Respiratory Flashcards
(25 cards)
Which organism most commonly causes infective exacerbations in COPD?
Haemophilus influenzae
Which COPD patients should be referred for assessment for home oxygen?
If peripheral oxygen saturation < 92% on air
Raised JVP or peripheral oedema
Polycythaemia
Cyanosis
Very severe outflow obstruction (FEV1 - <30%) or CONSIDER in severe airflow obstruction (FEV1 30-49%)
How is assessment for home oxygen carried out?
Must be done when stable (not during an acute exacerbation) and on optimised COPD treatment
Take 2x arterial blood gases at least 3 weeks apart.
Eligible if pa02 <7.3 kPa
OR
if pa02 <8 kPa with polycythaemia, peripheral oedema or pulmonary hypertension
Contraindications
If SMOKES
They all need a risk assessment before starting home 02.
Need to use it at least 15 hrs per day and ideally 20 hrs per day for maximal benefit
What are the Royal College of Physicians 3 questions as it pertains to asthma reviews and what suggests good v poor control?
- Do your asthma symptoms disrupt your sleep (including cough)?
- Have you had your usual asthma symptoms during the day?
- Does your asthma interfere with your usual activities (housework, school, work etc)
No to all 3 = can assume good control
Yes to 2 or 3 = poor control
NOT LICENSED FOR USE IN CHILDREN
for whom either the Childhood Asthma Control Test or the Asthma Control Questionnaire should be used instead
What is the first line treatment for patients diagnosed with pulmonary sarcoidosis?
Oral steroids (pred) initially a higher dose (0.5mg/kg/day) for 1 month then tapered down to a maintenance dose that controls symptoms for 1-2 years.
2nd line is immunosupressive, e.g methotrexate
What is the most common presenting symptom in lung cancer?
Cough (56%)
followed by chest pain (37%)
For which patients should a low-range peak flow meter be prescribed?
Only those with predicted / best PFs < 200l/min
What FEV1 values relate to what grade of severity in COPD?
Stage 1 / mild COPD = FEV1. > 80%
Stage 2 / Moderate COPD - FEV1 50 - 79%
Stage 3 / Severe COPD - FEV 1 30 - 49%
Stage 4 / Very Severe COPD = FEV1 < 30%
What is the typical presentation of extrinsic allergic alveolitis and what are some of the common pathogenic causes?
Extrinsic Allergic Alveolitis (AAA) is caused by inflammatory reaction in the alveoli to inhaled organic irritants
Presents w/ restrictive lung function pattern, widespread course creps, progressive SOB and dry cough
Farmer’s lung & those working in mushroom-growing units = caused by thermophilic actinomycytes
Bird fancier’s lung = caused by Avian bloom
According to NICE guidelines, what is the first line investigation to confirm diagnosis of COPD?
Post-bronchodilator spirometry (normally after 4 puffs of salbutamol)
(pre bronchodilator / reversibility readings are not necessary and can confuse the diagnosis!)
What features in an asthmatic increase the risk of them having an adverse reaction to NSAIDs?
Female gender
Middle age
Nasal polyps
Chronic rhinosinusitis /congestion
Which investigations should always done alongside spirometry for a patient newly diagnosed with COPD?
CXR - to exclude concurrent pathology
FBC - to identify any anaemia or polycythaemia
BMI
According to NICE, in which patients with newly diagnosed COPD should alpha 1 antitrypsin be tested?
Those with young onset (<45)
Those with minimal smoking history
Those with strong family history of COPD
According to NICE, what is the pathway of treatment for stable COPD?
Step 1 - smoking cessation, pneumococcal & inflluenza vaccination, refer to pulmonary rehab if appropriate (functional disability by COPD ie MRC grade 3 or above or recent hospitalisation - MUST be able to walk still and can’t have unstable angina or recent MI)
Step 2 - PRN SABA or SAMA
Step 3 - Assess if features of asthma / steroid-responsiveness (prev diagnosis of asthma / atopy, high blood eosinophils, significant variation in FEV1 of 400ml or more, diurnal variation in peak flow of at least 20%)
IF STEROID-RESPONSIVE COPD: LABA & ICS
IF NOT STEROID-RESPONSIVE: LABA & LAMA
Consider triple therapy (LABA & LAMA & ICS) for either group if persistent daily symptoms affecting QOL or 1x severe or 2x moderate exacerbations in a year.
what is the 1st line prophylactic antibiotic in COPD and what are the criteria to consider it?
Azithromycin 250mg three times per week
Only start if
- NON SMOKER
- Optimised inhaler therapy
- Frequent productive exacerbations (4+ per year) or prolonged productive exacerbations involving hospitalisation
Ensure they’ve had an ECG (to exclude QT interval prolongation) and baseline LFTs to ensure safe to start Azithromycin
Also should have had CT Thorax and Sputum culture before
Review after 3 months initially then every 6 months
TELL PATIENTS TO ALERT YOU IF DEVELOP HEARING LOSS OR TINNITUS FROM THE AZITHROMYCIN
What is Roflumilast and when is it used for patients with COPD?
Roflumilast is an oral phosphodiesterase-4 inhibitor that can be started by specialists if recurrent exacerbations despite triple therapy
Which patients with COPD should be ASSESSED for oxygen therapy?
Very severe (FEV1 < 30%)
Polycythaemia
Cyanosis
Peripheral oedema
Raised JVP
Oxygen sats 92% or less on air
What are the criteria for long-term oxygen therapy in COPD?
MUST NOT SMOKE
Must have 2x ABGs at least 3 weeks apart
Must have a Pa02 < 7.3 on 2x occasions
OR
Must have a Pa02 <8 PLUS either polycythaemia or peripheral oedema or pulmonary hypertension
When are the criteria for referring COPD patients for consideration for lung volume reduction surgery?
MUST NOT SMOKE
Must be able to walk at least 140m in 6 minutes
Must have completed pulmonary rehabilitation
Must have severe COPD (FEV1 <50%) with symptoms despite optimal inhaler therapy
(The lung volume reduction MDT will consider surgery for those with hyperinflation and emphysema who have their other comorbidities controlled)
What are the first line antibiotics for use in COPD exacerbations as per NICE?
Amoxicillin 5/7
Doxycycline 5/7
Clarithromycin 5/7
What are the 2nd line antibiotics for use in COPD exacerbations as per NICE and when should they be used?
Consider 2nd line if no response after 2-3 days of 1st line
2nd line abx:
Co-Amoxiclav 5/7
Co-trimoxazole 5/7
What are the features of an acute severe asthma attack?
RR 25+
HR 110+
Peak flow 33-50% of predicted
Inability to complete sentences
What is the minimum number of hours per day that patients on long-term oxygen therapy for COPD should be using their 02 for?
At least 15 hours a day
What are the 4 stages of breathlessness of the MRC Dyspnoea Scale?
Stage 0 - not troubled by breathlessness unless on strenuous exercise
Stage 1 - SOB when hurrying on the flat or going uphill
Stage 2 - walks slower than most people on the flat, stopping after 1 mile or 15 minutes
Stage 3 - breathless after walking 100 yards on the flat or after a couple of minutes of walking
Stage. - too breathless to leave the house
