Week 10 - Asthma / COPD and HTN / CKD / Hyperlipidaemia Flashcards
Chronic kidney disease - list the causes and risk factors for developing CKD
Causes:
- Hypertension
- Diabetes
- Glomerulonephritis
- Interstitial nephritis
- Polycystic kidney disease or other inherited kidney diseases
- Prolonged obstruction
- Recurrent pyelonephritis
Risk factors:
- Older age
- Hypertension
- Diabetes
- Smoking
- Nephrotoxic medications
Chronic kidney disease - list some symptoms and signs
Symptoms:
Can usually be asymptomatic
- Fatigue / lethargy
- Itchy skin
- Loss of appetite
- Confusion
- Insomnia
- Pulmonary oedema
- Peripheral oedema
Signs:
- Hypertension
- Oedema
- Electrolyte disturbances
- Anaemia
Chronic kidney disease - list some investigations to help confirm a diagnosis of CKD
- U&Es, looking at eGFR and serum creatinine
- Urine albumin:creatinine ratio (ACR), look for proteinuria
- Urine dip, look for haematuria
- (Renal) KUB ultrasound, for atypical patients
Chronic kidney disease - list some complications of CKD and how they are treated
Metabolic acidosis - oral sodium bicarbonate
Anaemia - iron supplementation and erythropoietin
Renal bone disease - Vitamin D
End stage renal failure - dialysis or renal transplant
Chronic kidney disease - list some indications for referral to a specialist
- eGFR < 30
- Raised ACR (≥ 70 mg/mmol)
- Accelerated progression defined as a 25% decrease in eGFR in 1 year
- Uncontrolled hypertension despite ≥ 4 antihypertensives
- Rare/genetic cause of CKD
Chronic kidney disease - outline the management steps
Slow progression:
- Optimise diabetic control
- Optimise hypertensive control
- Treat glomerulonephritis
Reduce risk of complications:
- Offer immunisations for influenza and pneumonia
- Exercise, maintain a healthy weight and stop smoking
- Special dietary advice about phosphate, sodium, potassium and water intake
- Offer atorvastatin 20mg for primary prevention of cardiovascular disease
Outline a rough definition of chronic kidney disease including how long it has to exist for
Reduction in kidney function or structural damage, present for > 3 months
Outline how chronic kidney disease is diagnosed (which parameters are looked at)
Markers of kidney damage:
- ACR ratio of > 3 mg/mmol
- Electrolyte disturbances
- Histological abnormalities (biopsy)
- Structural abnormalities (imaging)
Reduction in eGFR of < 60 ml.min.1.73m2
Outline any monitoring required for chronic kidney disease patients, looking for disease progression
Measure:
- eGFR
- ACR ratio
- FBC (anaemia)
- Serum calcium phosphate, PTH and vitamin D (renal bone disorder)
List some medications that might be offered in the management of CKD, to reduce CVS complications
Statins
- (20mg dose) used for primary prevention
Dapagliflozin
- SGLT2 inhibitor
Outline steps on how to reduce the risk of an AKI happening
- Regularly monitor U&Es (creatinine)
- Discuss the risk of AKI occuring in those with dehydrating conditions or nephrotoxic drugs
- Avoid nephrotoxic medications where possible
- Consider admission to hospital if pt appears hypovolaemic in primary care
Outline the ranges for hypertension classification (diagnostic criteria)
Normal < 120/80
Pre-hypertensive 120/80-140/90
Stage 1 hypertension 140/90 - 160/100
Stage 2 hypertension 160/100 - 180/120
Stage 3 hypertension either 180 or 120
Outline the symptoms of hypertension, including how hypertension presents in primary care
Almost always asymptomatic unless significant (> 180/110)
- Headaches
- Blurred vision
- Chest pain
- Dizziness
- Difficulty breathing
- Nausea / vomiting
- Anxiety
Outline some complications of hypertension
- Heart failure
- Coronary artery disease
- Stroke
- CKD
- PAD
- Vascular dementia
- Retinopathy
Outline the order of investigations for hypertension
If BP consistently over 140/90, offer:
- Ambulatory blood pressure monitoring
- Home blood pressure monitoring
Whilst waiting for confirmation, offer:
- Investigations for target organ damage or secondary causes of hypertension
- Assess CVS risk
Outline the lifestyle advice and medication management steps for hypertension
Lifestyle advice:
- Smoking cessation
- Reduce alcohol
