Asthma + COPD Flashcards by Callum Donoher

What is asthma?

Chronic inflammatory airway disease leading to variable air way obstruction

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What is the pathophysiology of asthma?

CRAB

Chronic
Reversible obstruction
Airway hypersensitivity
Bronchoconstriction

Smooth muscle in the airways is hypersensitive to stimuli leading to airway constriction and airway obstruction

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How does asthma typically present?

Episodic
Typically worse at night
SOB
Chest tightness
DRY cough
Wheeze

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What other conditions does asthma often present with?

What is this called?

Asthma
Hay fever
Eczema
Food allergies

Atopy

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How does asthma present on examination when the patient is well?

Typically normal

Widespread polyphonic expiratory wheeze

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What are some typical triggers of asthma?

Infection
Nighttime
Exercise
Animals
Cold, damp dusty air
Strong emotions

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What medications can worsen asthma?

Non selective beta blockers like propranolol
NSAIDs like. Naproxen

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What investigations are done for asthma?

Spirometry
Spirometry + reversibility testing
FeNO (Fractional exhaled nitric oxide)
Peak flow variability using a peak flow diary

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How is spirometry and reversibility testing used to diagnose asthma?

Work out FEV1:FVC ratio
If FEV1:FVC ratio < 70% patient has obstructive pathology

Patient is then given a bronchodilator like salbutamol, if the FEV1 has an increase in 12% or more it shows the obstruction is reversible (not COPD)

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What is the use of fractional exhaled nitric oxide (FeNO)?

Measures concentration of nitric oxide exhaled by the patient

Nitric oxide is a marker of airway inflammation (higher it is more airway inflammation there is)

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How can a peak flow diary be used to help investigate asthma?

Readings taken twice daily for 2-4 weeks
If there is variability of more than 20% between readings it’s positive

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What are the types of medications that are used to manage asthma?

Short acting Beta 2 agonists (SABA) = salbutamol
Inhaled corticosteroids (ICS) = beclometasone
Long acting Beta 2 agonists (LABA) = salmeterol
Leucotriene receptor antagonists = monteleukast
Long acting muscarinic antagonist = Tiotropium
Theophylline

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What are the BTS guidelines for the long term management of asthma?

1.) salbutamol (SABA) + Beclometasone (ICS)

If not controlled

2.) salbutamol (SABA) + [ Beclometasone (ICS) + formoterol/salmeterol (LABA)]

3.) salbutamol (SABA) + [ Beclometasone (ICS) + formoterol/salmeterol (LABA)] + Monteleukast (LTRA) or Tiotropium (LAMA)

4.) specialist referral

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How frequently should an asthma patient be reviewed following a change to their medications?

4-8 weeks after adjustment

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What are the initial medications given to manage long term asthma?

SABA = Salbutamol
+
ICS = beclometasone

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What changes to medications do you give if an asthma patient is not coping with Salbutamol (SABA) + Beclometasone (ICS)?

Add a LABA to the ICS inhaler (MART Therapy) LABA+ICS

So now on:
Salbutamol (SABA)
+
Beclometasone (ICS) + salmeterol or formoterol (LABA)

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What changes to medications do you give if an asthma patient is not coping with Salbutamol (SABA) + Beclometasone (ICS) + salmeterol/formoterol (LABA)?

Increase dose of Beclometasone (ICS) and can add Monteleukast (LTRA) or Tiotropium (LAMA)

So patient on:

Salbutamol (SABA)
+
Inc beclometasone (ICS) + salmeterol/formeterol (LABA)
+
Monteleukast (LTRA) or Tiotropium (LAMA)

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What changes might a specialist do to medications in an asthma patient who is not coping with Salbutamol (SABA) + increased dose Beclometasone (ICS) + salmeterol/formoterol (LABA) + Monteleukast (LTRA) or Tiotropium (LAMA)?

Increase beclometasone to a higher dose or give oral corticosteroids

May also consider theophylline or biologics

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What are the risk factors for developing asthma?

Fhx
Smoking
Polluted area
Atopy

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What is considered uncontrolled asthma?

Any asthma exacerbation requiring oral corticosteroids

Frequent regular symptoms needing reliever 3 or more times a day

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What is the non-pharmacological management of asthma?

Smoking cessation
Patient and family education to avoid triggers
Proper inhaler technique + adherence
Regular exercise
Yearly flu jab

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What is an acute asthma exacerbation?

