the patient Flashcards

Question

What causes OA?

Answer 1

Primary OA – no known cause  Secondary OA – link to previous injury to joint, congenital abnormality or inflammatory arthritis such as gout or RA  Aetiology unknown but risk factors pre‐dispose: Age, gender, obesity, bone density, joint injury or disease, occupation, joint abnormalities and genetics.

Answer 2

Pain in one or more joints  Gradual onset  Worsened by activity  Only short period of early morning stiffness  Muscle wasting around joints due to avoiding activity  Pain may be episodic, but can become persistent, occurring at rest  OA hands – Heberden’s and Bouchard’s nodes

Answer 3

No validated diagnostic tool  Combination of Hx of pain symptoms and physical joint findings  X‐ray  Blood tests do not assist  (maybe CRP for inflammation)  X‐ray and blood tests to eliminate 

Answer 4

Education  Self‐management plan  Non‐pharmacological treatment is key  Pharmacological intervention is adjunct to non‐pharmacological  Surgery

Answer 5

Weight loss  Exercise  Physical aids  Joint surgery

Answer 6

Adjunct to lifestyle interventions  Topical NSAIDs  Paracetamol  Oral NSAIDs or opioids  Topical capsaicin  Intra‐articular corticosteroids X Chondroitin and glucosamine X Intra‐articular hyaluronic acid

Answer 7

Asthma is a common long-term condition that affects the airways Central to all definitions is the presence of symptoms (more than one of wheeze, breathlessness, chest tightness, cough) and of variable airflow obstruction. More recent descriptions of asthma in both children and adults have included airway hyper-responsiveness and airway inflammation as components of the disease.

Answer 8

More than one of the following symptoms: wheeze, breathlessness, chest tightness and cough, particularly if: – symptoms worse at night and in the early morning

Answer 9

Triggers = irritate, tighten and inflame airways: >common cold/infection >allergies to pollen/dust/animal fur >air pollution

Answer 10

The airway lining becomes inflamed causing a build-up of sputum. This makes the airways even narrower, so harder to get air in and out of the lungs. ➢ Exercise-induced-asthma ➢ History of atopic disorder ➢ Family history of asthma and/or atopic disorder

Answer 11

The amount of air you breathe out is measured by: Spirometry- measures the total amount of air you can breathe out from your lungs and how fast you can blow it out (presence and severity of airflow obstruction) Peak flow meter-measures how fast you can breathe out after you’ve taken a full breath in. Diagnosed in accordance with BTS/SIGN

Answer 12

measures the total amount of air you can breathe out from your lungs and how fast you can blow it out (presence and severity of airflow obstruction)

Answer 13

peak flow meter-measures how fast you can breathe out after you’ve taken a full breath in.

Answer 14

Immediate Phase Reaction: on first exposure to antigen Late Phase Reaction: more sustained occurring 3 to 12 hours after early phase

Answer 15

Eosinophils are a type of white blood cell that protect your body from parasites, allergens, foreign bacteria and outside organisms. Eosinophils are larger than most cells and make up less than 5% of all white blood cells in your body Major cell in the LPR Primarily a secreting cell - Eosinophil Granular Associated Proteins Major Basic Protein (MBP) Eosinophil cationic protein Eosinophil-derived neurotoxin eosinophil peroxidase Platelet Activating Factor (PAF) Peptido leucotrienes (LTC4, LTD4 & LTE4) Free radicals species

Answer 16

Histamine Cyclo-oxygenase Products Lipoxygenase Products Bronchoconstriction: powerful response in asthmatics Increased Vascular Permeability: very potent PAF>LTD4>>Histamine Increased Mucous Secretion: very potent Bradykinin Platelet Activating Factor - PAF

Answer 17

Asthma is common, incurable but eminently treatable. Asthma is an inflammatory disorder – the inflammatory basis is an important target Relievers (bronchodilators): rapid symptomatic relief in an acute attack. Preventers - prophylactic therapy to suppress immune component of asthma Non-pharmacological and alternative medicine – no convincing data of benefit

Answer 18

Control of symptoms - preferable no chronic symptoms e.g. no nocturnal dyspnoea, best possible pulmonary function with minimal side-effects Stable long term control - no exacerbations Minimal nocturnal symptoms Minimal use of relievers Peak expiratory flow rate (PEFR) maintained at >80% best. Circadian variation on PEFR <20% Minimal limitations on exercise

Answer 19

Sort acting inhaled b2-bronchodilator (SABA) on prn basis (but no evidence against regular dosing) Asthma is not controlled at any step if using SABA >3 times a week having symptoms 3 times a week or more waking at least once a week Same strategy for adults and children under 5 years but evidence base best in adults Inhaled b-agonist 30min before exercise is treatment of choice for exercise induced-asthma

Answer 20

b-receptors on bronchial smooth muscle. Major effect. Most quickly effective agents available. Act as functional antagonists.

