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Medicine - Year 2 > The respiratory system - Breathlessness airflow > Flashcards

The respiratory system - Breathlessness airflow Flashcards

1
Q

List the different causes of asthma

A

Atopic asthma

Hygiene hypothesis

Aspirin-induces asthma

Occupation asthma

Excercise-induced asthma

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2
Q

a) What is atopy?

b) What are the 3 conditions that atopic individuals are predisposed to?

A

a) Atopy is a genetic predisposition to IgE-mediated allergen sensitivity

b)
- Allergic asthma
- Atopic dermatitis
- Allergic rhinitis

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3
Q

Patients with aspirin-induced exhibit Samter’s triad.

What is involved in Samter’s triad

A
  • Asthma
  • Aspirin sensitivity
  • Nasal polyps
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4
Q

Summarise the pathophysiology of asthma

A

The pathophysiology of asthma includes airway narrowing due to bronchial muscle contraction (bronchoconstction), inflammation caused by mast cell degranulation and increased mucus production

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5
Q

describe the histology seen in asthma

A

Curschmann spirals, which are where shed epithelium becomes whorled mucous plugs

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6
Q

List 5 pathological changes in asthma

A
  • Thinking of basement membrane
  • Hypertrophy of smooth muscle
  • Vasodilation
  • Oedema of mucosa and submucosa infiltration with eosinophils and neutrophils
  • Mucous plug
  • Desquamation of epithelium
  • Mucous gland hyperplasia
  • Thickening of basement membrane
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7
Q

Clinical features of asthma

a) Symptoms

b) Signs

A

a)
- Cough (may be worse at night)
- Dyspnoea
- Chest tightness
- Poor sleep

b)
- Polyphonic expiratory wheeze
- Prolonged expiratory phase
- Tachypnoea
- Hyperinflated chest
- Hyperresonant on percussion
- Harrison’s sulcus: a groove at the inferior border of the rib cage that may be seen in children with chronic sever asthma

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8
Q

Describe the symptoms, vitals, saturations and PEFR for the following severity of asthma attacks

a) Moderate

b) Severe

c) Life-threatening

d) Near-fatal

A

a)
Symptoms - increasing symptoms of asthma

Vitals - RR < 25 and pulse < 110 bpm

Saturations - ≥ 92%

PEFR - ≥ 50-70%

b)
Symptoms - can’t complete sentences

Vitals - HR ≥ 110, RR ≥ 25

Saturations - ≥ 92%

PEFR - ≥ 33-50%

c)
Symptoms - silent chest, cyanosis, exhaustion, confusion, poor respiratory effort

Vitals - PaO2 < 8kPa

Saturations - < 92%

PEFR - < 33%

d) Raised PaCO2 or requires mechanical ventilation with raised inflation pressures

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9
Q

Name the 1st and 2nd line diagnostic tests involved in asthma

A

1st line - Lung function testing: Spirometry and bronchodilator reversibility

2nd line -
- Peak expiratory flow rate (PEFR)
- Eosinophilic inflammation E.g., Fractional exhaled nitric oxide (FeNO) testing, blood eosinophilia, skin-prick testing

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10
Q

Describe the diagnostic changes seen in spirometry in asthma

A

FEV1: Reduced

FVC: may be normal but often reduced (due to air trapping)

FEV1/FVC: < 70%

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11
Q

How can asthma and COPD be differentiated in diagnostic testing?

A

Bronchodilator reversibility is demonstrated in asthma, but not COPD

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12
Q

What level of bronchodilator reversibility is diagnostic in asthma?

A

Increased in FEV1 OF 12% (15% in exercise-induced asthma)

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13
Q

What is the role of peak expiratory flow rate?

A

To monitor asthma

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14
Q

What PEFR variability is diagnostic in asthma?

A

> 20% is diagnostic

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15
Q

What level of FeNO is diagnostic of asthma?