What are some signs of an acute asthma exacerbation?

Rapid deterioration in symptoms :

-SOB
-use of accessory muscles
-Tachypnoea
-tight chest/reduced air entry
-symmetrical expiratory wheeze

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What is the ABG progression with a patient with worsening asthma severity?

Initially respiratory alkalosis since TACHYPNOEA

Normal or high pCO2 or low pO2 (hypoxia) is very bad since patients becoming exhausted with poor respiratory effort leading to RESPIRATORY ACIDOSIS

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What are the severity’s of an acute asthma exacerbation?

Moderate
Severe
Life-threatening
Near fatal

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What is considered a moderate asthma exacerbation?

Peak flow 50-75% best or predicted

What is the classification of severe asthma exacerbation?

Any 1 of: Peak flow 33-50% best or predicated RR over 25 HR over 110 Unable to complete sentences

What are the features/classification of life-threatening asthma exacerbation?

Any 1 of: Sats < 92% PaO2 < 8kPa Peak flow < 33% Silent chest Confusion

How do you classify a near fatal asthma exacerbation?

PaCO2 > 6kPa (Type 2 resp failure) Silent chest Will likely need ITU

How is a mild asthma exacerbation managed?

Inhaled SABA (Salbutamol) X4 dose of inhaled corticosteroids for 2weeks Or Oral steroids Abx if evidence of infection 48hr follow up

What is the management of moderate asthma exacerbation?

Nebulised salbutamol Steroids (oral pred or IV hydrocortisone)

What is the management for a severe /life-threatening asthma exacerbation?

15L non rebreathing oxygen aiming for 94-98% sats (titrate down) Nebulised oxygen (8L) driven salbutamol (2.5-5mg every 15mins) Oral Prednisolone 40-50mg for 5days IV magnesium sulphate

What side effects can salbutamol cause and needs to be monitored when treating asthma exacerbation?

Hypokalaemia Tachycardia Lactic acidosis

What is COPD?

Long term, progressive non reversible airway obstruction, chronic bronchitis and emphysema

What is chronic bronchitis?

Long term symptoms of a cough and sputum production due to inflammation in the bronchi

What is emphysema?

Damage and dilation of the alveolar sacs and alveoli decreasing the surface area for gas exchange

How can COPD be differentiated from. Asthma on spirometry?

COPD will have an FEV1:FVC ratio that’s less than 70% but FEV1 or FVC wont improve by 12% or more with a bronchodilator

What are the symptoms of COPD?

SOB Cough Sputum production Wheeze Recurrent respiratory tract infections

What is the scale used to score breathlessness?

MRC Dyspnoea Scale

How is the MRC dyspnoea scale graded?

Grade 1 - Grade 5

What is an MRC Dyspnoea Scale Grade 1 for breathlessness?

Breathless on strenuous exercise

What is an MRC Dyspnoea Scale Grade 2 for breathlessness?

Breathless on walking uphill

What is an MRC Dyspnoea Scale Grade 3 for breathlessness?

Breathlessness that slows the patient walking on the flat (Walk slower than others of the same age on the flat due to breathlessness or have to stop for breath on the flat)

What is an MRC Dyspnoea Scale Grade 4 for breathlessness?

Breathlessness stops them from walking more than 100m on the flat

What is an MRC Dyspnoea Scale Grade 5 for breathlessness?

Unable to leave the house due to breathlessness

What investigations would you do if a patient is long term short of breath, sputum production, cough and you think it may be COPD?

Spirometry (FEV1:FVC ratio, TLCO) BMI FBC Sputum culture CXR CT thorax ECG + ECHO Serum alpha-1 antitrypsin

What does TLCO test for?

How well oxygen and CO2 diffuse across the alveolar membrane through the lungs into the blood

What is the long term management of COPD?

Smoking cessation Pulmonary rehabilitation Pneumococcal and annual flu vaccine

What is the initial medical treatment for COPD?

SABA (Salbutamol) + SAMA (Ipratropium bromide)

After giving the pateitn a SABA + SAMA, there is no asthmatic or steroidal responsive features, what medications do you give for the COPD patietn?

LABA + LAMA = Anoro Ellipta inhaler

When COPD has asthmatic or steroid responsive features how is it treated?