- Reduce stress
- Increase exercise
- Weight loss / low fat diet
Medication:
- ACE-i / ARB or CCB
- Add other one in
- Add Thiazide-like diuretics e.g. Indapamide
- Add Spironolactone or beta-blocker
- Statins (QRISK score first)
Outline the investigation of hypertension in the following situations:
- Under 140/90
- 140/90 to 180/110
- > 180 or > 110
Under 140/90:
- Check BP every 5 years (sooner if very close to 140/90)
140/90 to 180/110:
- Offer ABPM (HBPM alternative)
- Investigate for target organ damage (non-urgent)
- Assess CVS risk factors
> 180 or > 110:
Urgent assessment for target organ damage
If target organ damage = start anti-hypertensives (without ABPM/HBPM)
If no target organ damage = repeating reading in 7 days and ABPM/HBPM and ensuring
Same-day specialist review if:
• Papilloedema
• Retinal haemorrhage
• Life-threatening symptoms
• Suspected pheochromocytoma
Outline the criteria for same-day specialist assessment for hypertension
Clinic BP either > 180 or >120 WITH signs of:
- Papilloedema
- Retinal haemorrhage
- Life threatening signs e.g. confusion, chest pain, HF, AKI
- Suspected pheochromocytoma
List BP targets in the following conditions
- Age < 80 years
- Age > 80 years
- CKD
- CKD and diabetes
Age < 80 years = < 140/90
Age > 80 years = < 150 / 90
CKD = between 120-140 / 90
CKD and diabetes (lower) = between 120-130 / 90
Outline the monitoring for hypertension
Annual review including:
- BP reading
- Review medication
- Discuss lifestyle
- Discuss issues with symptoms / medication
Outline the 2 possible causes of hypercholesterolaemia
- Familial hypercholesterolaemia
- Secondary hypercholesterolaemia
Outline when you would suspect that someone might have familial hypercholesterolaemia
- Total cholesterol greater than 7.5
- Personal or family history of premature CVS event (before 60 in a 1st degree relative)
- May also see tendon xanthomas or corneal arcus
Generally requires specialist involvement and genetic counselling
Outline some common causes of secondary hypercholesterolaemia
Lifestyle:
- Obesity
- Smoking
- Alcohol
Conditions:
- Diabetes
- Hypothyroidism
- CKD
- Nephrotic syndrome
- Primary biliary cholangitis (PBC)
- Pheochromocytoma
- Cushing’s syndrome
Drugs
List some drugs that can cause secondary hyperlipidaemia
- Steroids / Immunosuppressants
- Diuretics (thiazide)
- Beta-blockers
- Oestrogen / Progesterone
- Anti-HIV drugs
- Atypical antipsychotics
- Retinoids
State the name of the tool used to assess need for statin therapy in primary care
QRISK2 tool
Outline the role of the QRISK score, what the % score means and the significance of it being raised (>10%)
QRISK score is carried out to assess for the need of statin medication
- Estimates the percentage risk that a patient will have a stroke or myocardial infarction in the next 10 years
- QRISK of 10% means there is a 1 in 10 chance of developing a heart attack or stroke within the next 10 years
- If QRISK > 10%, offer a statin, initially Atorvastatin 20mg at night
Statins are also offered to all patients with:
- T1DM (for >10 years or over 40 years)
- CKD
Outline some complications of hyperlipidaemia
Cardiovascular disease
- Angina and ACS
- Stroke / TIA
- Peripheral arterial disease and claudication
- Acute limb ischaemia
- Erectile dysfunction
Outline the management of hyperlipidaemia for primary prevention and secondary prevention, including lifestyle advice and medications
Primary prevention - QRISK score:
Less than 10% = offer lifestyle changes e.g. healthy diet, increased exercise, weight loss, smoking cessation
Greater than 10% (or with T1DM if older or CKD) = offer 20mg Atorvastatin at night
Secondary prevention - higher doses (previous/existing CVD e.g. MI):
80mg Atorvastatin
Outline some rare and significant side effects of statins
- Myopathy
- Rhabdomyolysis
- Type 2 diabetes
- Haemorrhagic strokes (very rarely)
List some blood tests required prior to starting statins
- Lipid profile
- LFTs
- U&Es including eGFR
- HbA1c
- Creatine kinase (if muscle pains)
- Thyroid function tests if dyslipidaemia
What medication is offered to T1DM and CKD patients for primary prevention of CVS disease (hypercholesterolaemia)
