Asthma, CAP, COPD [completed] Flashcards
(127 cards)
1
Q
How is asthma diagnosed?
A
2
Q
What are some tools that can be used to check if asthma treatment is working?
A
RCP 3 questions
Asthma control questionnaire
Asthma control test or children’s asthma control test
Mini asthma QoL questionnaire or paediatric asthma QoL questionnaire
Peak flow diary
3
Q
What are the 3 RCP questions?
A
- In the last month/week have you had difficulty sleeping due to your asthma (including cough symptoms)?
- Have you had your usual asthma symptoms (e.g. cough, wheeze, chest tightness, shortness of breath) during the day?
- Has your asthma interfered with your usual daily activities (e.g. school, work, housework)?
4
Q
What does a YES to ANY of the RCP 3 questions mean?
A
Asthma has not been controlled.
5
Q
What is the aim of the asthma control test?
A
Finding out:
- effect on daily routine
- how often symptoms occur?
- when do symptoms occur (night or early morning)
- how often is blue reliever inhaler needed?
6
Q
What time frame does the asthma control test assess?
A
Last 4 weeks
7
Q
What needs to be considered when doing the Asthma control test?
A
If patient has had an infection or exposure to a trigger in the last 4 weeks.
8
Q
What does a score LESS than 20 mean in the Asthma Control Test?
A
Asthma may not have been controlled.
9
Q
Outline the BTS/SIGN Guidelines (2019) for asthma treatment in ADULTS.
A
- Regular preventer (LOW DOSE ICS) and reliever (SABA) to be used when required
- Add on LABA - this may be as a fixed dose inhaler or MART (if MART - remove reliever inhaler)
- Consider increasing ICS to MEDIUM dose or adding a LTRA (such as montelukast). Remove LABA if there has been no response
- Specialist therapies such as IgE inhibitors - requires referral to specialist.
10
Q
How will a clinician know when a patient should be moved up or down on the BTS/SIGN treatment guidelines?
A
- Monitoring sympotms
- Look at peak flow
- checking inhaler technique and adherence.
11
Q
What is MART?
A
Maintenance and Reliever Therapy - a single combination inhaler of an ICS and a FAST ACTING, LONG ACTING beta agonist such as formoterol.
12
Q
What is the only inhaler licensed for MART regimens that contains beclomethasone and formoterol?
A
Fostair 100/6 (NOT THE NEXTHALER)
13
Q
What are the only inhalers licensed for MART regimens that contain budesonide and formoterol?
A
Duoresp Spiromax 160/4.5
Fobumix Easyhaler 160/4.5 and 80/4.5
Symbicort Turbohaler 100/6 and 200/6
14
Q
Outline the BTS/SIGN Guidelines (2019) for asthma treatment in CHILDREN.
COME BACK TO THIS ONE LATER
A
- Regular preventer (VERY LOW DOSE ICS) and reliever (SABA) to be used when required. OR if child is UNDER 5 use a LTRA.
- Add on LABA or LTRA in children over 5 or add LTRA in children under 5.
- Increase ICS to low dose or add on LABA or LTRA in children over 5. Consider stopping LABA if there is no response.
- Specialist therapies - requires referral to specialist.
15
Q
What is the main difference between the drug choices in the BTS/SIGN guidelines and the NICE guidelines?
A
NICE - LTRA offered before LABA.
BTS/SIGN - LABA offered before LTRA
16
Q
What is the aim of an Asthma Action Plan?
A
Patient knows what to do to manage symptoms and exacerbations depending on severity.
17
Q
Who does the NICE 2017 guidelines consider to be an adult?
A
Anyone over 17 years old.
18
Q
Who does the BTS/SIGN 2019 guidelines consider to be an adult?
A
Anyone over 12 years old.
19
Q
What are the doses of corticosteroids according to NICE guidelines?
A
low. moderate, high
20
Q
What are the doses of corticosteroids according to BTS/SIGN guidelines?
A
low, medium, high
21
Q
What is an asthma exacerbation?
A
An acute or subacute episode of a progressive worsening of asthma symptoms including shortness of breath, wheezing, cough and chest tightness.
Decrease in peak expiratory flow rate and FEV1
22
Q
What are the levels of severity of asthma exacerbations according to BTS/SIGN guidelines?
A
Moderate
Severe acute
Life-threatening
23
Q
What should healthcare professionals be aware of in patients with severe asthma?
A
If patient has severe asthma and one or more adverse psychosocial factors they are at risk of death.
24
Q
What are some signs of a moderate asthma exacerbation?
A
Increasing symptoms
PEF > 50-75% best or predicted
NO features of acute severe asthma
25
What are some signs of an acute severe asthma exacerbation?
