Asthma and COPD

Question 1

What is asthma?

Answer 1

Chronic, obstructive, reversible inflammatory condition that causes bronchoconstriction

Question 2

Typical triggers of asthma (7)

Answer 2

Infection
Night time or early morning
Exercise
Animals
Cold/damp
Dust
Strong emotions

Question 3

Typical presentation of chronic asthma (6)

Answer 3

Episodic symptoms
Diurnal variability - worse at night
Dry cough with wheeze and sob
History of atopic conditions - eczema, hayfever and food allergies
Family history

Bilateral widespread “polyphonic” wheeze heard by a healthcare professional

Question 4

Guidelines on diagnosis of asthma (BTS)

Answer 4

High probability: Try treatment

Intermediate probability: Perform spirometry with reversibility testing

Low probability: Consider referral and investigating for other causes

Question 5

(NICE) First Line investigations forastma

Answer 5

Fractional exhaled nitric oxide

Spirometry with bronchodilator reversibility

Question 6

Follow up investigations in asthma if first line uncertain

Answer 6

Peak flow variability - several times a day, 2-4 weeks

Direct bronchial challenge test with histamine or methacholine

Question 7

Long Term Management of Astma

Answer 7

SABA (also reliever in acute exacerbations)
ICS (Beclometasone) maintaner/preventer
LABA (Salmeterol)
LTRA (montelukast) 
MART
Increase doses or LAMA
Refer to specialist

Question 8

Additional management of chronic asthma

Answer 8

Individual self-management programme for each patient
Yearly flu jab
Yearly asthma review
Advise exercise and avoid smoking

Question 9

Presentation of acute asthma (5)

Answer 9

Progressively worsening sob
Use of accessory muscles
Tachypnoea
Symmetrical expiratory wheeze on auscultation
Chest can sound “tight” on auscultation with reduced air entry

Question 10

Moderate grade acute asthma

Answer 10

PEFR 50-75% predicted

Question 11

Severe grade acute asthma

Answer 11

PEFR 33-50% predicted
Resp rate >25
Heart rate >110
Unable to complete sentences

Question 12

Life-threatening acute asthma

Answer 12

PEFR <33%
Sats <92%
Becoming tired
No wheeze. This occurs when the airways are so tight that there is no air entry at all - “silent chest”
Haemodynamic instability (i.e. shock)

Question 13

Treatment for acute exacerbation of asthma

Answer 13

Salbutamol nebs (as often as required)
Ipratropium bromide
IV hydrocortisone (5 days)
ABx if infection

O2
Aminophylline infusion
Consider IV salbutamol

Magnesium sulphate
HDU/ICU
Intubation

Question 14

ABG readings in asthma

Answer 14

Intially resp alk (tachypnoea causes drop in CO2)
Normal pCO2 or hypoxia indicates tiring
Resp acidosis due to high CO2 is a very bad sign in asthma

Question 15

Monitoring asthmatic response to treatment

Answer 15

Respiratory rate
Oxygen saturations

Respiratory effort
Peak flow
Chest auscultation

(Monitor K+ as salbutamol causes it to be absorbed into cells)

Question 16

DIscharging after acute attack in asthma

Answer 16

Discharge with “asthma action plan”
Consider prescribing a “rescue pack”
Referral to a respiratory specialist after 2 attacks in 12 months

Question 17

Presentation of COPD

Answer 17

Long term smoker with chronic: 
SOB
Cough
Sputum production
Wheeze
Recurrent respiratory infections, particularly in winter

Question 18

Differential diagnosis for COPD

Answer 18

Lung cancer
Fibrosis
Heart failure

(COPD does not cause clubbing, haemoptysis or chest pain)

Question 19

What is the dyspnoea scale?

Answer 19

5 point scale that NICE recommend for assessing the impact of their breathlessness:

Grade 1 – Breathless on strenuous exercise
Grade 2 – Breathless on walking up hill
Grade 3 – Breathless that slows walking on the flat
Grade 4 – Stop to catch their breath after walking 100 meters on the flat
Grade 5 – Unable to leave the house due to breathlessness

Question 20

How is COPD diagnosed?

