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1

Tx of acute asthma attack

OSHITME
Oxygen - oxygen driven nebs, back to backSalbutamol - 2.5-5mg back to backHydrocortisone IVIpatropium - 500mcg nebTheophyllineMagnesium sulphateEscalate care (intubation and ventilation)

TME given if needed with senior input

Do an ABG to assess O2 and CO2

Intensive care indications - requires ventilator, worsening acidosis/hypercapnia/hypoxia, exhaustion, drowsiness and confusion

2

Tx to settle exacerbation of asthma?

Oral pred for 5 days

3

Classify asthma severity

Life Threatening (PEFR <33%) - 33,92 CHEST:
• 33 - PEFR <33%
• 92 - Sats <92%
• Cyanosis
• Hypotension
• Exhaustion
• Silent chest
• Tachycardia
Severe (PEFR <50%) - cant complete sentences, RR >25, PR >110
Moderate (PEFR <75%)
Mild (PEFR >75%)

4

Discharge criteria for asthma

1. Stable on prescribed meds for 24 hrs
2. Peak flow is 75% of predicted
3. Discharge with 5 days oral prednisolone and asthma management plan.
Follow up with GP in 2 days. Follow up in 1 month in clinic.

5

Asthma LT tx guidelines. Pregnancy?

1st line SABA + ICS
2nd line + LABA (salmeterol)
3rd - Increase LABA (if good response) OR (if not good response) increase ICS or add 4th drug (theophylline or LAMA)
4th - Add 4th drug (theophylline, LAMA) OR increase ICS
5th line + oral corticosteroid

Use as usual during pregnancy

6

S&S that make asthma diagnosis likely?

• pt complains of >1 symptoms of :wheeze, SOB, cough, or chest tightness and if:
○ Worse at night and early morning
○ Worse in exercise, allergen or cold air
○ Worse after taking aspirin or beta blockers
• History of atopy
• Family history of atopy
Widespread wheeze on auscultation

7

S&S that make asthma unlikely?

• Prominent dizziness or peripheral tingling
• Chronic productive cough w/o wheeze or SOB
• Normal examination of chest when symptomatic
• Significant smoking history ie >20 pack yrs.
Cardiac disease

8

Qs to ascertain if asthma is unstable?

• Is there a nocturnal cough?
• Are you using the blue inhaler (rescue)?
Is your job impacted?

9

Ix for asthma?

Blood tests:
• Eosinophilia
• Increased IgE

Spirometry findings:
• Obstructive. Reversibility

PEFR - need more than one reading. Peak flow diary

10

Define occupational asthma

Symptoms improve at weekends or when away from work

11

Chemicals associated with occupational asthma

• Isocyanates - most common cause eg spray painting and foam moulding
• Flour
Epoxy resins

12

Tx of occupational asthma

• Serial measurements of PEFR at work and away
Referral to resp specialist for suspected occupational asthma

13

Tx of COPD exacerbation

Management - OSHIT
Oxygen - controlled oxygen (24-28% venturi) driven nebs, back to back. Do ABG after 15 mins to determine further therapy.SalbutamolHydrocortisoneIpatropiumTheophylline

Consider antibiotics and BiPAP if sats persist below 88%. IV abx if blood culture +ve

Intensive care indications - requires ventilator, worsening acidosis/hypercapnia/hypoxia, exhaustion, drowsiness and confusion

14

Tx for frequent exacerbation sof COPD?

Pts who have frequent exacerbations:
• Home supply of corticosteroids and abx eg prednisolone and amox.
• Abx only taken if sputum is purulent.
Contact you if exacerbation

15

NIV indications for COPD?

• COPD with resp acidosis pH 7.25-7.35
• T2RF secondary to chest wall deformity, neuromuscular disease, sleep apnoea
• Cardiogenic pulmonary oedema unresponsive to CPAP
Weaning from tracheal intubation

16

MOs causing exacerbations in COPD? Tx for each?

• Haemophilus influenzae - most common - treat with amox and prednisolone
• Strep pneumoniae
• Moraxella catarrhalis
• Resp viruses causes 30% with rhinovirus being most common.

To treat - increase bronchodilator use, give prednisolone oral. NO ABX unless sputum is purulent or clinical signs of pneumonia.

17

Bloods findings for COPD

FBC - Polycythemia in COPD pts due to reduced oxygen leading to increased erythropoietin and increased RBCs.

18

Diagnostic Ix for COPD

Spirometry - FEV/FVC ratio is <0.7. Deficit is not more than 15% reversible.

19

CXR findings for COPD

• to exclude other diagnoses
• Hyperinflation - >6 anterior ribs
• Bullae
• Flat diaphragm
Vertical orientation of heart

20

Classify severity of COPD

Post-bronchodilator FEV1/FVC FEV1 (of predicted) Severity
< 0.7 > 80% Stage 1 - Mild**
< 0.7 50-79% Stage 2 - Moderate
< 0.7 30-49% Stage 3 - Severe
< 0.7 < 30% Stage 4 - Very severe

21

ECG findings on COPD? Why might you order an ECG for COPD pts?

• If considering LT azithromycin ensure no long QT syndrome as azithromycin causes it.
• Reduced amplitude of QRS complexes due to excess air between electrode and heart
• Cor pulmonale may be evident:
○ Rightward shift of P wave axis
Prominent P waves in inferior leads

22

Lt medical tx of COPD

FEV<50% :
1st line - SABA or SAMA
2nd line - LABA + ICS combo inhaler OR LAMA
3rd line - LABA + ICS combo inhaler + LAMA

FEV>50%:
1st line - SABA or SAMA
2nd line - LABA or LAMA
3rd line - switch LABA to LABA + ICS combo then + LAMA

cannot tolerate inhalers - oral theophylline
Chronic productive cough - mucolytics

23

General management of COPD

• Smoking cessation
• Pulmonary rehab
• Annual influenza vaccine
• One off pneumococcal vaccine
If 3+ infections a year - Consider prophylactic abx eg azithromycin or erythromycin at low doses (anti inflammatory)

24

Tx for cor pulmonale in COPD

• Use loop diuretic for oedema eg furosemide
• Consider LTOT (long term oxygen therapy)
ACEi, CCBs, alpha blockers not recommended.

25

Indications for LTOT

Pt must have PaO2 of < 7.3 kPa under air when stable OR 7.3-8 kPa under air when stable AND:
○ Secondary polycythemia or
○ Nocturnal hypoxaemia or
○ Peripheral oedema or
○ Pulmonary hypertension
• Assessment of PaO2 done on 2 separate occasions 3 weeks apart
• 15 hours a day of oxygen minimum

26

S&S of COPD

• Exertional dyspnoea
• Chronic cough - 3mths +
• Regular sputum production
• Regular winter bronchitis
• Wheeze
• Peripheral cyanosis
• Clubbing
Cor pulmonale

27

Causes of COPD

• Smoking
• Pollution
Alpha 1 antitrypsin deficiency

28

Questions to ask regarding SOB?

• How far can you walk?
• How has SOB changed?
• What were you like before SOB?
Why are you here now? What has changed?

29

Resp Hx - SHx qs?

• Asbestos exposure?
Any contact with animals?

30

Qs about cough?

• Diurnal variation?
Is there a nocturnal cough?