Chronic Shortness of Breath Flashcards
(70 cards)
1
Q
What is the definition of asthma?
A
asthma is a chronic inflammatory airway disease characterised by intermittent airway obstruction and hyper-reactivity
it can be acute or chronic
2
Q
What symptoms does someone with asthma typically present to the GP with?
A
-
cough
- this tends to be worse at night
- wheeze
- shortness of breath
- symptoms tend to be worse in the winter when it is cold
- a patient does not tend to present acutely with an asthma attack
3
Q
What features are important in the history of someone with asthma?
A
- recurrent episodes
- diurnal variation (worst in the morning & evening)
- history of atopy (tendency to allergy)
- family history
-
smoking
- this doesn’t cause asthma, but will exacerbate it
- occupation
- pets
4
Q
What signs are present on general inspection and auscultation in someone with asthma?
A
General inspection:
- this tends to be normal
- there may be nasal polyposis
Auscultation:
- there is a polyphonic wheeze heard all over the chest
5
Q
What are the 4 different investigations that are done in asthma?
A
- spirometry (FEV1 : FVC ratio)
- FeNO test
- PEFR
- blood tests
6
Q
What results are expected from spirometry in a patient with asthma?
A
- FEV1 / FVC ratio < 0.7
- this shows an obstructive pattern
- FEV1 is reduced as not as much air can be forced out in 1 second due to obstruction
- there is reversibility and >/= 12% difference with a SABA
7
Q
What is a FeNO test and what result would be seen in asthma?
A
- this test measures the amount of nitric oxide that is being expired
- this tends to be higher in asthma and will be >/= 35-40 parts/billion
8
Q
What are the typical PEFR results that are seen in someone with asthma?
A
- PEFR varies by >/= 20% for >/= 3 days a week over several weeks
- often the patient is asked to keep a PEFR diary over a few weeks
9
Q
What is the order of tests that are done when diagnosing someone with asthma?
A
- do spirometry and see if it shows obstruction that is reversible
- FeNO test is done to see if levels are 40ppb or more
- look to see if there is variability in PEFR readings over 2-4 weeks
10
Q
What is the initial treatment given to someone who has just been diagnosed with asthma?
A
- they are given a short-acting beta-2 agonist (SABA)
- this is salbutamol in the blue inhaler
- this acts as a bronchodilator
11
Q
When is additional treatment considered for someone who is only taking a SABA for their asthma?
What is the next step up in treatment?
A
- if they are using their blue inhaler more than twice a week
- they are given an inhaled corticosteroid (ICS) in a brown inhaler
- the ICS is taken once daily (usually in the morning)
- patients should wash their mouth out afterwards to prevent candidiasis
12
Q
What is the next treatment step up from a SABA and ICS in treatment of asthma?
A
- a leukotriene receptor antagonist (LTRA) is added
- some people are sensitive to leukotrienes and some are not so decide whether or not to keep them on this treatment depending on whether they improve
- if the LTRA is not effective, switch out the LABA for a SABA
13
Q
If someone is taking a LABA and ICS and this is still not effective, then what treatment is performed?
A
- the dose of ICS is increased from moderate to high
- if high dose ICS is still not effective then trials are started
- e.g. theophylline LAMA
14
Q
What are the 5 stages in the treatment of asthma?
What are examples of these medications?
A
- start with a SABA - such as salbutamol
- then an ICS such as beclometasone or budesonide is added
- then a LTRA such as montelukast is added
- then the SABA is exchanged for a LABA + ICS
- this is usually symbicort, which is budesonide + formoterol
- finally, an oral corticosteroid, such as prednisolone is added
15
Q
What are the 4 categories of asthma according to severity?
A
- moderate acute asthma
- acute severe asthma
- life-threatening asthma
- near-fatal asthma
16
Q
What are the criteria for moderate acute asthma according to the BTS guidelines?
A
- increasing symptoms
- PEFR > 50-75% at best or predicted
- no features of acute severe asthma
17
Q
What are the features of acute severe asthma according to BTS guidelines?
A
any one of:
- PEFR 33-50% best or predicted
- respiratory rate >/= 25 per minute
- heart rate >/= 110 bpm
- inability to complete sentences in one breath
18
Q
What are the features of life-threatening asthma according to BTS guidelines?