20mg Atorvastatin
Don’t need to do a QRISK score - just give automatically
T1DM - if had it for > 10 years or > 40 years old
Outline the timing of a review after statins have been prescribed (including long term follow up timing)
Review after 3 months of treatment
Aim for a greater than 40% reduction in non‑HDL cholesterol
If this is not achieved, consider:
- Discuss adherence and timing of dose
- Optimise adherence to diet and lifestyle measures
- Consider increasing the dose
Thereafter - annual medication review to discuss:
- Medicine adherence
- Lifestyle modification
- CVD risk factors
Outline the dose of statin in
- Primary prevention
- Secondary prevention
Primary prevention: 20mg Atorvastatin at night
Secondary prevention: 80mg Atorvastatin at night
Outline the spirometry results for the following in terms of FEV1 and FVC and the FEV1:FVC
- Obstructive lung disease
- Restrictive lung disease
- Mixed picture disease
Obstructive lung disease
FVC = normal
FEV1 = decreased
FEV1:FVC = < 0.7
Restrictive lung disease
FVC = decreased
FEV1 = normal
FEV1:FVC = 0.7 or above
Mixed picture disease
FVC = decreased
FEV1 = normal
FEV1:FVC = decreased
How often should peak flow measurements be done when someone is first diagnosed with asthma
Twice a day for about 2-4 weeks
Can use a PEFR diary to track scores
What’s the name of a new test that’s being trialled in primary care, to replace a PEFR
Exhaled nitric oxide test (FeNO)
- Measures nitric oxide levels is exhaled breath
- Levels can be increased in active airway inflammation
- However may be affected by smoking and inhaled corticosteroids
List the 3 types of inhalers (different types of substance)
- MDI
- DPI
- SMI
(MDI) metered dose inhalers (pressurised) - generates an aerosol which is inhaled
(DPI) dry powder inhalers - dry powder is inhaled
(SMI) soft mist inhalers - soft mist is inhaled
Briefly outline how to use a spacer with an inhaler
- Attach the spacer
- Sit upright and tilt chin slightly upwards
- Press inhaler once
- Breathe in and out slowly and steadily 5 times
Outline the characteristic asthma symptoms as well as signs of asthma
Characteristic asthma symptoms (need 1 for diagnosis):
- Dry cough - often worse at night and early in morning
- Wheeze
- Shortness of breath
- Chest tightness
- History of other atopic conditions
Can vary over time and in intensity
Asthma signs:
- Reduced chest expansion
- Audible wheeze or wheeze on auscultation
- Tachypnoea
- Tachycardia
- Reduced O2 sats
- Reduced PEFR
Outline some risk factors for asthma
- Personal history of atopy (hay fever or eczema)
- Family history of asthma
- Viral respiratory infections early in life
- Passive or active smoking
- Air pollution
Outline how asthma is diagnosed
Based on clinical probability (but it’s not a clinical diagnosis)
High probability = try treatment
Intermediate probability = perform spirometry with reversibility testing
Low probability = consider referral and investigation for other causes
First line investigations:
- Spirometry with bronchodilator reversibility
If there is uncertainty after first line investigations, further testing:
- FeNO (fractional exhaled nitric oxide)
- PEFR variability (twice a day for 2 weeks)
- Direct bronchial challenge test with histamine or methacholine (done in hospital, irritates airways to recreate asthma symptoms)
Outline some steps undertaken when someone is first diagnosed with asthma and what advice should be given
Management steps:
- Assess baseline lung function e.g. PEFR or validated questionnaire e.g. Asthma control questionnaire
- Provide with asthma management plan
- Ensure they are up to date with vaccinations
- Arrange occupational health referral if occupational asthma
- Assess for anxiety / depression
Prescribe:
- Prescribe PEFR for home
- Prescribe appropriate medications, including inhaler technique
- Check inhaler technique
Advice:
- Advise about trigger avoidance
- Advise on smoking cessation
- Advise on weight loss
- Offer breathing exercise programmes
What follow up should a newly diagnosed asthma patient receive? What routine follow up should they expect in the future?
