Asthma & COPD in Primary Care Flashcards
What are the risk factors for asthma?
Personal or family history of atopic disease.
Male sex for pre-pubertal asthma and the female sex for the persistence of asthma from childhood to adulthood.
Respiratory infections in infancy.
Exposure (including prenatally) to tobacco smoke.
Premature birth and associated low birth weight.
Obesity.
Social deprivation.
Exposure to inhaled particulates.
Workplace exposures.
How is asthma diagnosed in primary care?
Presence of more than one variable symptom of wheeze, cough, breathlessness, and chest tightness.
Personal/family history of other atopic conditions, particularly atopic eczema/dermatitis and/or allergic rhinitis.
The results of fractional exhaled nitric oxide (FeNO) testing.
Spirometry should be offered to all symptomatic people over the age of five years. The FEV1/FVC ratio is normally greater than 70%. Any value less than this suggests airflow limitation. However, a normal spirometry result when the person is asymptomatic does not rule out asthma.
Bronchodilator reversibility (BDR)
What is the management of asthma in primary care?
Assess baseline asthma status.
Self-management and personalised asthma plan.
Ensure that the person is up to date with all routine vaccinations, including all childhood immunizations, and the annual influenza vaccination.
Advice avoidance of asthma triggers.
Initiate drug treatment.
When should SABA and ICS be used for the treatment of asthma?
SABA - should be prescribed for every patient with symptomatic asthma as a reliever.
ICS - this should be prescribed to patients who are using their SABA three times a week or more, have symptoms three/week or more, or are experiencing nighttime symptoms at least once a week.
LTRA -
What patients may need to be on a higher dose of ICS and why?
Smokers. Previous or current.
Smoking reduces the effectiveness of ICS.
What should be assessed before initiating an add-on therapy for a patient on SABA and ICS?
Inhaler technique. Adherence. Avoidance of triggers.
A patient (over the age of 17) has uncontrolled asthma despite using SABA and ICS appropriately with the correct technique what is the next option for add-on therapy? What can be used instead if adherence may be an issue?
Leukotriene receptor antagonist.
Long-acting Beta Agonist + ICS inhaler.
A patient (over the age of 17) has uncontrolled asthma despite using SABA, low-dose ICS and LTRA appropriately with the correct technique, what is the next option for add-on therapy?
LABA + ICS inhaler.
Clinical judgement based on adherence and response to LTRA should be used when deciding whether to continue treatment.
A patient (over the age of 17) has uncontrolled asthma despite using SABA, LABA + ICS and LTRA appropriately with the correct technique, what is the next option for add-on therapy?
Change the person’s ICS and LABA maintenance therapy to a maintenance and reliever therapy (MART) regimen with a low maintenance ICS dose.
MART treatment consists of a single inhaler containing both ICS and a fast-acting LABA, which is used for both daily maintenance therapy and the relief of symptoms as required.
When should a muscarinic receptor antagonist be considered in the step-wise treatment of asthma?
If asthma is uncontrolled on a moderate maintenance ICS dose with a LABA (either as MART or a fixed-dose regimen), with or without an LTRA.
When should you consider decreasing maintenance therapy?
Once a person’s asthma has been controlled with their current maintenance therapy for at least 3 months.
How often should a patient with asthma be followed up?
Annually.
What are the parameters for a moderate asthma attack?
PEFR more than 50–75% best or predicted (at least 50% best or predicted in children) and normal speech, with no features of acute severe or life-threatening asthma.
What are the parameters for an acute-severe asthma attack?
PEFR 33–50% best or predicted, respiratory rate of at least 25/min, pulse rate of at least 110/min or inability to complete sentences in one breath, or accessory muscle use, with oxygen saturation of at least 92%.
What are the parameters for a life-threatening asthma attack?
PEFR less than 33% best or predicted, oxygen saturation of less than 92%, altered consciousness, exhaustion, cardiac arrhythmia, hypotension, cyanosis, poor respiratory effort, silent chest, or confusion.