A
any one of the following in a patient with severe asthma:
- altered consciousness level
- exhaustion
- arrhythmia
- hypotension
- cyanosis
- silent chest
- poor respiratory effort
- PEFR <33% best or predicted
- SpO2 < 92%
- PaO2 < 8 kPa
- “normal” PaCO2 between 4.6 - 6.0 kPa
19
Q
What are the features of near-fatal asthma according to BTS guidelines?
A
- raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures
20
Q
What are the PEFR readings for the different types of asthma?
A
- moderate has a PEFR of 50-75%
- acute-severe has a PEFR of 33-50%
- life threatening has a PEFR of <33%
- near fatal asthma is characterised by a rise in pCO2
21
Q
Why is having normal pCO2 in asthma a concern?
A
- if pCO2 is normal then this means that the diaphragm is starting to tire
- there is not as much ventilation occurring, so pCO2 starts to rise
- if ventilation is impaired and CO2 cannot be blown off, this is near-fatal
22
Q
What is the A-E approach for managing asthma?
What specific things need to be done for asthma?
A
- Airway
- Breathing
- Circulation
- Disability
- Exposure
Specifically for asthma:
- basic obs - including HR, SpO2
- PEFR
- ABG (including K+ and glucose)
- repeat ABGs if O2 is low**, _PaCO2 is normal/raise_d** or patient deteriorates
23
Q
When should a patient with asthma be admitted to hospital?
A
- a patient with moderate asthma should be given a salbutamol inhaler and discharged
- in acute-severe asthma, the patient should be admitted if their PEFR does not go up
- they should be given corticosteroids and admitted for 24 hours
- life-threatening and near fatal asthma need to be admitted
24
Q
What is the treatment for patients with asthma who have been admitted to hospital?
A
- they are given O2
- they are then given nebulised salbutamol (5mg) and nebulised ipratropium bromide (0.5mg)
- this is followed by PO prednisolone (40-50mg) for 5 days
- IV hydrocortisone 100mg is also given
25
If patient doesn't respond to treatment in hospital for severe asthma, what is involved in senior support?
* IV magnesium sulphate
* IV aminophylline
* ITU + intubation
26
How often can salbutamol and ipratropium bromide be given?
* salbutamol can be given back-to-back PRN
* ipratropium bromide can be given every 4 hours PRN
27
What symptoms does someone with COPD typically present to their GP with?
* **shortness of breath**
* a **cough** that is **_productive_**
* **some wheeze**
28
What are important factors to take into consideration when taking a history from someone with COPD?
* the patient's **age**
* **family history**
* **smoking** status
* their occupation
29
What might be seen on inspection and palpation in a patient with COPD?
***_Inspection:_***
* tar staining
* cyanosis
* barrel chest
***_Palpation:_***
* reduced expansion
* **hyper-resonance** [on percussion]
30
What signs are present on auscultation in someone with COPD?
What other signs might be present?
***_Auscultation:_***
* reduced air movement
* wheezing
* **coarse crackles** (hair-like crackles)
***_Other:_***
* signs of **right heart failure**
31
How is the severity of COPD characterised?
What would the FEV1 % be in each of these scenarios?
***_Mild COPD:_***
* FEV1 **\> 80%**
* post-bronchodilator FEV1/FVC **\< 0.7**
***_Moderate COPD:_***
* FEV 1 is between **50 to 79%**
* post-bronchodilator FEV1/FVC **\< 0.7**
***_Severe COPD:_***
* FEV1 is between **30 to 49%**
* post-bronchodilator FEV1/FVC is **\<0.7**
***_Very severe COPD:_***
* FEV1 is **\<30%**
* post-bronchodilator FEV1/FVC is **\< 0.7**
32
What further tests are performed in suspected COPD to rule out other possible diagnoses?
* **_serial peak flow measurements_** to **exclude asthma** if diagnostic doubt remains
* **_alpha-1 antitrypsin_** (A1AT) if symptoms are **early onset** with **minimal smoking history** or **FHx**
* **_transfer factor for CO_** (TLCO) to investigate symptoms **disproportionate** to spirometry impairment
* **_CT chest_** to further investigate abnormalities seen on a **CXR** or to assess **suitability for surgery**
* **_ECG or Echo_** to assess cardiac status if there are features of **cor pulmonale**
33
What investigations are performed in COPD?