A

FeNO > 40 parts per billion (ppt)

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16
Q

List the criterial for specialist asthma referral

A
  • Diagnosis is unclear
  • Suspected occupational asthma
  • Poor response to treatment
  • Severe/life-threatening attack
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17
Q

Name the urgent investigations required in an acute asthma attack and their purpose

A

ABG - type II respiratory failure is a sign of life-threatening attack

Routine blood tests - to look for precipitating causes of an asthma attack e.g., infection

Chest x-ray - to exclude differentials

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18
Q

Describe the 1st line, 2nd line, 3rd line and follow up discharge management of an acute asthma attack

A

1st line
- Ipatriopium bromide nebuliser 500mcg: given 4-6 hourly
- Salbutamol nebuliser 2.5mg
- Oxygen if sats < 94%
- Steroids: prednisolone PO 40-50mg or hydrcoritsone. Continued for at least 5 days

2nd line
- IV magnesium sulphate
- Beta 2 agonist infusion
- IV aminophylline

3rd line
- Intensive care admission which may involve invasive ventilation

Follow up discharge
- for a patient to be discharged from hospital follow an asthma attack they must be stable on their regular asthma regime for 24 hours
- Review Inhaler technique before discharge

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19
Q

What are the indications for. patient to be discharged following an asthma attack?

A

Patient must be stable on their regular asthma regime for 24 hours

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20
Q

Describe the non-pharmacological management of chronic asthma

A
  • Smoking cessation
  • Avoidance of precipitating factors (e.g., known allergens)
  • Review inhaler technique
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21
Q

Describe the pharmacological management of adult chronic asthma

A
  1. SABA as PRN therapy (salbutamol) Low-dose ICS
    • LABA: Salmaterol, formeterol
  3. Increase ICS or LTRA (leukotriene receptor antagonist)
  4. Specialist referral
22
Q

Describe the pharmacological management in paediatric chronic asthma

A
  1. SABA as PRN therapy + very low dose ICS
  2. If ≥ 5 yo LABA, if <5 you add LTRA
  3. Increase ICS to low dose or if ≥ 5 yo add LABA/LTRA. If no response to LABA consider stoping it
  4. Specialist referral
23
Q

Name 3 ways to measure asthma disease control

A
  • RCP 3 questions
  • Asthma control questionnaire (ACQ)
  • Asthma control test
  • Mini-asthma quality of life questionnaire
24
Q

Name 3 asthma mimics and describe their symptoms

A

Acid reflux - dry cough, wheeze, SOB, hoarse voice, dental erosions, chest pain

Churg-Strauss syndrome - asthma, peripheral neuropathy, glomerulonephritis

Allergic bronchopulmonary aspergillosis (ABP) - wheeze, cough, dyspnoea, sputum production, reduced exercise intolerance

25
Q

What is COPD?

A

A clinical syndrome characterised by:
- Chronic bronchitis
- Emphysema
- Obstructive bronchiolitis

26
Q

Describe the epidemiology of COPD

A
  • Predominately affects adults > 40 years old
27
Q

Name two causes of COPD

A
  • Smoking
  • Alpha-1 antitrypsin deficiency
28
Q

How is alpha-1 antitrypsin deficiency inherited?

A

It is an autosomal recessive disorder with co-dominant expression

29
Q

Describes how alpha-1 antitrypsin deficiency causes COPD

A

Alpha-1 antitrypsin is a protease inhibitor that is synthesised by the liver. It acts in the lung parenchyma to oppose the action of elastase

Elastase is a protease that causes the breakdown of elastin, a protein important to the structural integrity of the alveoli. This causes emphysema

Smoking increases the risk of these patients’ developing symptoms

30
Q

Describe the pathophysiology of COPD

A

Chronic bronchitis - leads to goblet hyperplasia, mucus hyper secretion, chronic inflammation, fibrosis and narrowing of small airways