Answer 21

some reduction of ACh release (post-ganglionic nerves)

Answer 22

some decrease in viscosity leading to increased clearance

Answer 23

b-receptors stabilise. No proven anti- inflammatory action. Little change in hyper- reactivity

Answer 24

Skeletal Muscle tremor - diagnostic use Cardiac Stimulation -direct b2 and indirect reflex due to peripheral b2-vasodilatation Impaired ventilation/perfusion ratio Hypokalaemia Increased glucose metabolism Increased lipolysis CNS stimulation - variable, typically sleep disturbance

Answer 25

All b2-agonists are effective. Pharmacological differences account for differing profile of action Degree of b2-selectivity. Binding affinity: duration of action Binding Kinetics: onset of action Systemic effects can be clinically significant Vascular b: vasodilatation. Reflex tachycardia In high doses break through b1-agonism

Answer 26

None are catecholamines (rapid metabolism) Rapid onset of action (<10min, peak 30-90 min) and relatively short duration 4-8 hours when given by MDI Some may be used orally for prophylaxis (*) Relatively free of CVS effects by inhaled route Examples: Salbutamol Terbutaline

Answer 27

Some active orally. Increase SE profile and little evidence of benefit (unless unable to use inhaler) Parenteral administration used in severe or life- threatening asthma Caution in hyperthyroidism, CVS disease, diabetes. Risk of hypokalaemia – may be serious with systemic administration (via stimulation of skeletal Na+/K+/ATPase pumps coupled to beta receptors)

Answer 28

Chronic Asthma Step 2: regular preventer therapy Low dose Inhaled corticosteroids (ICS) Beclomethasone (BEC) 200mcg BD Budesonide 200mcg BD Fluticasone 100mcg BD Mometasone 200mcg BD NB: above for dry powder inhalers

Answer 29

Beclometsaone (BEC): Qvar™ extra-fine particles and more potent than traditional CFC containing inhalers and 2x potent than Clenil Clenil Modulite™ is same potency as dry powder and CFC BEC inhalers. Note: Qvar and Clenil are NOT interchangeable and should be rx by brand (MHRA 2008) Dose conversion advice in BNF Steroid card issued with high dose BEC

Answer 30

Regarded as less effective therapies Cromones: DSG ineffective in children, nedocromil not effective <5 years. Long Acting Beta-Agonits (LABAs) – have effect but should not be used without steroid therapy (evidence) – so not step 2! Leukotriene antagonists – have some effect. May be useful in children particularly <5 years Theophylline – may have beneficial effect but side effects. Caution

Answer 31

First used early 1950s by systemic route most powerful agents for asthma therapy major systemic actions no direct bronchodilator activity: no immediate relief from symptoms 6 hours before benefit and even with injection, maximum benefit only after 12-24 hours Inhaled administration of topically active steroid At suitable dosage minimises systemic actions – step two “Standard Dose” regimens Now a major component in asthma therapy

Answer 32

Agents must have potent topical action Beclomethasone diproprionate (BEC) & Budesonide equipotent Fluticasone (2x potentcy of BEC). No convincing evidence of advantage for any individual agent. Deposition in oropharyngeal tract is a problem (candidiasis, dysphoria can occur even at low dose). may be minimised by use of spacer or prior administration of beta-agonist. Rinse mouth after use. Particularly higher dose schedules

Answer 33

Hypothalamic-Pituitary-Adrenal Supression No significant risk BDP < 800g daily adult or 400 g child (but do see in child >400 g daily) Bone Resorbption - some controversy modest effects down to 500g daily in adult Carbohydrate Metabolism/Lipid Metabolism effects minor and not significant <800 g daily Growth Retardation: possible above 400 g daily in children – usually short term. Monitor growth and use lowest possible dose

