Week 2 resp(most important parts) Flashcards
What is COPD a combination of?
Chronic bronchitis and emphysema
What is FEV1
Forced expiratory volume in 1 min
What is a moderate fall in the PEFR
50-80% of best
What is a marked fall in the PEFR
<50% of best
In Obstructive lung disease, what is reduced?
FEV1 <70%, FVC MAY be reduced
Is bronchial asthma considered to be reversible?
Yes
What may smoking exacerbate
Alpha-1-antiprotease deficiency
What lung disease develops naturally over time?
Emphysema, (men>women, developing countries>developed)
What is the clinical definition of chronic bronchitis?
Cough productive of sputum in at least 3 consecutive months for 2 or more consecutive years
When does chronic bronchitis become complicated?
When FEV1 falls or sputum becomes infected
Describe the morphological changes in the large ariways in chronic bronchitis
- Mucous gland hyperplasia
- Goblet cell hyperplasia
Describe the morphological changes in the small airways in chronic bronchitis
- Goblet cells appear
- Inflammation and fibrosis in long standing disease
What is the pathological definition of emphysema
Increase beyond the normal in the size of airspaces distal to the terminal bronchiole arising from either dilatation or from destruction of their walls and without obvious fibrosis
What is an acinus?
Everything distal to terminal bronchiole
What is a terminal bronchiole?
Last conducting airway that is completely lined by resp endothelium
What is the most common pattern of emphysema
Centri-acinar
What pattern of obstructive lung disease is commonly seen in smokers?
Periacinar and scar emphysema
Describe how smoking causes emphysema
- Decreases anti-elastase
- Increases elastase
- Decreases repair mechanism for elastin synthesis
- Increases neutrophils and macrophages (just add to the elastase)
All come together to bring upon more elastase tissue destruction and cause emphysema
Define asthma (Generally)
Increased responsiveness of trachea and bronchi to various stimuli by widespread narrowing of airways
Describe the prevelance of asthma in children and adults with respect to gender
Children: 10-15%, M>F
Adults:5-10%, F>M
Are you more likely to have asthma if your mother or your father has asthma?
Mother
What are the symptoms of asthma?
- Wheeze
- Cough
- Dry sputum
- Chest tightness
What are the typical asthma triggers?
Exercise, cold air, smoke, perfume, URTIs, pets, trees, grass, pollen, food, aspiriation
What are the 3 types of variation seen in asthma?
- Daily
- Weekly
- Annualy
What are 2 factors which must be confirmed to diagnose asthma?
Airflow obstruction variability and reversibility
What are the diet risk factors for asthma?
- Decrease in anti-oxidants and N-3 polyunsaturated fatty acids
- Increase in N-6 polyunsatured FA
- Too much or too little Vit D
What signs may indicate a differential diagnosis?
- Cervical lymphadenopathy
- Stridor
- Assymetrical expansion
- Dull percussion note
- Crepitations
Describe the FEV1, FVC and FEV1/FVC in asthma
FEV1 <80%, FVC normal, FEV1/FVC <70%
What does FEV1 tell us about?
Airway diameter
What does FVC tell us about?
Lung capacity
What must be done after conformation of variability and reversibility
- Full pulmonary function tests
- Conformation with B2 agonists and steroids
What do full pul function tests excludes?
COPD and emphysema
Describe the residual volume and total lung capacity in asthmatic patients
Residual volume and total lung capacity both increased
RV/TLC > 30%
What is the effect of methacholine on the airways
Constricts
If bronchial provocation test is undertaken is more or less NO exhaled in asthma?
More NO exhaled than normal in asthmatics
What symptom must be had for a diagnosis of asthma?
A wheeze
Describe moderate acute asthma with reference to:
- HR
- RR
- PEF
- Oxygen Sat
- PaO2
- ability to speak
HR<110 RR<25 PEF: 50-70% SaO2 > 91% PaO2 > 8kPa
Describe severe acute asthma with reference to:
- HR
- RR
- PEF
- Oxygen Sat
- PaO2
- ability to speak
HR>110 RR>25 PEF: 33-50% of best/predicted SaO2>92% PaO2>8kPa Inability to complete sentences in one breath
What are the symptoms/signs which make an acute asthma attack life threatening?
- Grunting
- Impaired conciousness/confusion
- Bradycardia/arrhythmia/hypotension
- PEF <33%
- Cyanosis
- Silent chest
- SaO2 <92%
- PaO2 <8kPa
- Normal or raised PaCO2 levels
What are the goals of treatment for the management of asthma in children?
- Limited need for reliver medication
- No attacks
- Minimal symptoms
- No limitation of physical activity
Describe how to assess a child’s control of their asthma symptoms?
SANE
- Short acting beta agonist (how much is it used)
- Absence from school/nursery
- Nocturnal symptoms
- Exceptional symptoms
What is the 1st step of asthma treatment of a child?
Very low ICS or LTRA for <5 y/o
What is the 2nd step of asthma treatment of a child?
Very low ICS AND Inhaled LABA or LTRA if <5 y/o
What is the 3rd step of asthma treatment of a child
- If no response to LABA - stop and increase ICS dose dose to low dose
- if benefit from LABA but ocntrol is still inadequate - continue LABA and increase ICS dose to low. Can also keep ICS dose the same and consider trail of other therapy (LTRA)
What is the 4th step of asthma treatment of a child
consider trails of:
- Increasing ICS to medium dose
- Addition of 4th drug (SR therophylline)
What is the 5th step of the asthma treatment of a child?