Emphysema - alveolar wall destruction

Obstructive bronchiolitis

31
Q

Risk factors of COPD

a) Host factors

b) Exposure

A

a)
- Genetic (alpha-1 antitrypsin deficiency)
- Lung growth, low BW, age

b)
- Tobacco smoke
- Biomass fuels, open fires
- Occupational dusts and exposures
-Chronic uncontrolled asthma
- Lower socioeconomic status

32
Q

Clinical features of COPD

A

a)
- Chronic cough: usually productive
- Sputum production
- Breathlessness: usually on exertion in early stages
- Frequent episodes of ‘bronchitis’: usually in winter
- Wheeze

b)
- Dyspnoea
- Pursed lip breathing
- Wheeze
- Coarse crackles
- Loss of cardiac dullness (due to hyper expansion of lungs from emphysema)
- Downward displacement of liver (due to hyper expansion of lungs from emphysema)
- Signs of CO2 retention: drowsy, asterixis, confusion
- Signs of cor pulmonale: peripheral oedema, raised JVP, hepatomegaly (causes left parasternal heave)

33
Q

Describe the features of an acute exacerbation of COPD

A

Temperature
- Pyrexia > 38 degrees Celsius (if infective)

Respiratory distress
- Accessory muscle use
- Pursed lip breathing
- SOB

Productive cough
- Sputum

CO2 retention
- Flapping tremor
- Confusion

Auscultation
- Crackles
- Wheeze

34
Q

What scale is used to grade the severity of breathlessness

A

mMRC dyspnoea scale

35
Q

Describe the diagnostic changes seen in spirometry in COPD

A

FVC: May be normal but often reduced

FEV1: Reduced

FEV1/FVC: <70%

36
Q

Describe the factors that cause spirometry variation

A

Height - tall people have larger lungs

Age - respiratory function declines with age

Sex - lung volumes smaller in females

Race - studies show blacks and asians have smaller lung volumes

Posture - little difference between sitting and standing; reduced in supine position

37
Q

What features are supportive of COPD (vs asthma)?

A
  • Smoker or ex-smoker
  • Symptoms in older adults (> 35 years old)
  • Chronic productive cough
  • Persistent/progressive breathlessness
  • Nigh-time waking with symptoms uncommon
  • Variability uncommon (diurnal or day-to-day)
38
Q

Describe the following stages of COPD according to severity, FEV1/FVC, FEV1% predicted

a) Stage 1

b) Stage 2

c) Stage 3

e) Stage 4

A

a)
Severity: mild
FVE1/FVC: < 0.7
FEV1% predicted: ≥ 80

b)
Severity: moderate
FVE1/FVC: < 0.7
FEV1% predicted: 50-79

c)

Severity: severe
FVE1/FVC: < 0.7
FEV1% predicted: 30-49

d)
Severity: very severe
FVE1/FVC: < 0.7
FEV1% predicted: < 30

39
Q

Describe the investigations involved in COPD and their indications

A

Bedside
- Observations: pulse oximetry
- BMI
- Sputum culture: signs of infection
- ABG: if hypoxia or hypercapnia is suspected
- ECG: if cor pulmonate suspected

Bloods
- FBC: assess for anaemia and polycythaemia. Signs of infection
- Alpha-1 antitrypsin levels

Imaging
- CXR
- CT scan: if lunger cancer suspected, alternative diagnosis suspected
- Echocardiogram: if cor pulmonate suspected

40
Q

Describe the CXR changes in COPD

A

Hyperexpanded lungs

Flattened hemidiaphragms

Increased number of anterior ribs

Saber-sheath trachea diffuse coronal narrowing of the intrathoracic portion of the trachea with the concomitant widening of the sagittal diameter)