Answer 34

Major effect is suppression of cytokine synthesis and release and so recruitment of inflammatory cells (particulalry eosinophils) Affect many components of inflammatory response Inhibit phosopholipase A2 Inhibit macrophage activation Depress Antibody synthesis Depress activation & recruitment of T lymphocytes and of eosinophilsCheck compliance before action! Add Inhaled LABA to low dose ICS (combination inhaler) Depress release of peptido-leukotrienes. (Little immediate direct effect upon mast cells)

Answer 35

Check compliance before action! Add Inhaled LABA to low dose ICS (combination inhaler)

Answer 36

Slow onset of action, prolonged action Not normally for acute attacks and used on regular bd schedule for control Prolonged functional antagonism at bronchial smooth muscle. Do not replace steroids -no evidence for anti-inflammatory action Very potent (salmeterol 4x Salbutamol) Salmeterol (Serevent). Inhaled route Eformoterol (Foradil - Geigy). Inhaled Bambuterol (Bambec - Astra). Oral. *bis-dimethylcarbamate prodrug, lung conversion, 24hr dose

Answer 37

Several different combination (see BTS table 12 + 13) Examples: Fostair (BEC and Formoterol – 100/6). Can be used bd at step 3. (Note CFC free). Seretide (Fluticasone/salmeterol – 50, 125, 250) Symbicort (Budesonide/Formoterol – 100/6; 200/6 and 400/12). Used bd at step 3. Also can be used bd plus prn as a combined prophylaxis and acute therapy.

Answer 38

Stop LABA if no response and ICS to medium dose (see BTS) If benefit from LABA but NO control continue LABA + ICS If benefit from LABA but NO control continue LABA + ICS + trial of: >leukotriene antagonist

Answer 39

Increase ICS to high dose (see BTS) Add 4th agent: leukotriene antagonist m/r theophylline LAMA -Tiotropium (COPD inhalers) oral slow release b-agonist tablet (care with LABA)

Answer 40

Montelukast (Singulair - MSD) and Zafirlukast (Accolate – Zeneca) Cysteinyl leukotriene receptor (cysLT1) antagonists Long acting and orally active. Once daily therapy. Licensed for prophylaxis of asthma Montelukast for add on therapy in adults and children (>6 months) Zafirlukast for therapy of asthma adults and children >12 years

Answer 41

Inhibit EPR and LPR. Additive with inhaled & oral corticosteroids and with b-adrenoceptor agonists Not licensed as steroid sparing agents - additive with steroids. Do not replace and given with steroids. Inhibit aspirin induced and exercise asthma Main SE are GI disturbances including pain and headache. Both can induce Churg-Strauss Syndrome Vasculitis and eosinophilia – common background asthma Rare but fatal normally seen on steroid withdrawal. Monitor patients during steroid down-dosing

Answer 42

Clinical use theophylline - or as aminophylline (theoph./EDTA complex). Effective orally only. Bronchodilator over plasma range 30-100 mol/ml Side-effects at 100 mol/ml and serious at 200 mol/ml (CVS: most serious dysrhythmia) Small VD - little individual dose variation Clearance by hepatic metabolism - variable Increased by enzyme induction (rifampacin, phenobarb, phyenytoin, carbamazepine) Impaired by hepatic disease & inhibitors of metabolism (e.g. oral contraceptives, erythromycin, calcium channel blockers) Low therapeutic index and variable clearance. Plasma levels achieved not easy to predict.

Answer 43

Oral MR products minimise changes in plasma levels but show variable release Side effects Cardiac stimulation - can be marked (inotropic and chronotropic). High risk when by parenteral route – rare now Gastric Irritation - increased release of gastric acid and digestive enzymes CNS disturbances - insomnia, anxiety, nervousness and tremor. Seizure a risk – in children around upper dose range Not normally used in chronic asthma in children unless other therapies fail – specialist advice only

Answer 44

Mode of action in asthma is still not fully explained. Phosphodiesterase inhibition - likely to be involved but are plasma concns. too low? Adenosine antagonism - but an analogue enprofylline is active yet not an antagonist Inhibition of inflammatory cells - weak and not enough to explain action (< b-agonists) Potentiation of diaphragm contractility - useful action unique to these agents.

