Asthma And COPD

Question 1

What is a restrictive spirometry pattern?

Answer 1

a reduced FVC but with a normal FEV1/FVC ratio.

FEV1 is reduced in proportion
to the FVC

Question 2

What is an obstructive spirometry pattern?

Answer 2

normal FVC but with a reduced FEV1

FEV1/FVC ratio reduced

PERF also reduced

Question 3

What is A ‘mixed obstructive and restrictive picture’?

Answer 3

FVC is reduced AND the FEV1/FVC ratio is reduced

Question 4

How is bronchodilator reversibility done in spirometry?

Answer 4

Repeating spirometry testing 20-30mins after administering a dose of bronchodilator - Salbutamol 2x200mg puffs

Question 5

What will spirometry results show if airway obstruction is reversible?

Answer 5

Improvement in FEV1/FVC ratio after bronchodilation

Question 6

When should PEFR be measured?

Answer 6

During asthma diagnosis - monitor peak flow twice a day for 2-4wks

Long term monitoring of asthma

Question 7

What is FENO?

Answer 7

Exhaled Nitric Oxide test

Measures Nitric Oxide levels in exhaled breath, levels are increased when there’s active airway inflammation

Levels may be affected by smoking and ICS

Question 8

What are the different drug groups of inhaler?

Answer 8

SABA = Short Acting Beta Agonist

LABA = Long Acting Beta Agonist

SAMA = Short Acting Antimuscarinic (rarely used in asthma)

LAMA = Long Acting Antimuscarinic (rarely used in asthma)

ICS = Inhaled corticosteroids

Question 9

What are some drug combinations used in inhalers?

Answer 9

ICS/LABA (can be used in asthma and COPD)

LABA/LAMA (mainly used in COPD)

ICS/LABA/LAMA (mainly used in COPD)

Question 10

What can be offered to patients struggling with inhaler technique?

Answer 10

Spacers

Taught by asthma or COPD nurses correct technique

Question 11

What are some asthma symptom triggers?

Answer 11

Exercise

Allergen or irritant exposure

Weather changes

Viral resp infections

Question 12

What are the characteristic symptoms of asthma?

Answer 12

Cough

Wheeze

Chest tightness

Shortness of breath

Variable expiratory airflow limitation

Question 13

What is a personal asthma plan?

Answer 13

action plan tells you:

-which medicines to take every day
-what to do if your asthma symptoms get worse
-what to do if you have an asthma attack.

Question 14

What should be examined to assess the severity of the exacerbation?

Answer 14

Assess vital signs:
-Level of consciousness
-Temperature
-Pulse rate and rhythm
-Resp rate
-BP
-O2 sats
-Ability to complete sentences
-Use of accessory muscles and audible wheeze

Examine chest for wheeze - may become biphasic or less apparent

Check peak flow if well enough

Question 15

What are the features of a life-threatening asthma?

Answer 15

cyanosis,

drowsy,

exhaustion,

poor respiratory effort,

confusion (may be a sign of hypoxia);

oxygen saturation on air less than 92%;

hypotension;

PEF less than 33% best or predicted; and/or ‘silent chest’.

Question 16

What are some features of acute severe asthma exacerbation?

Answer 16

inability to complete sentences in one breath;

oxygen saturation on air less than 92%;

respiratory rate more than 25 breaths per minute;

pulse rate more than 110 beats per minute

PEF 33–50% best or predicted.

Question 17

What are some features of acute severe asthma exacerbation?

Answer 17

inability to complete sentences in one breath;

oxygen saturation on air less than 92%;

respiratory rate more than 25 breaths per minute;

pulse rate more than 110 beats per minute

PEF 33–50% best or predicted.

Question 18

What are some features of moderate asthma exacerbations?

Answer 18

talking in sentences

prefers sitting to lying

not agitated

no accessory muscle use

oxygen saturation on air 92% or more

PEF more than 50% best or predicted

and no features of acute severe asthma

Question 19

What should be reviewed in patient history to assess whether they should be admitted to hospital for an asthma exacerbation?

Answer 19

Timing of onset and cause

Severity of symptoms

Anaphylaxis symptoms

Risk factors for asthma-related death

Current asthma meds

History of near-fatal asthma - MUST go to hospital

Any recent or previous exacerbations

Question 20

What treatment can be given for life-threatening or acute sever asthma exacerbation while waiting for transfer to hospital?

