Asthma & COPD Flashcards by Amy Spicer

What is asthma?

Reversible small airway obstruction due to bronchial hypersensitivity
Characterised by bronchospasm + inflammation + oedema

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What are the precipitants of asthma?

Cold air
Smoking
Exercise
Damp
Allergens
Drugs (Aspirin, NSAIDs, BB)

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How does asthma present?

Nocturnal cough
Recurrent rhinitis
Exertional dyspnoea 
Reflux
Diurnal variation
Sx of atopy

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How does an acute asthma attack present?

Acute dyspnoea
Hyperinflated chest
Polyphonic wheeze
↑Mucous production 
↑HR + ↑RR (hyperventilation) 
↑Resonance on Percussion

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How is asthma investigated?

PEFR
Spirometry
Fractional exhaled NO test (>17yo)
Histamine/Methacholine direct bronchial challenge test

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How is asthma diagnosed?

Sx PLUS:
-FeNO >40 
OR
-FEV1/FVC <70%
OR
-FeNO 25-30 AND +ve bronchodilator reversibility test
OR
- +ve bronchodilator reversibility test >200ml or 12%

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How is spirometry used when investigating asthma?

FEV1/FVC <70% (<0.7)

Do bronchodilator reversibility test (give SABA)

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How is PEFR used when investigating asthma?

If uncertain ∆ post-FeNO/Spirometry/Reversibility
Monitor peak flow for 2-4w
Compare w/predicted peak flow
Monitor for diurnal variation

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How is asthma managed in an adult?

1) SABA (Salbutamol)
2) SABA + ICS (Beclamethasone BD)
3) SABA + ICS + LRTA (Montelukast) review in 4-8w
4) SABA + ICS + LABA (Salmeterol)- Stop LRTA
5) SABA + MART (ICS + LABA Combi inhaler) ± LTRA- Stop LABA
6) ↑Dose to mod ICS
7) ↑Dose to high ICS OR trial LAMA/Theophylline/Specialist

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In managing asthma when should moving up the ‘ladder’ be considered?

Using salbutamol >3 doses/week

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How is acute asthma treated?

OH SHIT ME!

O: O2 if <94%
S: Salbutamol news 5mg back to back every 20mins x3 doses
H: Hydrocortisone IV 100mg
I: Ipratropium nebs 500mcg 4-6hourly
T: Theophylline IV
M: 2g MgSO4 in 100mls NaCl IV over 20mins
E: Erm HELP!!- CPAP

O2 driven nebs- 6L
Give 1-4 at the same time

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What bronchodilator reversibility levels would suggest someone has asthma?

A 200ml improvement in FEV1 or 12% in response to:

400mcg salbutamol
6w trial of ICS (beclometasone 200mcg bd)

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How much salbutamol should be advised to give to a patient having an asthma attack (where nebs can’t yet be given)?

4 puffs of salbutamol
then
2puffs every 2 mins-max 10 puffs

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When someone is sent home post-asthma attack what meds need to be given?

If PEFR <50% initially: Prednisolone 40mg 5days
Can be stopped abruptly if continuing ICS
Salbutamol weaning: 6 puffs QDS, 4 puffs QDS

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What are the differences in:
FEV1
FVC
FEV1/FVC
in obstructive &amp; restrictive lung diseases?

O: ↓FVC, ↓↓FEV1, ↓FEV1/FVC
R: ↓↓FVC, ↓FEV1, ↑FEV1/FVC

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What are the common obstructive lung diseases?

Asthma
COPD
Bronchiectasis
Bronchiolitis obliterans

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What are the common restrictive lung diseases?

Pulmonary fibrosis
Asbestosis
Sarcoidosis
NM disorders
ARDS

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In an asthma attack, what constitutes a moderate attack?

↑Sx

PEFR 50-70%

In an asthma attack, what constitutes a severe attack?

PEFR 33-50%
Inability to complete sentences
↑RR ≥ 25
↑HR >110

In an asthma attack, what constitutes a life threatening attack?

PEFR <33%
SpO2 <92%
PaO2 <8
Normal PaCO2
Cyanosis
HypoT
Silent chest
Confusion/exhaustion
Arrhythmia

In an asthma attack, what constitutes a near fatal attack?

PaCO2 >6- requires mechanical ventilation

What is COPD?

Progressive, irreversible, obstructive airway disease

2types: Chronic bronchitis, Emphysema

How are chronic bronchitis and emphysema differentiated?