Answer 45

Oldest drugs for asthma e.g. strammonium All are muscarinic antagonists – none are selective for muscarinic receptor sub-types. Reduce cholinergic tone to bronchial SM and submucous glands Atropine highly effective but marked systemic effects Dryness of mouth; dilation of pupils; cycloplegia; dryness of skin; constipation; urinary retention Airway “selectivity” is achieved by inhaled administration

Answer 46

Ipatropium bromide (Atrovent - Boehringer) Oxitropium bromide (Oxivent - Boehringer) Both are quarternary compounds with poor absorption across mucous membranes When inhaled, actions are local in the respiratory tract Slow onset of action but prolonged duration – ipatropium 8hr and oxitropium up to 12hr. No value as add-on in chronic asthma Value in acute asthma

Answer 47

LAMA usually for COPD! Aclidinium bromide (Eklira genuair) >Competitive, selective muscarinic receptor antagonist, with a longer residence time at M3 receptors which mediate contraction of smooth muscle in the airways; induces bronchodilation. >Once absorbed it is rapidly broken down in the plasma, resulting in minimal systemic anticholinergic side-effects. Glycopyrronium bromide (Seebri breezehaler) Umeclidinium (Incruse Ellipta)

Answer 48

Derived from original research on khellin from seeds of Amni Visnaga Not bronchodilators Very safe with few side-effects. LD50 in animals >4grams/kg Little clinical Value - NICE Guidelines. No value at stage 3 for adults. Possible alternative to low-dose inhaled steroid (step 2 in children. Have some value in exercise asthma May be considered for occupational asthma – predictable No value in acute asthma. Often termed “mast cell stabiliser”. Decreases mediator release from by Ca dependent mechanism. Not the only mode of action

Answer 49

Breast feeding in infants – may also protect development of early asthma Avoidance of tobacco smoke Weight reduction (where obese)

Answer 50

Avoid house dust mites – measures to reduce Immunotherapy where clear antigen

Answer 51

Buteyko breathing technique

Answer 52

Nutritional Supplementation Immunotherapy Fish oils and fatty acids or electrolytes

Answer 53

Air pollution – more research needed

Answer 54

Acupuncture Herbal Medicine Hypnosis Ionisers – definitely not recommended Exercise programmes

Answer 55

Avoid triggers such as smoke, animal fur and dust. Manage asthma by: Maintaining healthy weight Keeping fit and active Having an annual flu jab Quit smoking Breathing exercise programme Supported self-management: 1. Asthma action plans 2. Adherence and concordance

Answer 56

In UK 200 deaths per annum – majority chronically severe asthma Risk factors for acute asthma More than 3 drugs for control Previous acute attacks or poor control Brittle asthma –wide variation in PEFR (Type 1) or sudden severe attacks when apparently controlled (Type 2) Psychiatric illness or treatment Alcohol or drug abuse Social factors e.g. isolation, poverty, stress, abuse

Answer 57

Any of: Respiratory rate > 25/min (>30/min child over 5 and >50 child under 5) Pulse rate > 110/min (>125/min child over 5 and >140 under 5) PEFR 33-50% of best Breathlessness - affects speech. Cannot complete sentences

Answer 58

Cyanosis Weak respiratory effort PEFR < 33% of best fatigue, confusion, exhaustion Bradycardia or exhaustion common. Child tachycardia symptom of severe, falling rate a pre-terminal event

Answer 59

High flow O2; all patients High Dose b-agonist: Inhaled when possible. Nebulised salbutamol or terbutaline in life threatening. IV used when inhaled impossible. Steroid: oral if possible (40-50mg OD adult) or IV hydrocortisone max 100mg QDS when oral impossible Ipatropium Br: add to nebuliser in life threatening or if bronchodilator response poor Life Threatening: IV Magnesium Sulphate, IV aminophylline. Needs senior medical decision.

Answer 60

Additional problems: recurrent cough and wheezes often associated with upper respiratory viral infections. May not indicate worsening of asthma. Diagnosis relies on symptoms - few functional tests. Condition may suddenly worsen. Oral b-agonist not recommended – inhaled best. Metered dose inhaler with spacer and mask. Can use oral steroid in hospital setting. Inhaled ipatropium bromide in combination with inhaled b-agonist can be considered.

Answer 61

Heart rate Pulse rate Maintain SpO2 >94–98% Peak expiratory flow 15–30 minutes after starting treatment Blood gas measurements Chart PEF before and after giving β2 agonists and at least 4 times daily throughout hospital stay

Answer 62

Chronic Obstructive Pulmonary Disease (COPD) is characterised by airflow obstruction. The airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. The disease is predominantly caused by smoking

Answer 63

C-chronic (long term condition) O-obstructive (narrowing of airways) P-pulmonary (affects your lungs) D-disease (its medical condition)

Answer 64

means the airways are inflamed and narrowed. People with bronchitis often produce sputum, or phlegm.