Long acting beta agonist (salmeterol) + ICS (beclometasone) = Fostair

What is a medication that can be given to breakdown mucus?

Carbocisteine (mucolytic agent)

What is the issue with Azithromycin?

Patients need an ECG and liver function monitoring before and during treatment

When is a patient given Long-term oxygen therapy?

Severe COPD: -chronic hypoxia < 92% -2 ABGs with Pa02 < 7.3kPa -Polycythaemia -cyanosis -cor pulmonale

What patients can you not give Long-term oxygen therapy to?

Smokers

What is Cor pulmonale?

Right sided heart failure due to respiratory disease leading to pulmonary hypertension leading to increased afterload for the right ventricle leading to back flow of blood through the right side of the heart to systemic veins

What are some causes of Cor pulmonale?

COPD PE ILD Cystic fibrosis Primary pulmonary hypertension

What are some symptoms of cor pulmonale?

SOB Peripheral oedema Breathless on exertion Syncope Chest pain

What are some signs of cor pulmonale?

Hypoxia Cyanosis Raised JVP Peripheral oedema Parasternal heave Mitral regurgitation (pan systolic murmur) Hepatomegaly

How is cor pulmonale managed?

Diuretics Long term oxygen therapy Treat underlying cause

What is the most common cause of a COPD exacerbation?

Infection (bacterial or viral)

What would the ABG of a patient with an acute COPD exacerbation look like?

Acidotic Low pO2 High pCO2 Raised bicarbonate (patients bicarb is high normally due to chronic aspect of COPD but the exacerbation is too much for the bicarb to prevent the pH being acidotic)

What investigations would you do for a patient who is having a COPD exacerbation?

FBC ABG U+Es Sputum culture Blood cultures (if signs of sepsis) ECG CXR

What are the target saturations of a patient at risk of retaining CO2?

88-92%

What are the target saturations of a patient with COPD who you are confident do not retain CO2?

94-98%

What oxygen masks are given to patients with COPD to deliver a very specific amount of oxygen?

Venturi masks

What is the first line medical management for an acute infective exacerbation of COPD?

Regular inhalers or nebulisers (salbutamol and ipratropium bromide) Steroids (Prednisolone 30mg OD for 5 days) Abx Respiraotry physiotherapy

What is the management of a severe acute exacerbation of COPD. When the initial management isn’t enough?

IV aminophylline Non-invasive ventilation (NIV) Intubation and ventilation (ITU)

What is NIV (Non invasive ventilation)/how does it work?

Full face mask and hood where the is Inspiratory positive airway pressure forcing air into the lungs and then expiratory positive airway pressure to keep the lungs open on exhalation

When is NIV used?

Persistent respiratory acidosis (pH < 7.35 and PaCO2 >6) despite max treatments Potential to recover Acceptable to patient

What is the contraindication to NIV?

Untreated pneumothorax

What investigations should be done regularly while receiving NIV?

ABGs

What are some causes of COPD?

Smoking Air pollution Occupational exposure Alpha-1-antitrypsin TB

What is necessary for a safe asthma discharge bundle (following an exacerbation)?

PEFR > 75% best Nebulisers stopped 24hrs before discharge Inpatient asthma nurse review for technique and adherence 5 day oral Prednisolone 2 day GP follow up Resp clinic follow up

What is an asthma management plan?

Patient has a card which says their best peak flow result on it It has 2 other values on it stating they should take rescue steroids if their peak flow falls below a set number Or Seek immediate 999 help

What are some signs of COPD?

Barrel chest Hyper resonant chest percussion Reduced chest expansion Wheeze Tripodding Pursedlips breathing Use of accessory muscles Cor pulmonale signs

What is the management for acute bronchitis?

Oral doxycycline but often resolves without

What is the main blood test abnormality with acute bronchitis?

CRP

What is an alternate name for Non invasive ventilation (NIV)?

BiPAP (Bilevel Positive Airway Pressure)

What is the management of severe/life threatening asthma exacerbation if the patient doesnt respond to: 15L non rebreathing oxygen aiming for 94-98% sats (titrate down) Nebulised oxygen (8L) driven salbutamol (2.5-5mg every 15mins) Oral Prednisolone 40-50mg for 5days IV magnesium sulphate

Nebulised ipratropium bromide IV 100mg Hydrocortisone Escalate to ITU Consider NIV (non invasive ventilation or ventilation)