Asthma and COPD

Question 1

Name 4 symptoms and 4 signs of asthma.

Answer 1

Any 4 of the following.

Symptoms - intermittent dyspnoea, wheeze, cough (often nocturnal), diurnal variation, sputum production.

Signs - tachypnoea, audible wheeze, hyper-inflated chest, hyper-resonance, reduced air entry.

Question 2

How can severe, life-threatening and near-fatal asthma attacks be differentiated?

Answer 2

Severe - 33%-50% PEF, HR >110, RR >25, can’t finish sentences.

Life-threatening - <33% PEF, O2 <92%, cyanosis, exhaustion, confusion, silent chest.

Near-fatal - hypercapnia present.

Question 3

What 2 tests can be used to investigate asthma? What results would be expected in an asthmatic patient?

Answer 3

Not always necessary, unless there is diagnostic uncertainty:

PEF - reduced compared to expected

Spirometry - FEV1 <80% predicted; FVC may be low or normal; FEV1/FVC <0.7

Question 4

What is first line medical management for asthma treatment? Name the drug class and 2 examples.

Answer 4

SABA e.g. salbutamol, tertrabutaline

Question 5

A patient has been using salbutamol, but finds that they are having to use their inhaler at least 5 times a day. What is the next medical management?

Answer 5

Add low-dose ICS, such as beclometasone.

Question 6

A patient on SABA and low-dose ICS is struggling to manage their asthma. What would be the next appropriate escalation of therapy? Give drug class and an example.

Answer 6

Addition of a LABA - salmeterol, formoterol

Question 7

A patient is using a MART inhaler. What are the 3 common MART inhalers, and what drug types do they contain?

Answer 7

Symbicort, Fostair, Seretide

LABA and ICS

Question 8

A patient is on terbutaline, formoterol, and low-dose fluticasone. Their symptoms have improved but they still suffer frequent coughing fits. What would be the next medical management?

Answer 8

Increase dose of fluticasone to medium.

Or

Add LTRA.

Question 9

What are the symptoms of bronchitis and when can it be considered chronic?

Answer 9

Cough and sputum most days for at least 3 months of the year, for 2 consecutive years.

Question 10

Describe the step-wise approach to managing an acute asthma attack.

Answer 10

1. Nebulised salbutamol with oxygen to reach O2 >92%
2. Steroid use: 4x ICS at outset, use of oral prednisolone (IV hydrocortisone if oral not appropriate)
3. Nebulised ipratropium if PEF remains <75% expected
4. Magnesium sulphate. Obtain specialist review at this point.

Question 11

Name 3 features that may indicate COPD instead of asthma.

Answer 11

Any 3 of following:

Older patient, significant smoking history, no/little diurnal variation, dyspnoea is constant, no apparent triggers.

Question 12

Name 4 complications of COPD

Answer 12

Any 4 of following:

Exacerbation +/- infection, polycythaemia, respiratory failure (type 1 or 2), cor pulmonale (RVH, raised JVP, oedema), pneumothorax, lung carcinoma.

Question 13

Explain what is meant by “pink puffers” and “blue bloaters”. What complications are each more likely to suffer from?

Answer 13

2 ends of a spectrum in COPD presentations

Pink puffers [more emphysema] - very dypnoeic but not hypoxic. May be normo- or hypocapnic (are CO2 responsive). Not cyanosed. Cachectic appearance.
Complications - pneumothorax

Blue bloaters [more chronic bronchitis] - cough and sputum, hypoxic and hypercapnic (CO2 insensitive, rely on hypoxic drive). Cyanosed. Obese and oedematous.
Complcations - polycythemia, cor pulmonale

Question 14

What lifestyle advice and supportive therapy is offered to COPD patients?

Answer 14

Smoking cessation. Encourage exercise and diet change. Treat anxiety/depression around diagnosis. Offer pneumococcal and influenza vaccination.

Mucolytics and diuretics may be appropriate.

Question 15

What is first line for treatment of chronic COPD? Give drug classes and an example of each.

Answer 15

SABA - salbutamol, terbutaline.

SAMA - ipratropium

Question 16

A COPD patient on ipratropium requires an increase in therapeutic management due to frequent exacerbations. They have features of asthma. What is the next appropriate management? Give drug classes and an example of each.

Answer 16

Addition of a LABA and ICS

LABA - salmeterol, formoterol

ICS - beclometasone, budenoside, fluticasone

Question 17

A COPD patient is on salbutamol but has not had any relief of their symptoms. There are no features of asthma. What is the next appropriate management?

Answer 17

Addition of both LABA and LAMA

LABA - salmeterol, formoterol
LAMA - tiotropium

Question 18

A COPD patient who is on tiotropium and salmeterol is still symptomatic. What is the next therapeutic management?

Answer 18

Add ICS.

So treatment would be ICS, LAMA (tiotropium), LABA (salmeterol)

Question 19

A COPD patient is on fomoterol and fluticasone. They are still symptomatic. What is the next therapeutic management.

Answer 19

Add LAMA.

So treatment would be LAMA, LABA (fomoterol), ICS (fluticasone)

Question 20

A COPD patient presents to A&E due to increasing dyspnoea and worsening purulent productive cough. They have a fever of 38 C and oxygen saturation of 79%.

1. How should oxygen therapy be administered to this patient?
2. What is the appropriate medical management?
3. What complication has this patient developed and how may it be managed?

Answer 20

1. Initial use of Venturi mask (24-28%), increasing as required. Aim for target oxygen 88-92%.

2.

a) Nebulised salbutamol and ipratropium.
b) Oral prednisolone for 5 days.

3. Antibiotics as infection is likely the cause of this exacerbation. Tayside guidance recommends amoxicillin 1st line, doxycycline 2nd line.