Regular follow ups to start off with, to review progress and adherence/satisfaction with medications e.g. 4-6 weeks
Future: review at least once annually
- Determine whether their treatment needs to be changed
- Closer monitoring of people with severe asthma, recent history of attack, poor lung function
Outline what a personalised asthma action plan involves
- List of asthma triggers
- Best PEFR
- Medications taken
- What to do if worsening of symptoms (% of normal PEFR)
- Emergency action for an asthma attack (% of normal PEFR)
- Date of next review
Outline some parameters in which you can tell if asthma is under control
- No daytime symptoms and no waking at night due to asthma
- No asthma attacks
- No rescue medication needed
- No limitations on exercise
- Minimal side effects from medication
Outline what is covered in an annual asthma review
Annual review to cover:
- Number of asthma attacks / use of rescue packs
- Night time symptoms / affect on sleep
- Adherence to medication
- That they have their asthma management plan
- Check smoking exposure
Outline the general pharmacological mangement steps for asthma
Stepwise approach based on BTS guidelines - can move up and down the ladder
Want to be on the minimum level of treatment that has no symptoms
- Short acting beta agonist (SABA) e.g. Salbutamol
- Low dose ICS e.g. Beclometasone
- Long acting beta agonist (LABA) e.g. Salmeterol
- Leukotriene receptor antagonist (LTRA) e.g. Montelukast
Can have Maintenance and Reliever combined (MART) - LABA and ICS
Can move back down the ladder if symptoms free for 3 months
Outline some non-pharmacological mangement steps for asthma
- Avoidance of triggers if possible
- Work modifications if occupational asthma e.g. redeployment or protective breathing equipment
- Smoking cessation if they smoke
- Avoidance of NSAIDs and other drugs
- Weight loss
- Breathing exercises e.g. Papworth method (breathing in slowly through your nose and breathing out through pursed lips as if blowing out a candle)
Outline how asthma management changes for children
- Paediatrics (5-17)
- Under 5
Paediatrics (5-17):
- Use SABA e.g. Salbutamol when required
- Use VERY LOW DOSE ICS one a day
Under 5:
- Use SABA e.g. Salbutamol when required
- Don’t use ICS, use Montelukast instead
What parameters do you look at in assessing the severity of a patient’s asthma attack?
- PEFR
- HR
- RR
- O2 sats
- Ability to complete sentences
- Skin colour (cyanosis)
- Presence of wheeze / silent chest
- Conscious level
- Maybe ABG
If someone requires hospital admission for a severe asthma attack, what steps can be taken when waiting for a transfer?
- Controlled oxygen if low O2 sats
- Give 5mg Salbutamol nebuliser driven by O2, back to back (inhaler if nebuliser not available)
- Consider Ipratropium Bromide
- Quadruple (4x) ICS dose at start of asthma attack (if not suitable, given oral Prednisolone)
- Monitor PEFR
If someone has an asthma attack, but doesn’t require hospital admission, what steps can be taken?
- Salbutamol inhaler (via a spacer)
Adult = 4 puffs initially, followed by 2 puffs every 2 minutes, up to 10 puffs
Child = puff every 30–60 seconds, up to 10 puffs
Repeat every 10–20 minutes according to response - Consider quadruple ICS dose at start of asthma attack, continue for 2 weeks after the attack (if not suitable, prescribe course of oral Prednisolone)
- Safety net and check inhaler technique
Recommend that they monitor their PEFR and seek advice if symptoms worsen again
If someone has an asthma attack, either has been admitted to hospital or not, when should you follow them up next?