PEF 33-50% best or predicted
respiratory rate ≥ 25/min
heart rate ≥ 110 bpm
inability to COMPLETE SENTENCES IN ONE BREATH
26
What are signs of a life-threatening asthma exacerbation?
In a patient with severe asthma:
PEF < 33% best or predicted
SPO2 < 92%
PaO2 < 8kPa
NORMAL PaCO2
Silent chest
Cyanosis (turning blue)
Poor respiratory effort
Arrythmia
Exhaustion
Altered consciousness
Hypertension
27
What are signs of a near fatal asthma exacerbation?
Raised PaCO2
Requiring mechanical ventilation with raised inflation pressures
28
Outline management of acute severe asthma.
People aged 5 years and over should receive ORAL OR INTRAVENOUS STEROIDS within ONE HOUR of presentation.
Delivery of salbutamol via nebuliser
VERY REGULAR MONITORING - symptoms, potassium level as b2 agonists can cause HYPOkalaemia.
29
What is CAP (Community Acquired Pneumonia)?
Infection of the lung tissue when the air sacs become filled with microorganisms, fluid and inflammatory cells affecting lung function.
It is acquired OUTSIDE OF HOSPITAL.
30
What type of infection is CAP usually caused by?
Bacterial infection - exact causative organism often not identified.
31
What are the symptoms of CAP?
Cough
Dyspnoea
Pleural pain (chest)
Fever - high temp., sweating, shivers
Aches and pains
32
When is pneumonia more likely to be of bacterial origin rather than COVID?
Patient becomes rapidly unwell after only a few days
No history of typical covid symptoms
Pleuritic pain
Purulent sputum
33
What is the CURB-65 score used for?
Determine the severity of community acquired pneumonia.
34
What does CURB-65 stand for?
1 point given for:
Confusion
Urea > 7 mmol/L
Respiratory rate > 30/min
Blood Pressure (SBP<90 or DBP ≤ 60)
65 years old
35
What does a CURB-65 score of 0-1 mean?
Low severity:
Can be sent home with antibiotics OR
stay in hospital and given antibiotics if there are comorbidities, socials reasons etc.
36
What does a CURB-65 score of 2 mean?
Moderate severity:
Stay in hospital and given antibiotics
Supportive care
Microbiological investigations
37
What does a CURB-65 score of 3-5 mean?
High severity:
Stay in hospital and given antibiotics
Supportive care
Microbiological investigations
Urgent senior review
May need to go to critical care unit if score is 4-5
38
What is the treatment for low severity CAP?
Amoxicillin 500mg THREE TIMES A DAY for 5-7 days but can be up too 10 DAYS.
If penicillin allergic or not clinically appropriate - doxycycline, clarithromycin or erythromycin (PREGNANCY)
39
What is the treatment for moderate severity CAP?
Amoxicillin 500mg - 1g THREE TIMES A DAY orally AND clarithromycin 500mg TWICE A DAY ORALLY or erythromycin (pregnancy)
In penicillin allergy - doxycline
40
What is the treatment for high severity CAP?
Co-amoxiclav 1.2g THREE times a day INTRAVENOUSLY AND CLARITHROMYCIN 500mg TWICE daily INTRAVENOUSLY.
41
What is sepsis?
A life threatening reaction to an infection when the immune system overreacts to an infection and starts to damage body tissue and organs.
42
Who is at an increased risk of sepsis
People aged under 1 year or over 75 years
Diabetic patients
Patients with a weakened immune system/taking immunosupressants
Recent surgery or illness
Women who have just given birth or had a miscarriage or abortion.
43
When should sepsis be suspected?
Non specific non localised presentations such as feeling very unwell
MAY NOT have a high temperature
Changes in usual behaviour
44
What is the NEWS-2 score used to identify?
Clinical deterioration in a patient and most suitable response
45
What is the response to a NEWS SCORE of 0-4?
Ward-based
46
What is the response to a NEWS SCORE of 3 in an INDIVIDUAL PARAMETER?
Urgent ward based response - e..g. GP referral/ walk in centre
47
What is the response to a NEWS SCORE of 5-6?
Urgent response - A&E?
48
What is the response to a NEWS SCORE of 7+?
Urgent or emergency response - e.g. calling an ambulance
49
Why do patients need to be advised to rinse their mouth after using an ICS?
Risk of oral thrush
50
What is important when prescribing beclomethasone?
Needs to be prescribed by brand
51
What factors can affect the choice of inhaler device?
Age of patient
Severity of disease
Manual dexterity
Personal preference
52
What are some drug-drug interactions for beta agonists?
