Asthma + COPD Flashcards by Hannah Gibson

Pathology of asthma

Bronchial muscle contraction, triggered by stimuli

Mucosal swelling caused by mast cell and basophil degranulation, releasing inflammatory mediators

Increased mucus production

Hyper-responsiveness of airways Reversible airway obstruction

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S+S of asthma

Episodic - diurnal variability (worse at night or early morning)

Wheeze

Atopy

SOB

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Pathway if pt is likely to have asthma

Initiate carefully monitored treatment (6 weeks inhaled corticosteroids)

FEV1 test

If good response to meds, diagnose asthma

If poor response, check technique + adherence + consider alternative diagnosis

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Investigations for asthma

Spirometry with bronchodilator reversibility (improvement of FEV1 >12% or >200ml increase in volume)

Peak flow + reversibility to diagnose (using 4 puffs of salbutamol inhaler, 15 min pause)

FeNO (fractioned exhaled nitric oxide) - higher level of nitric oxide in exhaled air = asthma

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Supported self management for asthma

Education on triggers

Smoking cessation

Weight loss

Breathing exercises

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What is defined as ‘controlled’ asthma?

No daytime symptoms

No night time waking

No need for rescue meds

No asthma attacks

No limitations on activity

Normal lung function

Minimal side effects

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Ladder for management in adults

Short acting B2 agonist (salbutamol)

+ Low dose ICS (beclametasone/ budesonide) - brown, called Clenil

Add inhaled LABA (salmeterol) - stop if no effect

Increase ICS dose (max 2g a day)

or add: +LTRA (leukotriene receptor antagonist eg Montelukast), SR theophylline, LAMA (tiotropium bromide)

+ daily steroid tablet

+ refer

Don’t give LABA without ICS

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What medications can be added in specialist centres for asthma?

Omalizumab (anti IgE mAb)

Given by SC injection

Immunosuppressants = methotrexate

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RF for developing fatal asthma

Previous hosp admission

Requiring >3 medications

Heavy use of B2 agonist

Adverse behavioural features eg non-adherance, mental illness, stress, drug abuse

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Adult classification of severe asthma

PEF 33-50%

Resp rate >25

HR >110

Inability to complete sentences in one breath

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Adult classification of life threatening/ fatal asthma

Altered consciousness, arrhythmias, hypotension, cyanosis, silent chest

PEF <33%

O2 <92%

PaO2 <8 kPa

Near fatal = Raised PaCO2

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Child classification of severe asthma

Can’t complete sentences

SpO2 <92%

PEF 33-50%

HR >140 (1-5 y/o) >125 (>5 y/o)

RR >40 (1-5 y/o) >30 (>5 y/o

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Child classification of life-threatening asthma

Silent chest, cyanosis, hypotension, confusion

Sp02 <92%

PEF <33%

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Acute asthma management in adults

O2 Salbutamol 5mg nebs

Ipratropium bromide nebs

Hydrocortisone IV

Magnesium sulphate IV

Aminophylline/ IV salbutamol

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What to give on discharge of acute asthma?

Prednisolone for 5-7 days

Weaning plan for salbutamol

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What should be monitored in primary care for asthma?

Asthma control

Lung function assessed by spiromatry/ PEF

Inhaler technique

Adherence

Bronchodilator reliance

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What are the 3 questions to ask (RCP) in an asthma pt?

Any difficulty sleeping?

Any symptoms during the day?

Has it interfered with activities?

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S+S COPD

Exertional SOB, chronic cough, regular sputum production, frequent winter bronchitis, wheeze

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RF for COPD

Smoking

Pollutants in work place

Alpha-1 antitrypsin deficiency

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Investigations for COPD

CXR - hyperinflation, flat diaphragms, bullae

Spirometry

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Staging of COPD

Stage 1 = <0.7 FEV1/FVC, >80% FEV1 % predicted

Stage 2 = <0.7 FEV1/FVC, 50-79% FEV1 % predicted

Stage 3 = <0.7 FEV1/FVC, 30-49% FEV1 % predicted

Stage 4 = <0.7 FEV1/FVC, <30% FEV1 % predicted

What is pulmonary rehab?

