistent asthma
Age 1-5 years old
Abandon terms such as “reactive airway” “bronchospasm”
Require all 3 of the following during 2+ episodes
- Documentation of airflow obstruction (cough/difficulty breathing/wheeze)
- Preferred: documented by physician
- Alternative: convincing parental report of wheezing - Documentation of reversibility of airflow obstructions
- Preferred: physician observed improvement in signs of airflow obstruction to SABA +/- oral corticosteroid
Mild symptoms, 4 puffs salbutamol, reassess 30 min
Mod symptoms, 4 puffs salbutamol, reassess 60 min (may need 2-3 doses of 4 puffs within 60 min)
OR mod symptoms oral steroid (dexamethasone 0.15-0.6 mg/kg max 50 mg) 1 dose, reassess in 3-4 hours
- Alternative: convincing parental report of symptomatic response to 3 month trial medium dose ICS with PRN SABA, expect 50% decrease in # off exacerbations (should document daytime/nighttime symptoms, SABA use, exacerbations) - No clinical evidence of an alternative diagnosis
Diagnosis asthma 6+ years old
- Patient and family history
- MUST have spirometry and in its absence, a positive methacholine or exercise challenge test or sufficient peak expiratory flow variability
- If refractory to treatment, exclude other pathology
- Assess for atopy which predicts persistent asthma
- Any signs/symptoms of variable lower airway obstruction + response to therapy suggests asthma diagnosis but definitive diagnosis needed
DO NOT order full pulmonary function testing or CXR to confirm asthma unless questioning a diagnosis other than asthma
For accuracy, discontinue ICS+/- LABA 24 hr prior to spirometry
Spirometry (preferred) - Children >6 Decreased FEV1/FVC <0.8-0.9 Increased FEV1 12% with bronchodilator - Adults Decreased FEV1/FVC <0.75-0.8 Increased FEV1 12% with bronchodilator
PEF (alternative) - Children >6 Increased min 20% with bronchodilator - Adults Increased 60L/min (min 20%) with bronchodilator Diurnal variation >8% if measured BID
Methacholine
PC20 <4 mg/mL (4-16 borderline, >16 negative)
Exercise
Decreased FEV1 minimum 10% post exercise
Asthma control
Daytime symptoms <4 days/week Need for Ventolin < 4 dose/week Night-time symptoms <1 night/week FEV 1 or PEF 90%+ personal best PEF diurnal variation <15% Sputum eosinophils (mod to severe asthma) <3% Physical activity normal Exacerbation mild, infrequent Absence from work/school secondary to asthma none
Asthma nonpharmacologic management
Encourage aerobic exercise
Strongly encourage smoking cessation
Consider avoiding NSAIDs (10-20% are sensitive to NSAIDs/aspirin and non-cardioselective BB)
Avoiding all allergens and environmental triggers is unrealistic
If risk of anaphylaxis, ensure auto-renewable prescription of epi-pen
Consider annual influenza vaccination
SABA drugs, doses, routes
Short acting beta 2 agonist (SABA)
- Ventolin (Salbutamol) 100 mcg 2 puffs q4-6 hours
- Bricanyl Turbuhaler (Terbutaline) 2.5 mg 1-2 puffs q6h
Inhaled corticosteroid adverse effects
Delay growth velocity
Oral thrush
Dysphonia
Risk of LABA monotherapy
Associated with increase asthma morbidity
Role of SAAC in asthma
less effective than SABA
ICS drugs, doses, routes
Inhaled corticosteroid
- Flovent (fluticasone) 50, 125, 250 mcg 1 puff BID
- Pulmicort (Budesonide) 100, 200, 400 mcg 1 puff BID
ICS + LABA drugs, doses, routes
ICS + long acting beta 2 agonist (LABA) ** NO LABA MONOTHERAPY
- Symbicort budesonide/formoterol 100/6, 200/6 2 buffs BID
- Advair fluticasone/salmeterol 100/50, 250/50, 500/50 1 puff BID
LTRA drugs, doses, routes
Leukotriene receptor antagonists (LTRA)
- Singulair (montelukast) 4 mg granules, 4 mg tablets chewable, 5 mg tablets chewable, 10 mg tablets - 1 tab PO Qpm
6-11 years old asthma medication ladder
SABA (Ventolin) prn
- ICS (Flovent 50 ug BID)
- Increase ICS dose (Flovent 100 ug BID)
- ICS + LABA (Advair 100/50 BID) REFER
or
ICS + LTRA (Flovent 125 BID + Singulair) REFER - Increase ICS + LABA (Advair 250/50 ug BID)
12 Years old and older asthma medication ladder
SABA (Ventolin) prn
- ICS (Flovent 50-125 ug BID)
- ICS + LABA (Symbicort 100/6 or Advair 100/50 BID)
* Symbicort can be used as a controller and reliever in 12+ yo - Increase ICS + LABA (Symbicort 200/6 BID or Advair 250/50 BID) REFER
OR
ICS/LABA + LTRA (Advair/Symbicort + SIngulair) REFER - Increase ICS/LABA +LTRA (high dose Advair or Symbicort + Singulair)