Corticosteroids
Theophylline
Beta-blockers
Due to increased risk of hypokalaemia.
53
What are some drug-drug interactions for corticosteroids?
Beta agonists
Antidiabetic medications
54
What are some interactions for theophylline?
Many drug-drug interactions due to enzyme inducers/inhibitors
SMOKING!!!
55
Why does theophylline need close monitoring?
Narrow therapeutic window
56
What is COPD?
Chronic obstructive pulmonary disease (COPD) is a common, treatable (but not curable) and largely preventable lung condition.
It is characterised by persistent respiratory symptoms and airflow obstruction which is usually progressive and not fully reversible. (NICE CKS)
57
According to GOLD and NICE guidelines what should we look out for when diagnosing COPD?
Clinical features of COPD
ABSENCE OF CLINICAL FEATURES OF ASTHMA
Smoking history
58
How can we confirm a diagnosis for COPD?
Spirometry
59
What are some other investigations we can carry out when diagnosing COPD?
Chest X-ray
Full blood count - ruling out anaemia and polycaephaemia
BMI calculation
60
What are some risk factors for COPD?
TOBACCO SMOKING!!!!
Family History
Occupational exposure to fumes, dust and chemicals
Smoke from domestic fuels for example cooling and heating fuels
61
How many COPD related deaths are there per year in the UK?
30,000
62
What are some clinical features of COPD?
Dyspnoea - progressive, persistent and worsens with exercise
Chronic cough - may be intermittent and may be unproductive
Chronic sputum production
History of exposure to risk factors
63
True or False. Nearly all cases of COPD have a history of smoking.
True
64
Is COPD rare in people under 35?
Yes
65
Is a chronic productive cough a symptom of asthma or COPD?
COPD
66
Describe breathlessness during COPD.
Persistent and progressive - worsens over time.
67
Are nighttime symptoms such as waking up due to breathlessness, a symptom of asthma or COPD?
Asthma
68
True or false. It is common for there to be significant diurnal or day to day variability in COPD.
FALSE
69
According to NICE/GOLD guidelines a POSTBRONCHODILATOR FEV1 that is less than or equal to 80% of the predicted value indicates..
Stage 1 - mild COPD
70
According to NICE/GOLD guidelines a POSTBRONCHODILATOR FEV1 that is between 50-79% of the predicted value indicates..
Stage 2 - moderate COPD
71
According to NICE/GOLD guidelines a POSTBRONCHODILATOR FEV1 that is between 30-49% of the predicted value indicates..
Stage 3 - severe COPD
72
According to NICE/GOLD guidelines a POSTBRONCHODILATOR FEV1 that is less than 30% of the predicted value indicates..
Stage 3 - very severe COPD
73
In all stages of COPD the POST BRONCHODILATOR VALUE of FEV1/FVC is....
less than 0.7
74
The MRC dyspnoea scale grades breathlessness from...
1-5
75
What does grade 1 breathlessness in relation to activities mean?
Not troubled by breathlessness except on strenuous exercise.
76
What does grade 2 breathlessness in relation to activities mean?
Shortness of breath when hurrying or walking up a slight hill
77
What does grade 3 breathlessness in relation to activities mean?
Walks slower than contemporaries on level ground or has to stop to take breath when walking at own pace
78
What does grade 4 breathlessness in relation to activities mean?
Stops for breath after walking 100m or after a few minutes on level ground
79
What does grade 5 breathlessness in relation to activities mean?
Too breathless to leave the house or breathless when dressing or undressing
80
What does a higher score on the COPD Assessment Test (CAT) indicate?
COPD has a greater impact on the person's quality of life.
81
What does the COPD assessment test look at?
Cough
Phlegm
Mucus
Chest tightness
Breathlessness
Limit to doing activities at home
Feeling confident to leave the house
Sleeping
Energy
82
What does the CAT score indicate?
> 30 = very high impact
> 20 = high impact
10-20 = medium impact
< 10 = low impact
5 = upper limit in a norma healthy non-smoker
83
Why may BMI fluctuate in COPD patients?
Lower BMI
Not wanting to eat due to breathlessness
Less food due to struggle of carrying out tasks such as shopping
Higher BMI
Lack of activity due to breathlessness and muscle weakness
84
Weight changes in older people with COPD must be paid attention to especially if the change is more than...
3kg
85
What is Cor Pulmonale?
Right sided ventricular failure
86
How does cor pulmonale arise?
Chronic hypoxia within the body
Pulmonary vasoconstriction
Pulmonary hypertension
Right ventricle of heart becomes enlarged
87
What are some signs/ symptoms of cor pulmonale?
