2. Asthma and COPD

Question 1

Characteristics of Asthma

Answer 1

Smooth muscle contraction (bronchoconstriction) , irritation and swelling with mucosal oedema, mucous plugging of bronchioles (goblet cells)

Question 2

What factors predispose to asthma

Answer 2

Airway hyperresponsiveness, sensitation to house dust mite, F sex smoking at age 21, atopy

Question 3

What airway remodelling can occur in Asthma

Answer 3

Thickened basement membrane - can get fixed airway obstruction

Question 4

How to diagnose asthma

Answer 4

Clinically - 1 or more of
Chest tightness, breathlessness, cough, wheeze esp if worse at night and early morning, in response to exercise, allergen and cold air, after taking aspirin or BB and M/FHx of asthma/atopy

Widepreade wheeze on chest ausc
Unexplained low FEV1/ PEF

Question 5

Provoking factors for asthma

Answer 5

Viral infections, house dust mite, NSAIDS, aspirin and B blockers, other allergens, exercise, temp changes, anxiety, cigarette smoke, food and additives, obesity

Question 6

What investigations should be done for Athma with intermediate probability

Answer 6

Need to check for airflow obstruction with revesibility testing/ treatment trials with bronchodilator or steroids. Need to have more than 200 mls improvement and >12%

Can monitor PEF- variability 20%

CXR, eos, IgE and skin prick tests can also be done.

Assessment of airway responsiveness- histamin to induce bronchoconstriction.

Question 7

What should be done if asthma is suspected

Answer 7

initiate treatment with low dose ICS 6 weeks

Question 8

Mx algorithm for asthma

Answer 8

1: Low dose ICS
2: Give SABA preventer if asthma diagnosed
3: Recheck compliance, technique, eliminate trigger factors. THEN Add on inhaled LABA to low dose ICS (beclamethasone + fometerol or fluticasone and vilanterol)
4a: If no response to LABA, stop it and consider increase ICS.
4b: IF LABA beneficial but control still inadequate, increase ICS to medium dose.
5: LABA beneficial but control still inadequate, continue both and add LTRA, SR theophyllines, or LAMA

Question 9

NEW mx of Asthma

Answer 9

AIR therapy- low dose ICS/formeterol for Sx
If highly sx then use low-dose MART instead (ICS/formeterol comb inhaler for maintenace and relief)

Moderate dose MART

If FENO or eo is raised, refer to spec, otherwise trial LTRA or LAMA + moderate MART

Question 10

SE of SABA

Answer 10

Tachycardia, vasodilation, arrhythmias, hypokalaemia, tremor, insomnia

Question 11

How does beclamethasone help with asthma

Answer 11

Reduces inflammatory cell infiltration, vascular permeability, and increases B2 responsiveness on airway smooth muscle

Question 12

How do LTRAs work

Answer 12

prevent smooth muscle contraction, oedema, increased vasc permeability, mucus secretion and eos chemoattractatnt

Question 13

How does theophylline work

Answer 13

Bronchodilation, rasies intracellular cAMP and is an adenosisne antaggonist

Question 14

Possible drugs for severe asthma

Answer 14

High dose ICS
Tiotropium
IST
Macrolide Abx
Omalizumab or Mepolizumab

Question 15

What is asthma exacerbation

Answer 15

PEF <0.8 pred, incr bronchodilator use, incr nocturnal Sx, incr sx scores for 2 or more days

Question 16

What is a mild asthma ex and how to treat

Answer 16

PEF> 80 but incr salb freq , give 2-4 puffs BA 4hrly

Question 17

What is a moderate asthma ex and how to treat

Answer 17

PEF 50-80, High dose bnronchodilator ( MDI via space or neb), and oral predni 40mg 5 days

Question 18

What is moderate acute asthma

Answer 18

Normal speech, RR< 25, pulse <110

Question 19

Severe acute asthme

Answer 19

Cannot complete sentences, RR>25, Pulse >110, spiro 33-50

Question 20

Life threatening asthma

Answer 20

Silent chest, cyanosis, poor resp effort, brady, dysrhthmia, hypotension, exhuastion, confusion, coma
spiro <33
TIIRF

Question 21

How to treat severe acute asthma

Answer 21

High flow O2 + similar as moderate ex, add ipa (SAMA) if no response

Magnesium recommended for severe attack
Aminophylline/ IV slab last line

Question 22

Who to refer to ICU for acute asthma

Answer 22

If vent support required, or severe or life threatening asthma is not responsive, eg derioriating PEF, persiting or worsening hypoxia, hypercapnia, exhaution and feeble resp, drowsiness , confusion, coma or resp arrest