When to step up asthma therapy
- Usually using first line medications if no risk factors for exacerbations AND 0-1 daytime symptoms per month
- Second line meds if risk factors for exacerbations OR 2-8 daytime symptoms/mo or awakenings at night. Can consider intermittent ICS
- Usually using 3rd line if daytime symptoms most days or awakening 4+ nights per month. REFER IF MODERATE DOSE ICS IS INSUFFICIENT IN A CHILD
- Respirology may consider high dose ICS/LABA, LAMAs (in adults), biologic therapy (Anti-IgE, Anti-IL5) or oral prednisone)
Consider step down therapy only if exacerbation risk is low and asthma is well-controlled for at least 3 months
Classifying severity of asthma exacerbation in <6 y/o
PRAM score
SaO2
0- 95%+
1- 92-94%
2- 0-91%
Suprasternal retraction
0- absent
2- present
Scalene contraction
0-absent
2- present
Air entry 0- normal 1- decreased at the base 2- decreased at the apex/base 3- minimal or absent
Wheeze 0- absent 1- expiratory 2- inspiratory 3- audible without stethoscope
0-3 mild
4-7 moderate
8+ severe
Indications to transfer asthma case 6+ years old to acute care with O2, SABA, ipratropium + reliever
Severe or life threatening:
Posture - Hunched forward, not talking in sentences
Decreased consciousness
Quantitative findings RR >30 P >120 O2 0-89% Accessory muscle use Silent chest
Acute asthma exacerbation action plan for 6-11 years old
If on SABA - consider starting regular ICS
If on ICS and SABA - Prednisone 1 mg/kg x 3-5 days (max 50 mg) OR dexamethasone 0.15-0.6 mg/kg/d (max 10 mg)
If on ICS/LABA and SABA - Prednisone 1 mg/kg x 3-5 days (max 50 mg) OR dexamethasone 0.15-0.6 mg/kg/d (max 10 mg)
Notes
- Warn parents to seek medical attention if child exposed to varicella
- In preschool children, dexamethasone can be given at 0.15-0.3 mg/kg/d as the first dose to subsequent 2-4 day course of prednisone or at 0.6 mg/kg/day as part of a 1-2 day course
- CPS recommends prednisone or dexamethasone in children
- 6 RCTs prednisone x 5d = dexamethasone 0.3-0.6 mg/kg/day x 1-2 days (less vomiting with dexamethasone)
Acute asthma exacerbation action plan for 12+ years old
If on SABA - consider starting regular ICS
If on ICS and SABA -
increase ICS 4 fold x 7-14 days OR
Prednisone 30-50 mg 5+ days
If on Symbicort +/- SABA -
Increase Symbicort 4 puffs BID x 7-14 days OR
Prednisone 30-50 mg x 5+ days
If on Advair and SABA or Symbicort -
Increase ICS 4 fold x 7-14 days OR
Prednisone 30-50 mg 5+ days
Notes
- Warn parents to seek medical attention if child exposed to varicella
- CPS recommends prednisone or dexamethasone in children
- 6 RCTs prednisone x 5d = dexamethasone 0.3-0.6 mg/kg/day x 1-2 days (less vomiting with dexamethasone)
Asthma criteria for hospital admission
Unable to speak sentences
Tachypnea >25/min
Tachycardia >110/bradycardia
PEF <40% predicted
Silent chest
Cyanosis
Confusion
Management of status asthmaticus
Oxygen
CXR, ABG, PEF
B2 agonists with spacer, anticholinergic therapy, corticosteroids
IV salbutamol prn
Structured evaluation at scheduled asthma visits
- Document height and weight of children + adolescents (growth velocity and potential side effects of corticosteroid)
- Document signs and symptoms of adrenal suppression
- Review disease control, symptoms, activity level, triggers and comorbidities
- Review risks for exacerbations (hx exacerbations, hospitalizations, intubations, cormobidities, environmental irritants, FEV1 <60%, very high SABA use ex. >1 canister/month, nonadherence/no action plan)
- Review medication adherence and action plan (technique, barriers)
- F/u within 1-3 months of diagnosis + initiating treatment and then at least twice per year or as clinically needed. Serial FEV1 (spirometry) at 3-6 months after initiating tx and q1-2 years once control achieved or as clinically indicated
Why can you use same dose of asthma medication regardless of age
auto-scaling
When to refer asthma patients
Children 1-5 with 2+ exacerbations needing oral steroid or 8+ symptom days/month despite moderate ICS
Children 6-11 who fail control on medium dose ICS
Recurrent need of oral steroids or frequent symptoms 8+/month
Diagnostic uncertainty
Need for environmental allergy testing
Suspected occupational-related asthma
Considering immunotherapy/biologic therapy