How are asthma exacerbations treated in primary care? (not needing hospital admission).
Use a short-acting beta-2 agonist via a large-volume spacer to relieve acute symptoms. For an adult, give 4 puffs initially, followed by 2 puffs every 2 minutes according to response, up to 10 puffs. Each puff should be given one at a time and inhaled with five tidal breaths. Repeat every 10–20 minutes according to clinical response.
Consider advising quadrupling inhaled corticosteroid (ICS) at the onset of an asthma attack and for up to 14 days in order to reduce the risk of needing prescribed oral steroids.
For those people who are not suitable for increased ICS dosing consider prescribing a short course of oral prednisolone.
When should a person be followed up after an acute asthma exacerbation if they were not admitted to the hospital? What should be assessed?
48 hours after the initial presentation.
Review symptoms and check peak expiratory flow.
Check inhaler technique.
Consider stepping-up treatment by increasing inhaled corticosteroids (if they have not already increased their ICS dose) or adding in new preventive therapy.
Address potentially preventable contributors to the exacerbation, such as exposure to trigger factors and non-compliance with treatment.
Provide advice on lifestyle, vaccinations, diet, exercise, and smoking.
Advise on recognizing poor asthma control (worsening symptoms or peak flow readings), early signs of an exacerbation (sudden persistent worsening symptoms), what to do at the early signs of an exacerbation (increasing beta-2 agonist and starting oral corticosteroids), and seeking medical help if symptoms are not controlled.
When should a patient be admitted to hospital for an asthma exacerbation?
Admit all people with features of a life-threatening asthma exacerbation.
Admit people with any feature of a severe asthma attack persisting after initial bronchodilator treatment.
Admit people with a moderate asthma exacerbation with worsening symptoms despite initial bronchodilator treatment and/or who have had a previous near-fatal asthma attack.
What are the risk factors for COPD?
Smoking.
Occupational exposure.
Air pollution.
Genetics. (Alpha-1-antitrypsin deficiency)
Lung development in utero.
Asthma.
How is COPD diagnosed?
People over 35 with one or more of the following:
Breathlessness — typically persistent, progressive over time, and worse on exertion.
Chronic/recurrent cough.
Regular sputum production.
Frequent lower respiratory tract infections.
Wheeze.
A postbronchodilator FEV1/FVC less than 0.7 confirms persistent airflow obstruction.
Consider other causes in older people without typical symptoms of COPD who have an FEV1/FVC ratio less than 0.7.
Consider COPD in younger people who have symptoms of COPD, even when their FEV1/FVC ratio is above 0.7.
What are the parameters for the stages of COPD?
Stage 1, mild — FEV1 80% of predicted value or higher.
Stage 2, moderate — FEV1 50–79% of predicted value.
Stage 3, severe — FEV1 30–49% of predicted value.
Stage 4, very severe — FEV1 less than 30% of predicted value or FEV1 less than 50% with respiratory failure.
What signs may be present that are indicative of COPD?
Cyanosis.
Raised jugular venous pressure and/or peripheral oedema (may indicate cor pulmonale).
Cachexia.
Hyperinflation of the chest.
Use of accessory muscles and/or pursed lip breathing.
Wheeze and/or crackles on auscultation of the chest.
What are some of the differentials for COPD?
Asthma
Bronchiectasis
Heart failure
Lung cancer
Interstitial lung disease
Anaemia
Cystic Fibrosis
TB
Upper airway obstruction
What is the management of COPD in primary care?
Explain the diagnosis, risk factors for progression and the importance of a healthy diet and physical activity.
Smoking cessation.
Offer pneumococcal and influenza vaccinations.
Offer pulmonary rehabilitation if indicated.
Develop a personalised self-management plan in conjunction with the person.
Optimise treatment for comorbidities.