Continuous or frequent use of oral steroids:
- Use daily steroid tablet in the lowest dose providing adequate control
- Maintain medium dose ICS
- Consider other treatments to minimise ICS
With reference to B2 agonists, what would be considered ‘poorly controlled’
If used more than 2 days a week
What is an MDI?
Metered dose inhaler - co-ordinate taking a breath at the same time of administering medication
What are the types of administration for asthma medication?
MDI, DPI
What is salbutamol and how can it be administered?
Short acting beta agonist. MDI and DPI
What is terbutaline and how can it be administered?
SABA, DPI only
What would the treatment plan of mild to moderate acute asthma attack be?
Increased inhaler use Oral steroids Treat the trigger Early follow up Back up plan
What would the treatment plan of a moderate to severe asthma attack be?
Nebuliser - Salbutamol or terbutaline
Oral or IV steroid
Mg
Aminophylline
Define COPD
A lung disease characterised by chronic obstruction of lung airflow that interferes with normal breathing and is NOT fully reversible
Describe the relationship between smokers and COPD
- Have more respiratory symptoms and lung function abnormalities
- Greater rate of decline in FEV1
- Greater COPD rate than non-smokers
- <50% of smokers develop COPD in their lifetime
- After 25 years of smoking at least 25% of smokers will have clinically significant COPD (Stage 2 or worse)
What are the common symptoms of COPD?
Cough Breathlessness Sputum production Frequent chest infections Wheeze
What are uncommon symptoms of COPD?
Weight loss
COPD
Swollen ankles
Describe the MMRC dyspnoea scale
0 - breathless with strenuous exercise
1 - breathless when hurrying on level ground or up slight hill
2 - On level ground i have to walk slower than people my own age or have to stop for a breath when walking at my own pace
3 - I stop for breath after walking approx 100yards/a few mins on level ground
4 - I am too breathless to leave the house/I am breathless when dressing
Describe the Investigations/diagnosis of COPD
No single diagnostic test, rather a combo of symptoms, history and spirometry Diagnose if meet the following criteria - >35 y/o - Presence of risk factors - Absence of clinical features of asthma
Describe the spirometry of a patient with COPD
- Diagnosed airflow obstruction
- FEV1/FVC <70% post bronchodilator
- Lack of reversibility
Describe Stage 1 COPD
FEV1 of 80% best/predicted
Describe Stage 2 COPD (Moderate)
FEV1 between 50-79% of best/predicted
Describe Stage 3 COPD (Severe)
FEV1 between 30-49% of best/predicted
Describe Stage 4 COPD (Very severe)
FEV1 between <30% of predicted/best
What condition can arise as a severe exacerbation of COPD?
Cor Pulmonale
Describe Cor pulmonale
= Right sided HF due to Lung disease
Comes about because of smoking and hypoxia affecting pulmonary vessels:
- Causes vasoconstriction which shunts blood flow to healthy alveoli in the lungs
- However over time lung causes back pressure to occur in the pul arteries
- Chemical from smoking can also cause vasculature causing hf as increased muscle density on right side of heart and increased pressure on the left side of the heart including JVP
Compare the following factors in relation to how often the occur in COPD
- Smoker or ex smoker
- Symptoms under 35 y/o
- Chronic productive cough
- Breathlessness
- Night time waking with breathlessness/wheeze
- Variability of symptoms
Smoker or ex smoker: Nearly all
- Symptoms under 35 y/o: rare
- Chronic productive cough: Common
- Breathlessness: Often persistent and progressive
- Night time waking with breathlessness/wheeze: Uncommon
- Variability of symptoms: Uncommon
Compare the following factors in relation to how often the occur in Asthmatics
- Smoker or ex smoker
- Symptoms under 35 y/o
- Chronic productive cough
- Breathlessness
- Night time waking with breathlessness/wheeze
- Variability of symptoms
- Smoker or ex smoker: Possibly
- Symptoms under 35 y/o: Often
- Chronic productive cough: Uncommon
- Breathlessness: Variable
- Night time waking with breathlessness/wheeze: Common
- Variability of symptoms: Common
Is COPD more prevelant in men or women?
Women
Describe the non pharmacological management options for COPD?
- smoking cessation
- Vaccination (annual flu, pneumoccoal vaccine)
- Pulmonary rehabilitation
- Nutritional assessment
- Psychological assessment
Describe the 3 types of inhaled therapy possible for COPD?
Short acting bronchodilators
Long acting bronchodilators
High Dose ICS
Describe the use of short acting bronchodilators in COPD
SABA - salbutamol
SAMA - iprotropium
Describe the use of long acting bronchodilators in COPD
LAMA - umeclidinium, totropium etc
LABA - Salmeterol
Describe the use of high does ICS in COPD
Relvar (fluticasone/vilanterol)
Fostair MDI
What are the requirements for long term oxygen therapy in COPD?
- Need to be hypoxic
- Need to have quit smoking for 6 months
Describe the primary care management for emergency COPD?
Short acting bronchodilators - Slbutamor or ipratropium - Nebulisers if cannot use inhalers Steroids - Prednisolone 40mg per day fo 5-7 days Abx - Most exacerbations are secondary to viral infection - If there is evidence of infection (fever, increase in volume/purulence of sputum) Consider hospital admission if showing: - Tachypnoea - Low oxygen sat - Hypotension
What are the treatment guidelines for COPD
1st - SABA
2nd - SABA + LAMA
3rd - SBA + LAMA/LABA combo