* spirometry (FEV1 : FVC ratio)
* ABG
* bloods
* CXR
34
What are spirometry results like in COPD?
FEV 1 : FVC ratio shows an **_obstructive_ picture**
FEV1/FVC **_\< 0.7_**
35
What is involved in the stepwise approach to treatment for COPD?
* treatment starts with **either a _SABA_ or a _SAMA_**
* if the patient has **_asthmatic features_**, they are then given a **_LABA + ICS_**
* this includes diurnal variation in cough, wheeze, sensitivity to cold weather, etc.
* if the patient has **_NO_ asthmatic features**, they are then given a **_LABA + LAMA_**
* the final step up in treatment involves **_LAMA + LABA + ICS_**
* the LABA is consistent
36
What are examples of SABA, ICS, LABA + ICS and oral CS used to treat COPD?
* SABA - **_salbutamol_**
* ICS - **_beclometasone_** or **_budesonide_**
* LABA + ICS - this is **_symbicort_** (**budesonide + formoterol**)
* oral CS - **_prednisolone_**
37
What is involved in the general management of COPD?
* **smoking cessation**
* **annual influenza vaccination**
* a one-off **pneumococcal vaccination**
* **long-term oxygen therapy** is a treatment but there are very strict criteria in order to get this
38
What are the criteria for COPD patients to get long-term oxygen therapy?
* they must have a **_pO2 of \< 7.3 kPa_**
* OR a **pO2 of 7.3 - 8 kPa** and **_one_** of the following:
* secondary polycythaemia
* nocturnal hypoxaemia
* peripheral oedema
* pulmonary hypertension
39
What is the definition of COPD?
What are the 2 different types?
COPD is a **_preventable_** and treatable disease state characterised by **airflow limitation** that is **_not fully reversible_**
it encompasses both **_emphysema_** and **_chronic bronchitis_**
it can be acute or chronic
acute describes an **infective exacerbation** of COPD
40
What oxygen is given to someone who is admitted to hospital with an acute exacerbation of COPD?
they are given **_24% O2_ through a _blue venturi_**
* in a healthy person, when pCO2 rises, the patient begins to **hyperventilate**
* in COPD, this is constant and eventually the brain switches and begins **breathing normally**, leading to **_retention of CO2_**
* they switch from a hypercapnic to a **hypoxic drive**
41
What is the next stage up following giving 24% oxygen to treat exacerbations of COPD?
* **nebulised salbutamol 5mg** and **nebulised ipratropium bromide 0.5mg**
* this is followed by **PO prednisolone (40-50mg)** for 5 days
* and **IV hydrocortisone (200mg)**
* **IV amoxicillin / co-amoxiclav** are given if there are infective features
42
What is involved in the senior support treatment for COPD?
* IV aminophylline
* followed by BiPAP
43
How does CPAP work?
it provides a **continuous positive pressure** throughout **inspiration and expiration**
this splints the airways open
it involves **pushing air into the airways**, as there must be some pressure otherwise the alveoli would collapse
44
In what conditions is CPAP used?
* type 1 respiratory failure due to pneumonia or acute pulmonary oedema
* obstructive sleep apnoea
45
What is BiPAP?
What are the 2 different types?
BiPAP provides a **_differing air pressure_** throughout **inspiration and expiration**
these are both positive pressures - but one is more positive than the other
iPAP involves pushing air into the lungs to ventilate the bases / apices of the lungs
ePAP is lower to recruit alveoli and maintain them open for ventilation
46
What are the 4 respiratory causes of clubbing?
* malignancy
* empyema (lung abscess)
* interstitial lung disease
* cystic fibrosis
47
What is the definition of interstitial lung disease (ILD)?
ILD is an umbrella term for a large group of disorders that cause **_scarring (fibrosis)_** of the lungs
the scarring causes **_stiffness_** in the lungs which makes it **difficult to breathe**
this includes conditions such as:
* idiopathic pulmonary fibrosis
* sarcoidosis
* hypersensitivity pneumonitis / EAA
* pneumoconiosis
48
How does someone with ILD typically present?
* **shortness of breath on exertion** (SOBOE)
* **_dry_ cough**
* no wheeze
49
What are key features to look for in a history of a patient presenting with possible ILD?