Follow-up within 48 hours of presentation (can be 2 working days if hospital admission - slightly more lenient)
List some core symptoms of COPD (not signs)
- Productive cough (constant throughout the day)
- SOB
- Wheeze
On a b/g of:
- Significant smoking history
- Recurrent chest infections
- May be evidence of cor pulmonale if late presentation e.g. leg oedema, syncope
List some clinical signs of COPD
- Cyanosis
- Asterixis if CO2 retention
- Pursed lip breathing
- Barrel chest deformity
- Wheeze on auscultation
- Coarse crackles on auscultation
- Hyperresonance on percussion
- Prolonged expiratory phase, may have reduced breath sounds
List some risk factors for COPD
- Significant smoking history / exposure to smoke
- Exposure to irritating particles e.g. occupational dust
- Family history of alpha-1 antitrypsin deficiency
- Air pollution
- History of childhood respiratory infections
- History of asthma
List possible chest x-ray findings for COPD
- Barrel chest deformity / hyperexpansion
- Flattened diaphragm (may have floating heart sign, from flattened diaphragm)
- May also show complications of COPD e.g. pneumonia / pneumothorax
Outline what an FBC for someone with COPD might show
- Polycythaemia / raised haematocrit (response to chronic hypoxia)
- Anaemia
- Possible increased WBC count
Outline some investigations that might be carried out to confirm a diagnosis of COPD
- Spirometry with reversibility testing
- Chest x-ray
- FBC (including for anaemia, WCC, CRP)
- Alpha-1 antitrypsin levels
- PEFR
Investigations to rule out other conditions e.g. CT thorax, sputum culture, quantiferon test
Investigations for heart disease e.g. ECG or echo
Outline why cor pulmonale can occur in COPD and other chronic lung diseases
- Lung disease causes inflammation, loss of capillaries at the alveoli and hypoxia
- This causes chronic vascular resistance, leading to pulmonary hypertension
- Chronic hypertension causes increased strain on the right side of the heart, leading to eventual failure
Outline the aims of COPD management
- Prevent / control symptoms
- Reduce frequency / severity of exacerbations
- Increase exercise tolerance
- Reduce mortality
- Prevent further deterioration
- Improve quality of life
Outline what asthma-COPD overlap syndrome is and some factors that might suggest it
- Official diagnosis of asthma or atopy (i.e. diagnosed when younger and continued to smoke)
- Eosinophilia
- Substantial variation over time in FEV1
- Substantial diurnal variation in PEFR
Outline the non-pharmacological management for COPD
Non-pharmacological:
- Smoking cessation (reduce other risk factors)
- Pulmonary rehabilitation / advice exercise
- Offer immunisations
- Develop a personalised self-management plan
- Manage other comorbidities
Outline the pharmacological management for COPD
Initial management:
- SABA e.g. Salbutamol inhaler or SAMA inhaler e.g. Ipratropium bromide
Ongoing management: (if symptoms/exacerbations are still an issue)
- No asthmatic features LABA inhaler e.g. Salmeterol or LAMA inhaler e.g. Tiotropium
- Asthmatic features LABA + ICS
May also need:
- Mucolytics e.g. Carbocisteine
- Long term prophylactic antibiotics (e.g. azithromycin)
- Long term oxygen therapy at home
- Oral Theophylline
- Roflumilast (phosphodiesterase inhibitor - reduce inflammation)
When should patients be referred for long term oxygen therapy in COPD? What should be checked before providing oxygen at home?
Severe COPD that is causing problems such as:
- Chronic hypoxia (<92% on air)
- Polycythaemia
- Cyanosis
- Cor pulmonale (peripheral oedema or raised JVP)
Check if patient smokes
Can’t be used if they smoke = significant fire hazard
When should someone be referred for pulmonary rehabilitation for COPD and when is it not appropriate?