Program of exercise, education + support

SIRS criteria

RR >20

Temp high or low

HR >90

WCC <4 or >12

COPD x ray appearance

Hyperinflated Flat diaphragms Bullae

Management of COPD exacerbation

Controlled O2 - check ABG Salbutamol nebs Ipratropium bromide nebs - crossout LAMA Corticosteroids - IV hydrocortisone Antibiotics Aminophylline Resp support (BiPAP if rising CO2)

Ongoing management of COPD post exacerbation

Prednisolone 30mg OD for 7 days Continue antibiotics

What medications precipitate asthma?

Beta blockers + aspirin

Management of mild + moderate COPD

All COPD pts: SABA or SAMA (ipratropium) If mild (\>50%): LABA (salmetrol) or LAMA (tiotropium) + ICS if not working If moderate (\<50%) = LABA (salmetrol) or LAMA (tiotropium) AND ICS If starting LAMA, stop SAMA - causes heart block Remember flu vaccine + pneumococcal jab annually

Obstructive vs restrictive FEV1/ FVC ratio

Obstructive \<75% (due to decreased FEV1, slightly decreased FVC) Normal 75-80% Restrictive \>80% (due to slightly decreased FEV1, decreased FVC)

SE of steroid use

Immunosuppression Mood + behaviour changes Adrenal suppression after stopping Steroids increase INR Mineralcorticosteroids increase BP Increases blood glucose - caution in diabetics

What happens when stopping steroids?

Adrenal insufficiency if stopped suddenly after prolonged period - use 6 week reduction course

SE of salbutamol

Palpitations Tremor Hypokalaemia

What is trelegy?

Inhaler with 3 drugs ICS + LABA + LAMA

What are light blue, teal, orange, red+white, purple, green, brown, white+turquoise inhalers?

Blue - salbutamol Teal - salmeterol Orange - fluticasone (ICS) Red+white - Symbicort (budesonide + formoterol) Green - ipratropium Brown - budesonide Purple - fluticasone + salmeterol White+turquoise - tiotropium

What is the centor + fever pain criteria?

Fever Purulence Attend rapidly severely Inflamed tonsils No cough Centor: tonsillar exudate, fever, tender lymphadenopathy, absence of cough

Causative organisms for COPD exacerbations

Haemophilus influenza Strep pneu Moraxella catarrhalis Rhinovirus

Investigations for acute COPD

ABG (bicarb for acute on chronic) CXR (hyperinflation, flat diaphragms, bullae) FBC + U+Es, CRP ECG Peak flow Culture sputum +- blood Measure theophylline baseline

Management of acute exacerbation of COPD

COSI CAA Controlled Oxygen (88-92) through venturi - repeat ABG 30 mins after changing O2 Salbutamol 5mg Ipratropium bromide 500mcg neb Corticosteroids: Hydrocortisone IV/ Pred oral 30mg 7-14 days Amoxicillin + clarithromycin/ doxycycline Aminophylline if no response to steroids NIV if indicated

Indications for NIV + 2 types

COPD with respiratory acidosis (BiPAP) Type 2 failure Pulmonary oedema (CPAP)

Severity of asthma (moderate, severe + life threatening)

Mod = 50-75% PEFR sats \>92% Severe = RR\>25 HR \>110 33-50% PEFR sats \>92%, unable to complete sentences Life threatening = silent chest, cyanosed, bradycardic, hypotensive, confusion, sats \<92%

What is the GOLD criteria?

Uses MRC + CAT score with number of exacerbations = produces a group (A-D) Group dictates what inhaler to use

What is the MRC scale?

For COPD pts Grade 1-5: not troubled by SOB to too breathless to leave house

When should MDI + spacers be used?

Reduce SE Improve amount inhaled Increase efficiency of use

What is the Anthisonian criteria?

For acute exacerbation of COPD. 2 of: increased SOB, increased sputum volume or presence of purulent sputum)

What is brittle asthma (+ the types)?

Difficult to control form of asthma Type 1 = prolonged wide PEF variability Type 2 = sudden severe attacks on stable background

When do steroids need to be tapered?

If the pt has been on them for \>3 weels

When is NIV + invasive ventilation used in asthma?

NIV = never, unless on ICU Invasive = if pt has worsening hypoxia or increasing CO2, decreasing pH or they're becoming exhausted/ confused, respiratory arrest

What abx are given to COPD pts + what needs to be checked?

Azithromycin LFTs + QT length on ECG

Criteria for LTOT

Non-smoker Sats \<88% pO2 \<7.2 Evidence of HF or polycythaemia = pO2 \<8 Check pCO2 doesn't rise with oxygen therapy = NIV may be needed

What is the BODE index?

Scoring system for COPD survival