* exposure to animal / vegetable dusts
* smoking status
* occupation
* drugs such as:
* bleomycin
* methotrexate
* amiodarone
50
51
What will be visible on general inspection, ausculation and other signs in someone with idiopathic pulmonary fibrosis?
* **_clubbing_** is visible on general inspection
* on auscultation there are **_bi-basal, fine, inspiratory crepitations_**
* these sound like velcro
* there may be signs of **right heart failure** if disease is advanced
52
What is seen on spirometry in someone with idiopathic pulmonary fibrosis?
spirometry shows a **_restrictive_ pattern**
the **FEV1 / FVC ratio is _\> 8_**
53
What is seen on a CXR and a high resolution CT scan in someone with idiopathic pulmonary fibrosis?
***_Chest X-ray:_***
* this shows **late changes**
* ground-glass appearance / reticulonodular
* cor pulmonale
* honeycombing
***_HR - CT:_***
* this shows **early changes**
* **ground-glass** appearance
54
55
What are the key symptoms that someone with hypersensitivity pneumonitis / EAA will present with?
they tend to look like a COPD patient, but without sputum production
* shortness of breath on exertion (SOBOE)
* **dry** cough
* fever
56
What are the key features to note in the history of someone with hypersensitivity pneumonitis?
* acute +/- chronic history
* often keep pets
* occupation
* picking mushrooms
* keeping birds
* farmer
* plumber
* malt-worker
57
What will be present on general inspection and auscultation in someone with hypersensitivity pneumonitis?
* there may be **clubbing** but this is rare
* **mild pyrexia**
* on auscultation there are **_bi-basal, fine, inspiratory crepitations_**
58
What does spirometry look like in someone with hypersensitivity pneumonitis?
spirometry shows a **_restrictive_ pattern**
FEV1 / FVC ratio is **_\> 0.8_**
59
What does a CXR and HR-CT look like in someone with hypersensitivity pneumonitis?
* the chest X-ray shows **late changes**, but is often **_normal_**
* HR-CT shows **early changes** and often has a **_ground-glass appearance_**
60
What specific test can be done for hypersensitivity pneumonitis and what does this show?
**_bronchoalveolar lavage_** (BAL) which will show **_increased cellularity_**
61
What symptoms does someone with pneumoconiosis present with?
* shortness of breath
* dry cough
62
What are key features that will be picked up in the history of someone with pneumoconiosis?
* **occupation**
* coal-worker
* builder
* **long latency**
* patients are often **_asymptomatic_**
* **asbestosis** is a form of pneumoconiosis
63
What will be present on general inspection and auscultation in asbestosis and silicosis?
***_Asbestosis:_***
* there is **_clubbing_** on general inspection
* on auscultation there is **_bi-basal, fine inspiratory crepitations_**
***_Silicosis:_***
* on auscultation there is **_decreased breath sounds_**
* for both there may be signs of **right heart failure**
64
What are the 2 different types of pneumoconiosis?
* **_simple_** pneumoconiosis is **asymptomatic**
* **_complicated_** pneumoconiosis is **symptomatic**
65
What will spirometry look like for a patient with pneumoconiosis?
spirometry shows a **_restrictive_ pattern**
the FEV1 / FVC ratio is **_\> 0.8_**
66
What is visible on CXR and HR-CT for someone with pneumoconiosis?
* CXR shows **_micronodular mottling_** in a patient with **simple pneumoconiosis**
* HR-CT shows **bilateral lower zone reticulonodular shadowing** and **_pleural plaques_** in a patient with complicated pneumoconiosis
* asbestosis is fibrotic changes and not just plaques
67
What is the definition of obstructive sleep apnoea?
this is characterised by **_recurrent collapse_** of **pharyngeal airway** and **_apnoea_** (cessation of airflow for \>10 seconds) during sleep, followed by **_arousal from sleep_**
68
What symptoms does someone with sleep apnoea tend to present with?
* chronic fatigue
* unrefreshed sleep
* snoring
69
What are key features that may be noted in the history of someone with obstructive sleep apnoea?
* obesity, smoking and alcohol
* fatigue
* truck driver
70
What investigations are performed for obstructive sleep apnoea?
* **sleep study / polysomnography**
* **thyroid function tests (TFTs)**
* a massive goitre in chronic thyroid problems can contribute to sleep apnoea
* **glucose** and **IGF-1**
* acromegaly is diagnosed based on random IGF-1