Referral if:
- Patient are functionally disabled by COPD (unable to do ADLs) = usually MRC dyspnoea 3
- Recent hospitalisation due to exacerbation
Not appropriate:
- Patient unable to walk
- Patient had a recent MI or unstable angina
Outline the inhalers given to patients with COPD in the following circumstances:
- 1st line for all symptomatic COPD patients
- Patients without asthmatic features / steroid responsiveness
- Patients with asthmatic features / steroid responsiveness
1st line for all symptomatic COPD patients:
- SABA e.g. Salbutamol inhaler
- SAMA inhaler e.g. Ipratropium bromide
Patients without asthmatic features / steroid responsiveness:
- LABA inhaler e.g. Salmeterol
- LAMA inhaler e.g. Tiotropium (add ICS if asthmatic features)
(may add on ICS if severe exacerbations)
Patients with asthmatic features / steroid responsiveness:
- LABA inhaler e.g. Salmeterol
- ICS e.g. Beclometasone
(may add on LAMA if severe exacerbations)
Outline some features which separate a severe COPD exacerbation from an otherwise mild exacerbation
- Significant breathlessness
- Significant tachypnoea
- Pursed-lip breathing
- Use of accessory muscles at rest
- New-onset cyanosis
- New-onset peripheral oedema
- Acute confusion or drowsiness
- Marked reduction in activities of daily living
Mild exacerbation:
- Worsening breathlessness
- Cough with increased sputum volume and purulence / change in colour
- Wheeze
- Fever without an obvious source.
- Recent URTI (past 5 days)
- Tachypnoea
- Tachycardia
If someone requires hospital admission for a severe COPD exacerbation, what steps can be taken when waiting for a transfer?
- Controlled O2 therapy within hypercapnic model of 88-92%
- Salbutamol inhaler / nebuliser
If someone has a COPD exacerbation, but doesn’t require hospital admission, what steps can be taken?
- Increase the dose of SABA, may need a nebuliser
- Consider 5 day course oral corticosteroids
- Consider antibiotics e.g. Amoxicillin
If someone has an exacerbation of COPD, either has been admitted to hospital or not, when should you follow them up next?
Follow up when they are clinically stable e.g. 6 weeks later
What safety netting advice should you give to a patient with a mild/moderate COPD exacerbation (doesn’t require hospital admission) who has been given antibiotics
- Potential adverse effects, including diarrhoea
- Seek medical help if symptoms worsen rapidly or symptoms do not start to improve within 2–3 days (might be a longer time frame if antibiotics haven’t been given)
Outline what it means by ‘end-stage COPD’
- Severe and worsening decline in symptoms, QOL and functioning
- Acute exacerbations are common and increase the risk of dying
List some medications that can help breathlessness in end-stage COPD
Opiates e.g. Morphine
Benzodiazepines e.g. Lorazepam
Oxygen (not LTOT)
When should you refer someone to hospital for an asthma attack?
- Features of a life-threatening asthma exacerbation e.g. cyanosis, PEFR <33%, O2 sats < 92%, silent chest, low HR and RR, altered conscious level
- Features of severe asthma attack persisting after initial treatment
- Admit people with a moderate asthma exacerbation with worsening symptoms with the following: previous near-fatal asthma attack, under 18 years, pregnancy etc.
When should you refer someone to hospital for an acute COPD exacerbation?
- Cyanosis
- O2 sats < 90%
- Impaired consciousness / acute confusion
- Rapid onset of symptoms / severe breathlessness
- New onset arrhythmia
- Failure of exacerbation to respond to initial treatment
- Already on LTOT (poorly controlled)
- Inability to cope at home (or living alone)
Outline some aims of palliative care in COPD
- Reduce symptoms
- Improve quality of life
- Increase participation in day-to-day activities
Outline some methods that can be used in COPD palliative care to improve their quality of life
- Management of dyspnoea (combination of LABA, ISC and Ipratropium Bromide)
- Oxygen therapy
- Nutritional support
- Anxiolytics and antidepressants