Answer 20

Controlled O2 in adults, high flow in kids - aim for 94-98% sats

Nebulised salbutamol 5mg and nebulised ipatropium bromide 0.5mg via oxygen driven neb.
Can repeat salbutamol every 20-30 mins

First dose oral prednisolone 40-50mg

Question 21

What treatment can be given in primary care for moderate asthma exacerbation?

Answer 21

Give controlled oxygen to adults and high-flow oxygen to children 94–98% sats is aim

Give salbutamol (100 micrograms) by pMDI and large-volume spacer one puff every 60 seconds - max of 10 puffs

If there is no clinical improvement, give salbutamol 5 mg via oxygen driven neb

Give a first dose of oral prednisolone

Question 22

What are the signs that a patient with a moderate asthma exacerbation can be managed at home?

Answer 22

a good response to initial treatment and symptoms have improved

PEF is improving to more than 60–80% of best or predicted

Oxygen saturation on air is more than 94%

person is able to manage at home with appropriate support

Question 23

How soon should a patient be reviewed after an acute asthma exacerbation and what should this include?

Answer 23

Within 2 working days of the exacerbation:

Reassess the person’s symptoms and signs to check if the exacerbation is resolving

Assess whether the person needs additional short-term oral prednisolone treatment until full recovery

Assess for and manage any modifiable risk factors and triggers for exacerbations

inhaler technique and adherence

Review and update the person’s personalised asthma action plan

Ensure the person attends for regular follow-up in primary care

Question 24

What safety netting advice should be given to patients managing asthma exacerbations at home?

Answer 24

Continue using AIR or MART therapies as usual

Advise to ring 999 if the person is needing one puff of AIR or MART inhaler every 1–3 minutes up to 6 puffs

Advise to ring 999 if the person is needing a SABA by pMDI and large-volume spacer one dose every 30–60 seconds up to a maximum of 10 puffs

Continue oral pred - dont stop ICS

Question 25

When should a COPD patient be referred for LTOT?

Answer 25

Oxygen saturations of 92% or less breathing air. Very severe (forced expiratory volume in 1 second [FEV1] less than 30% predicted) or severe (FEV1 30–49% predicted) airflow obstruction. Cyanosis. Polycythaemia. Peripheral oedema. Raised jugular venous pressure.

Question 26

What non-pharmacological treatments can be offered to COPD patients?

Answer 26

Explain modifiable risk factors and suggestions how to improve - healthy diet, physical activity etc Smoking cessation support Annual pneumococcal and influenza vaccine Pulmonary rehabilitation if indicated Develop personalised self-management plan with patient

Question 27

What inhaled therapies can be offered to COPD patients?

Answer 27

Bronchodilator - SABA or LAMA LABA+LAMA Consider ICS if eosinophils greater than 300 cells per microlitre

Question 28

What is pulmonary rehabilitation and when should it be offered to COPD patients?

Answer 28

It’s a tailored MDT care plan - optimises physical and psychological conditions through exercise training, education and nutritional, psychological and behavioural interventions Refer if: -MRC scale 3 or more -Recent hospital admission for exacerbation -Functionally disabled by COPD

Question 29

When should a COPD patient NOT be referred for pulmonary rehabilitation?

Answer 29

Unable to walk Have unstable angina Had recent MI

Question 30

What advice should be given to people using oxygen?

Answer 30

Don’t smoke as their risk or fire or explosion

Question 31

When should you not offer short-burst oxygen therapy for breathlessness?

Answer 31

people with COPD who have mild or no hypoxaemia at rest

Question 32

What’s the initial management for all COPD patients?

Answer 32

-SABA or SAMA as required to relieve breathlessness Ensure non-drug options have been optimised before stepping up

Question 33

What are the step up treatment options for COPD patients with NO asthmatic features/steroid responsiveness?

Answer 33

Offer LABA and LAMA in pts continuing to be breathless or having exacerbations -Discontinue SAMA id LAMA given

Question 34

When should ICS treatment be considered in COPD patients with NO asthmatic features/steroid responsiveness?