Fatigue
Peripheral oedema
Worsening cough
Haemoptysis - coughing up blood may be frothy and pink
Worsening shortness of breath
Chest pain unresponsive to GTN
88
What do we need to consider when prescribing initial pharmacological treatment for COPD? [GOLD]
Exacerbations including moderate and exacerbations leading to hospitalisation
89
What is the initial treatment in COPD for patients who have experienced:
≥ 2 moderate exacerbations OR
≥ 1 leading to hospitalisation
GROUP E
Long acting beta agonist
Long acting muscarinic antagonists
ICS may also be used if plasma eosinophils are over 300/microliter and patient has asthma history/asthma like symptoms
GROUP E
90
What is the initial treatment in COPD for patients who have experienced 0 or 1 moderate exacerbations not needing hospital admissions if:
mMRC (dyspnoea test) 0-1
CAT score < 10
GROUP A
A bronchodilator - long acting is preferred unless breathlessness is very occasional
GROUP A
91
What is the initial treatment in COPD for patients who have experienced 0 or 1 moderate exacerbations not needing hospital admissions if:
mMRC (dyspnoea test) ≥ 2
CAT score > 10
GROUP B
LABA and LAMA
GROUP B
92
Outline the management cycle of COPD.
Review: symptoms, dyspnoea and exacerbations
Assess: inhaler technique, adherence and non pharmacological approaches
Adjust: escalate/de-escaalate treatment, switch inhalers
93
True or false. If the patient responds well to initial treatment for COPD they should be maintained on this.
True
94
What should be checked if person does not respond well to initial for COPD?
Check adherence, inhaler technique and possible interfering comorbidities
Look for the predominant symptom that needs to be treated - DYSPNOEA or EXACERBATIONS
95
What is the treatment pathway when dyspnoea is the main symptom of COPD to be targeted?
LABA or LAMA
then LABA AND LAMA
Consider switching inhaler device
Non-pharmacological treatment
Investigate for other causes of dyspnoea
96
What is the treatment pathway when exacerbations in COPD to be targeted?
LABA or LAMA
Then LABA and LAMA if blood eos<300 or LABA and LAMA and ICS if blood eos>300
If blood eos is over 100 on LABA AND LAMA then add ICS but if lower an exacerbation is still ongoing then use Roflumilast or azithromycin
If exacerbation is still going after LABA AND LAMA AND ICS add roflumilast or Azithromycin
97
When is roflumilast used in COPD?
When treatment with LABA and LAMA and ICS has not helped with exacerbation and FEV1 < 50% or patient has chronic bronchitis
98
When is Azithromycin used in COPD?
When treatment with LABA and LAMA has not helped with exacerbation and patient is a former smoker
99
What is the non pharmacological advice for patients in COPD group A (0-1 moderate exacerbations, no hospital admission, mMRC 0-1 and CAT<10)
Essential: SMOKING CESSATION
Physical activity
Vaccines: Flu, Pneumococcal, Pertussis, COVID, Shingles
100
What is the non pharmacological advice for patients in COPD group B:
0-1 moderate exacerbations and did not need hospitalisation
mMRC > 1
CAT SCORE > 10
and COPD Group E:
2 or more moderate exacerbation and at least 1 leading to hospitalisation
Essential: SMOKING CESSATION and PULMONARY REHABILITATION
Physical activity
Vaccines: Flu, Pneumococcal, Pertussis, COVID, Shingles
101
What are the NICE guidelines for treatment for COPD?
Non pharmacological first:
Smoking cessation
Vaccines
Pulmonary rehabilitation
Self management plan
Co-morbidities
First offer SABA or SAMA to use when feeling breathless
The if person still has exacerbations
102
What are the PCRS guidelines for treating COPD?
Smoking cessation, flu vaccine, BMI, exercise and pulmonary rehabilitation (if dyspnoea mMRC score is ≥ 3
If breathlessness is main trait:
SABA daily and then
SABA and LABA OR [LAMA]
If breathlessness still persists SABA AND (LAMA AND LABA)
If exacerbations are the main trait
SABA and LAMA or [LABA] and if this is ineffective SABA AND (LAMA AND LABA)
If patient has COPD with asthma
SABA AND (LABA AND ICS)
If still poorly controlled - refer to specialist --SABA + LAMA + (LABA and ICS)
103
What are some newer LABA products?
Indaceterol (Onbrez)
- ONCE DAILY
- breezehaler device using capsules
Oldaterol (Striverdi Respimat)
- ONCE DAILY
- solution for inhalation
Fluticasone furoate/ vilanterol (Relvar)
- ICS and LABA
- ONCE DAILY
- Dry powder device
104
What are some newer LAMA products?