Question 23

What is chronic bronchitis

Answer 23

Cough productive of sputum on most days for 3 months over 2 consecutive years

Question 24

Characteristic of d chronic bronchitis

Answer 24

Hyperplasia of goblet cells in the airways, leads to mucus hypersecretion, usually associated with increased inflammatory cells in these areas of the lungs

Question 25

What is emphysema

Answer 25

Permanent dialatation of airspaces distal to terminal nbonchiles, accompanied by destruction of their walls, w/o obv fibrosis Loss of elastic recoil leads to airflow limitation

Question 26

Types of emphysema, which lobe they are predominant in, and who they are common in

Answer 26

Centrilobular, UL, common in smokers Panlobular ( whole lobule destroyed) , LL, common in a-1 AT deficiency ( predominantly pasal)

Question 27

Risk factors for COPD

Answer 27

SMOKING Occu dust and chemicals eg. coal mining Second hand smoke Air pollution Recurrent childhood infxns SES --- a-1 antitrypsin deficiency Hyper-responsiveness

Question 28

How are airways affected in asthma and COPD respectively

Answer 28

Bronchoconstriction vs small airway narrowing and alveolar destruction

Question 29

Characteristics of dyspnoea in COPD

Answer 29

Persistent Progressive Characteristically worse with exercise

Question 30

Describe cough in COPD

Answer 30

Chronic, but may be intermittent and may be unproductive (Emphysema) , and may have chronic sputum production ( chronic bronchitis phenotype)

Question 31

Possible Sx of COPD on inspection Which ones are more common in emphysematous phenotype

Answer 31

Use of accessory muscles, overinflation of lungs eg. protruding abdomen, central cyanosis, peripheral oedema, weight loss, barrell shaped chest, pursed lip breathing

Question 32

What breath sound is common in COPD

Answer 32

Wheezing . Respiratory crackles may occur with coughing esp if pneumonia is present

Question 33

Is COPD dx spirometry based or clinical

Answer 33

Both Consider Sx of sputum pdtn, cough, or dyspnoea. or exposure to risk factors + Spirometry - FEV1/FVC <0.7

Question 34

How to measure severity of COPD

Answer 34

post bronchodilator FEV1, not FEV1/FVC Mild- FEV1>80 Moderate - 50 to 80 Severe 30 to 50 Very sever Less than 30

Question 35

What is a sig. response to bronchodilators suggestive of asthma

Answer 35

Large increase in FEV1 (>400)

Question 36

What scale to assess Sx of COPD/ asthma

Answer 36

mMRC 0- breathless with strenous ex 1- when hurrying on level or up slighthill 2- slower than most on level, or have to stop for breath on the level 3- stop for breath after 100m/ few mins on the level 4- Too breathless to leave the house/ breathless when dressing or undressing CAT- self assessment tool

Question 37

What is ABCD assessment for COPD

Answer 37

Based on risk ie. number of excaerbations ( or whether there was at least one that led to hospital), and symptoms ie. mMRC or CAT

Question 38

What can CT scan be used for in COPD

Answer 38

To quantify emphysema (and bronchiectasis)

Question 39

Residual volume and diffusing capacity in COPD

Answer 39

High RV, low DC due to gas trappinf

Question 40

Vaccination for COPD

Answer 40

Influenza and penumococcal vacc (one off)

Question 41

what chemical does BA increase and what is it

Answer 41

cAMP, results in bronchodilation

Question 42

What must ICS be combined with in COPD Tx

Answer 42

LABA eg. beclomethasone and formoterol OR LABA LAMA

Question 43

First line for COPD

Answer 43

SABA/SAMA (Ipa)

Question 44

How to increase therapy for COPD

Answer 44

Add LABA or LAMA, or ICS if asthmatic qualities? For severe, high risk, can give triple therapy if further exacerbations/ persistent Sx on LABA+ICS and then consider roflumilast if FEV1 <50 % predicted and chronic bronchitis in pt, or macrolides in former smokers

Question 45

Most common bacterial and viral pathogens that cause COPD exacerbations

Answer 45

H influenzae, S pneumonia, M catarrhalis --- Rhinovirus and Influenza, esp during winter months

Question 46

When should nebuilisers be given to COPD pts

Answer 46

if extremely bronchoconstricted (long term home therapy for severe COPD and Sx disease, or short term for exacerbations)

Question 47

How to treat COPD exacerbation

Answer 47

Increase bronchodilator frequency, consider neb and give predni 30mg for 5 days

Question 48

When should abx be given for COPD

Answer 48

If sputum is purulent or clinical signs of penumonia in exacerbation Give amox or clarithro or doxy

Question 49

when should NIV be given for COPD

Answer 49

If TIIRF i.e respiratory acidosis pH 7.25-7.3 BIPAP given