41
Q

What 3 parameters are used to diagnosis

A

Symptoms

Risk factors

Spirometr

42
Q

Describe the non-pharamocologcial management of COPD

A
  • Education
  • Smoking cessation
  • Vaccination: influenza, pneumococcal
  • Pulmonary rehabilitation
  • Self-management plans: rescuer pack with antibiotics and steroids
  • Management of co-morbidities
  • Nutrition including vitamin D supplementation
  • Review inhaler technique and adherence
43
Q

Describe the pharmacological management of stable COPD

A
  1. SABA or SAMA
  2. LABA + LAMA or LABA + ICS is evidence of steroid responsiveness or asthmatic features)
  3. LABA + LAMA + ICS (If on LABA + LAMA then 3 month trial of triple therapy and if on LABA + ICS then triple therapy straight away)
44
Q

Name the oral therapies apart from inhalers that can be used in COPD and their indications

A

Corticosteroids - acute exacerbations

Theophylline - bronchodilator actions

Mucolytics - used in patients with a chronic productive cough to reduce frequency of cough and sputum productions

Antibiotics - for infective acute exacerbations

45
Q

Describe the management of an acute exacerbation of COPD

A

Oxygen - in acute setting use non-rebreather mask but once confirmed they are a CO2 retainer use a Venturi mask with target rate of 88-92%

Bronchodilator - salbutamol 2.5mg nebulised, ipatroprium 500mcg nebulised

Corticosteroids - prednisolone 30mg once daily given for at least 5 days

Antibiotics - to treat exacerbations of COPD with signs of infection (e.g., more purulent sputum). Can use doxycycline or co-amoxiclav

46
Q

Why must you be cautious when using oxygen therapy in COPD users and how is the prevented

A

Patients who have COPD may be CO2 retainers, therefore high oxygen may cause CO2 to increase. Therefore at increased risk of developing T2RF

This is prevented by using a venturi mask with a saturation target of 88-92%

47
Q

Describe the indications for Bilevel Positive Airway Pressure (BiPAP) in COPD

A
  1. Acute or acute or chronic hypercapnia respiratory failure
  2. Cardiogenic pulmonary oedema
  3. Type 1 respiratory failure and clinically tiring
  4. Weaning from mechanical ventilation
48
Q

a) Describe the indications of long-term oxygen therapy (LTOT)

b) How long should patients be on LTOT per day and how much oxygen should they be on in order to see a benefit?

c) What must you advise patients before LTOT?

A

a)
- Pao2 < 7.3 kPa OR
- PaO2 < 8 kPa with any of: pulmonary hypertension (pulmonary artery pressure > 25mmHg)
- Increases respiratory rare optimisation of oxygen therapy

b) LTOT is required for at least 15 hours a day/at 2-4 litres/min

c) Must stop smoking 3 months before

49
Q

Name 5 complications of COPD

A
  • Cor pulmonale
  • Respiratory failure
  • Pneumonia: often recurrent
  • Pneumothorax: rupture of bulls disease
  • Polycythaemia or anaemia
  • Depression
50
Q

Other causes of a chronic cough

a) Intrathoracic

b) Extrathoracid

A

a)
- Asthma
- Lung cancer
- Tuberculosis
- Left heart failure
- Interisital lung disease
- Cystic fibrosis
- Idiopathic cough

b)
- Chronic allergic rhinitis
- Post nasal drip syndrome
- Upper airway cough syndrome
- Gastroesophageal reflux
- Medications (e.g., ACEi)

51
Q

Other causes of a chronic cough

a) Intrathoracic

b) Extrathoracid

A

a)
- Asthma
- Lung cancer
- Tuberculosis
- Left heart failure
- Interisital lung disease
- Cystic fibrosis
- Idiopathic cough

b)
- Chronic allergic rhinitis
- Post nasal drip syndrome
- Upper airway cough syndrome
- Gastroesophageal reflux
- Medications (e.g., ACEi)

52
Q

What are indications to step up the management of asthma/COPD

A
  • Ongoing symptoms
  • PRN (If > 3 doses/week)

Medicine - Year 2 (27 decks)

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