CB: Cough >3m for 2 consecutive years, ↓alveolar ventilation + undamaged capillary bed → ↑residual lung volume + hypoventilate (→ T2 RF +cyanosis)
E: Enlarged alveolar airspace, ↑alveolar ventilation + damaged capillary bed → muscle waste + hyperventilate (→ T1 RF)

What are the 2 types and causes of emphysema?

Centrilobular: Smoking
Panlobular: α1-Antitrypsin deficient due to Cirrhosis

Which type of COPD relies on the hypoxic drive for respiratory effort?

Chronic bronchitis patients

Who should be worked up for ?COPD?

>35yo current or ex-smoker w/chronic cough

What are the signs of COPD on spirometry?

``` FVC <0.7 FEV1/FVC <70% FEV1 varies TLC↑ RV↑ ```

What are the different stages of COPD?

Mild/S1: FEV1 >80%, FVC <0.7 post-bronch Mod/S2: FEV1 50-79%, FVC <0.7 Severe/S3: FEV1 30-49%, FVC <0.7 V.Severe/S4: FEV1 <30%, FVC <0.7

When in COPD is spirometry CI?

Recent MI/Stroke/Surgery Unstable angina Pneumothorax TB

What investigations should be done when initially diagnosing COPD?

Spirometry CXR FBC ↑PCV (assess polycythaemia) BMI (work out BODE Index)

What is the BODE Index?

``` 4yr Survival predictor B: BMI (>21/ <21) O: Obstruction (FEV1 post-bronch) D: Dyspnoea scale E: Exercise capacity (6min walk) ``` 0 to 2 Points: 80% 3 to 4 Points: 67% 5 to 6 Points: 57% 7 to 10 Points: 18%

What will be seen on an ABG of someone with emphysema & chronic bronchitis?

E: ↓PaO2 CB: ↓PaO2 ↑PaCO2

How is stable COPD managed?

1) SABA (Salbutamol)/ SAMA (Ipratropium) 2) FEV1 >50% = LABA (Salmeterol)/ LAMA (Tiotropium) 2) FEV1 <50% = LABA + ICS (Beclomethasone/Fostair) OR LAMA ALONE 3) LABA + ICS + LAMA 4) Theophylline + Salbutamol Productive cough: Mucolytic (Carbocristine)

What are the indications for BiPAP?

``` pH <7.3 PCO2 >6 Resp weakness Chest wall deformity Obesity Hypoventilation ```

What is the criteria for LTOT in COPD?

pH <7.3 when stable AND one of: - Polycythaemia - Nocturnal hypoxaemia sats <90% - Peripheral oedema - Pulmonary HTN

What are the signs of COPD on CXR?

``` Hyperexpanded- >6 ant ribs Large central pulmonary arteries Bullae Peripheral vascular markings Flattened hemi-diaphragm ```

Other than medications, in COPD what other treatments are available?

Vaccines: Annual flu & Pneumococcal (↑↑ risk of Hib) | Pulmonary rehab

How is an acute exacerbation of COPD managed?

COSI CAR: CO: Controlled O2- 28% venturi S: Salbutamol 5mg nebs w/O2 OR air I: Ipratropium 500mcg C: CXR- ALL & Corticosteroids IV hydrocortisone 200mg A: IV Abx if from infection (Clarith or Doxy) R: Resp support- BiPAP if CO2 rising

When someone is sent home post-COPD exacerbation what meds need to be given?

Prednisolone 30mg 7d | Abx: IF Hx of fever/purulent sputum = Amoxicillin

How can individuals feeling unwell with COPD avoid hospital?

Use rescue packs: ↑ Salbutamol use to control Sx PO Steroids Abx if purulent sputum

What are the complications of COPD?

Cor Pulmonale | Over-oxygenation

How does Cor Pulmonale occur?

COPD destroys cap bed Leads to ↑pulm pressure + hypoxia = reflex pulmonary vasoC + ↑vasc resistance ↑Pul pressure past threshold → R ventricular failure = HF

How does Cor Pulmonale present?

``` Bronchiectasis Peripheral oedema Dyspnoea Nausea ↑ JVP ```

How is O2 titrated in COPD exacerbations?

CRITICALLY ILL: 15L/min reservoir mask SERIOUSLY ILL: 2-6L/min via nasal cannula or 5-10L/min via mask, Sats <85% = 15L reservoir MILD: 28% venturi recheck ABG at 30-60mins titre up if needed