Answer 34

patients on a LAMA and LABA who have a severe exacerbation (requiring hospitalisation) or at least two moderate exacerbations (requiring systemic corticosteroids and/or antibacterial treatment) within a year, consider the addition of an inhaled corticosteroid (ICS)—triple therapy. Must review annually

Question 35

When should ICS be trialled for 3 months in COPD patients with NO asthmatic features/steroid response?

Answer 35

patients on a LAMA and LABA whose day-to-day symptoms continue to adversely impact their quality of life consider trialling the addition of an ICS for 3 months If symptoms have improved, continue triple therapy and review at least annually. If no improvement, step back down to a LAMA and LABA combination

Question 36

What is the recommended step up treatment for COPD patients WITH asthmatic features/steroid responsiveness?

Answer 36

Consider LABA and ICS in pts continuing to be breathless or having exacerbations Must review ICS annually

Question 37

When would you consider adding a LAMA to COPD patients WITH asthmatic features/steroid responsiveness?

Answer 37

patients on a LABA and ICS who have a severe exacerbation (requiring hospitalisation) or at least two moderate exacerbations (requiring systemic corticosteroids and/or antibacterial treatment) within a year, or who continue to have day-to-day symptoms adversely impacting their quality of life Add LAMA Discontinue SAMA

Question 38

What prophylactic antibiotics can be considered to reduce COPD exacerbations?

Answer 38

Azithromycin Risk factors must be optimised and have had all treatment options available

Question 39

What must be monitored before offering prophylactic antibiotics to COPD patients?

Answer 39

-CT of thorax -Baseline ECG -Sputum culture and sensitivity -LFTs

Question 40

How often should COPD patients on prophylactic Abx be monitored?

Answer 40

Review after first 3 months Then at least 6 monthly

Question 41

What are some features suggestive of an acute COPD exacerbation?

Answer 41

Worsening breathlessness. Increased sputum volume and purulence. Cough. Wheeze. Fever without an obvious source. Upper respiratory tract infection in the past 5 days. Increased respiratory rate or heart rate increase 20% above baseline.

Question 42

What are some features suggestive of a severe COPD exacerbation?

Answer 42

Marked breathlessness and tachypnoea. Pursed-lip breathing and/or use of accessory muscles at rest. New-onset cyanosis or peripheral oedema. Acute confusion or drowsiness. Marked reduction in activities of daily living

Question 43

What clinical assessment must be done if a patient is presenting to primary care with a suspected COPD exacerbation?

Answer 43

Check vital signs (including temperature, oxygen saturation [using pulse oximetry], blood pressure, and heart rate). Assess for confusion or impaired consciousness. Examine the chest. Check ability to cope at home

Question 44

What treatment can be given to COPD patients waiting for hospital transfer?

Answer 44

Give oxygen (if available) while awaiting emergency transfer to hospital and monitor response with pulse oximetry - if sats less than 90% Otherwise, initially give patients with COPD oxygen via a Venturi 24% mask at 2-3 l/min or Venturi 28% mask at a flow rate of 4 l/min or nasal cannula at a flow rate of 1-2 l/min (if a 24% mask is not available).

Question 45

What treatments should be started in COPD patients having exacerbation but don’t need hospital admission?

Answer 45

Increase dose or frequency of SABA - don’t exceed max dose Nebs may be appropriate it pt likely to become fatigued Offer 30 mg oral prednisolone once daily for 5 days Consider the need for osteoporosis prophylaxis for people requiring frequent courses of oral corticosteroids (3–4 courses per year Consider the need for an antibiotic: -Amoxicillin -Doxycycline -Clarithromycin

Question 46

What follow up should be arranged for COPD patients after having an exacerbation?

Answer 46

Follow up when clinically stable Reassess COPD symptoms Send sputum for culture and sensitivity testing if symptoms not improved after abx Optimise managements Assess inhaler technique Consider referral to resp specialist Offer rescue pack of oral steroids and abx

Question 48

How should a patient with end stage COPD be managed?

Answer 48

Advanced care plan Optimise treatment for symptoms Consider specialist admission to hospice

Question 49

What are some drugs that can be given for breathlessness in end stage COPD?

Answer 49

Opioids Benzodiazepines TCAs LTOT