Aclidinium (Eklira Genuair)
- TWICE DAILY
- Inhalation powder
Glycopyrronium (Seebri)
- ONCE DAILY
- Breezhaler device using capsules
Umeclidinium
- ONCE DAILY
- Dry powder device
105
What are some oral therapies that may be used in COPD?
Theophylline
Mucolytics
Oral corticosteroids
Prophylactic antibiotics
106
Outline the use of theophylline in COPD?
Short acting bronchodilators and long-acting bronchodilators must have been trialled first OR PATIENT cannot use inhaled devices
Narrow therapeutic window - TDM
Smoking cessation causes sudden increase of plasma theophylline - risk of toxicity
Mixed evidence for use
107
Outline the use of mucolytics in COPD.
Carbocisteine
Consider in patients with a chronic cough with sputum
Continue using if there is symptomatic improvement but WILL NOT PREVENT EXACERBATIONS
108
Outline the use of oral corticosteroids in COPD.
Not usually recommended
Usually used in exacerbations but can be maintain in advanced COPD if cannot be withdrawn afterwards
Keep dose as low as possible
Monitor for osteoporosis, and give PPI for gastroprotection
109
Outline the use of prophylactic antibiotics in COPD
Azithromycin 250mg three times a week may be considered if patient meets criteria - consult specialist first
110
What is the most important change that will help slow down the progression of COPD?
SMOKING CESSATION
111
What smoking cessation products are available?
NRT
Varenicline (Champix)
Bupropion (Zyban)
112
What is pulmonary rehabilitation?
- individual exercises and programmes for patients with COPD or other lung disease that help to improve physical and social performance and autonomy.
113
How does the pulmonary rehabilitation programme work?
6- 12 weeks long
Minimum 2 unsupervised session a week and 1 unsupervised
Exercise 5 times a week for 30 mins
Muscle resistance AND aerobic training
114
What is a COPD exacerbation?
an acute worsening of respiratory symptoms such as breathlessness, cough and sputum production that results in additional therapy.
115
What are the three classifications of COPD exacerbations and their treatments?
Mild - short acting bronchodilators
Moderate - Short acting bronchodilator with antibiotics and/or oral corticosteroids
Severe - (hospitalisation) may also have acute respiratory failure
116
What does a lower pH of blood suggest?
acidosis
117
What happens in respiratory acidosis?
pCO₂ rises
(if [HCO₃⁻] decreases then this is compensation)
118
How is severity of an exacerbation assessed?
Resp rate
Use of accessory respiratory muscles
Mental status
Arterial blood gases
Chest radiograph
ECG
Pulse oximetry
WBC and U&Es
119
How should a severe exacerbation be treated according to GOLD?
Supplemental oxygen therapy
Increase dose/frequency of SABDs
Combine SABA and anticholinergic
Spacer or nebulisers?
Consider oral corticosteroids
Oral antibiotics if signs of infections
120
What additional monitoring is needed during a severe COPD exacerbation?
fluid balance
risk of thromboembolism if immobile (LMWH?)
indentify and treat associated conditions (e.g. cor pulmonale)
121
How should a COPD exacerbation be treated according to NICE?
Antibiotics
Corticosteroids
Oral therapy
Physiotherapy
Treatments only delivered in hospital
122
wha is the ideal volume to be used in a nebuliser?
4-5ml given over 15-30 minutes
< 1ml drug won't have effect
larger vol. = long nebulisation time = uncomfortable
123
What are the risks of using a mask over a mouthpiece when using a nebuliser?
Drug can escape through sides and top of mask.
Drug can get into eyes - inhaled antimuscarinics can get into eye, increase IOP and cause glaucoma - USE GOGGLES
"Currently all inhaled antimuscarinic drugs used in COPD and asthma treatment have a warning because the possibility of worsening narrow-angle glaucoma"
124
What are the advantages od nebulisers?
No inspiratory effect is required (inhalers require inspiration)
Breath coordination not required
High doses of drugs can be delivered
125
What are the disadvantages of nebulisers?
Time consuming
Electricity supply required
Must be cleaned regularly
Expensive
Can be a source of infection
risk vs benefit of high doses
Patient can become psychologically dependent
May mask deterioration
126
What is the aim of a COPD management plan?
Helps a person manage their COPD based on the symptoms they are having/severity of symptoms
127
What sort of ongoing multidisciplinary care may a person with COPD require?
Monitoring
Oxygen therapy
Non invasive ventilation
Self-management plan
mental health
nutrition
vaccination
palliative care