Answer 20

Clinical presentation + spirometry

Question 21

What will spirometry show in COPD?

Answer 21

Obstructive picture

Overall lung capacity is not as bad as ability to quickly blow air out of their lungs

FEV1/FVC <0.7

No dramatic respose to reversibility testing

Question 22

Measuring the severity of COPD

Answer 22

Stage 1: FEV1 >80% of predicted
Stage 2: FEV1 50-79% of predicted
Stage 3: FEV1 30-49% of predicted
Stage 4: FEV1 <30% of predicted

Question 23

Investigations in COPD (8)

Answer 23

CXR (exclude other pathologies)
FBC (exclude polychythaemia/anaemia)
BMI
Sputum culture
ECG/Echo
CT thorax (explore alternative such as fibrosis, cancer or bronchiectasis)
Serum alpha-1 antitrypsin - deficiency can lead to early onset and more severe disease
Transfer factor for carbon monoxide (TLCO) decreased in COPD

Question 24

Management of chronic COPD

Answer 24

Stop smoking
Pneumococcal and flu vaccines

1. SABA or SAMA
2. If no asthmatic or steroid responsive features - combined LABA + LAMA

If asthmatic or steroid responsive features - LABA + ICS

LABA + LAMA + ICS

Question 25

Examples of combined LABA + LAMA

Answer 25

Anoro Ellipta Ultibro Breezhaler DuaKlir Genuair

Question 26

Examples of combined LABA + ICS

Answer 26

Fostair Symbicort Seretide

Question 27

Examples of combined LABA + ICS + LAMA

Answer 27

Trimbo | Trelegy Ellipta

Question 28

Management of chronic COPD in more severe cases (5)

Answer 28

Nebulisers (salbutamol and/or ipratropium) Oral theophylline Oral mucolytic therapy to break down sputum (e.g. carbocisteine) Long term prophylactic antibiotics (e.g. azithromycin) Long term oxygen therapy at home

Question 29

When is Long term oxygen therapy used?

Answer 29

Severe COPD causing: chronic hypoxia polycythaemia cyanosis heart failure secondary to pulmonary hypertension (cor pulmonale) Can’t be used if they smoke as oxygen plus cigarettes is a significant fire hazard

Question 30

Triggers for COPD exacerbation

Answer 30

Usually bacterial or viral infection

Question 31

What does raised bicarb indicate on ABG in COPD?

Answer 31

Chronic retention of CO2 | Kidneys have responded by producing more bicarbonate to balance the acidic CO2 and maintain a normal pH

Question 32

Types of respiratory failure

Answer 32

Low pO2 indicates hypoxia and respiratory failure Normal pCO2 with low pO2 indicates type 1 respiratory failure (only one is affected) Raised pCO2 with low pO2 indicates type 2 respiratory failure (two are affected)

Question 33

Investigations in COPD exacerbation (6)

Answer 33

Chest xray to look for pneumonia or other pathology ECG to look for arrhythmia or evidence of heart strain (heart failure) FBC to look for infection (raised white cells) U&E to check electrolytes which can be affected by infection and medications Sputum culture if significant infection is present Blood cultures if septic

Question 34

Medical treatment for exacerbation of COPD at home (3)

Answer 34

Prednisolone 30mg once daily for 7-14 days Regular inhalers or home nebulisers Antibiotics if there is evidence of infection

Question 35

Medical treatment for exacerbation of COPD at hospital (4)

Answer 35

Nebulised bronchodilators (e.g. salbutamol 5mg/4h and ipratropium 500mcg/6h) Steroids (e.g. 200mg hydrocortisone or 30-40mg oral prednisolone) Antibiotics if evidence of infection (Amox, clarith[not in long QT], doxy) Physiotherapy can help clear sputum

Question 36

Treatment options in severe COPD exacerbation that aren't responding to first line treatment

Answer 36

IV aminophylline Non-invasive ventilation (NIV) Intubation and ventilation with admission to intensive care Doxapram can be used as a respiratory stimulant where NIV or intubation is not appropriate

Question 37

What Abx is recommended prophylactically for patients with frequent exacerbations and optimised pharmacological management

Answer 37

Azithromycin