Answer 65

affects the air sacs at the end of the airways in the lungs. They break down and the lungs become baggy and full of holes which trap air.

Answer 66

These processes narrow the airways, making it harder to move air in and out as you breathe: - the lung tissue is damaged so there is less pull on the airways - the elastic lining of the airways flops - the airway lining is inflamed

Answer 67

Most likely to develop COPD if >35 years and are, or have been, a smoker Jobs where people are exposed to dust, fumes and chemicals can also contribute to developing COPD Some people are more affected than others by breathing in noxious materials. You have higher risk if respiratory problems run in the family. A rare genetic condition called alpha-1-antitrypsin deficiency makes people very susceptible to develop COPD at a young age.

Answer 68

COPD is the second most common lung disease in the UK, after asthma. Around 2% of the whole population – 4.5% of all people aged over 40 – live with diagnosed COPD. Nearly 30,000 people die from COPD each year, making it the second greatest cause of death from lung disease and the UK’s fifth biggest killer. Along with lung cancer and pneumonia, COPD is one of the three leading contributors to respiratory mortality in developed countries such as the UK. An estimated 1.2 million people are living with diagnosed COPD. Men are more likely to be diagnosed with COPD and to die from it than women. COPD is rare under 40 and becomes commoner with age, affecting 9% of those aged >70. COPD prevalence, incidence and mortality rates are highest in Scotland and the north of England. Prevalence and incidence are over twice as great in the most deprived population quintile than in the least.

Answer 69

getting short of breath easily when doing everyday things (e.g. going for a walk or doing housework) having a cough that lasts a long time wheezing in cold weather producing more sputum or phlegm than usual You might get these symptoms all the time, or they might appear or get worse when you have an infection or breathe in smoke or fumes. In severe COPD = lose appetite, lose weight and ankle swelling COPD is different to asthma; In COPD airways are permanently narrowed and is irreversible

Answer 70

The diagnosis of COPD depends on thinking of it as a cause of breathlessness or cough. It is suspected on the basis of symptoms and signs and is supported by spirometry. Diagnosis of COPD should be considered for: Patients >35 years and * Smokers (or significant dusty occupation) patients who present with one or more of the following: Exertional breathlessness, Chronic cough, Regular sputum production, Frequent winter ‘bronchitis’ and wheeze. Spirometry is one of the essential lung function investigations in the diagnosis, severity assessment and monitoring of disease progression of COPD. Further investigations for all patients at initial diagnostic evaluation include – 1. Chest radiograph to exclude other pathologies 2. FBC - to identify anaemia or polycythaemia 3. BMI calculated 4. Eosinophilia

Answer 71

In COPD airways are permanently narrowed and is irreversible

Answer 72

FEV1: forced expiratory flow in 1 second FVC: forced vital capacity

Answer 73

It indicates how much air you can exhale in one second, and a low FEV1 implies that your airflow is obstructed.

Answer 74

Forced vital capacity (FVC) is the amount of air that can be forcibly exhaled from your lungs after taking the deepest breath possible. It's measured by spirometry

Answer 75

STOP SMOKING! This is the only therapeutic approach other than oxygen therapy that impedes development of the condition. Patients should be given assistance to stop. Unless contraindicated, use NRT or bupriopion (antidepressant) or varenicline (nicotinic receptor partial agonist) as appropriate in support

Answer 76

Offer treatment and support to stop smoking Offer pneumococcal and influenza vaccinations Offer pulmonary rehabilitation if indicated Co-develop a respiratory action plan Optimise treatment for co-morbidities

Answer 77

if fundemental COPD care has been offered needed to relieve breathlessness compliance with inhalers

Answer 78

New long acting sympathomimetic agent Single dose duration 24 hours – od dosing Licensed only for maintenance treatment of COPD – not for asthma! Not tested in long term asthma therapy In COPD alternative to salmeterol or formoterol

Answer 79

Sustained antagonism of muscarinic receptors: high receptor affinity Topically active and administered by inhalation Tiotropium (bromide) powder or solution for inhalation. Licensed only for maintenance treatment of COPD – no value in acute attack. Must stop SAMA when using LAMA

Answer 80

Aclidinium bromide (Eklira genuair) >Competitive, selective muscarinic receptor antagonist, with a longer residence time at M3 receptors which mediate contraction of smooth muscle in the airways; induces bronchodilation. >Once absorbed it is rapidly broken down in the plasma, resulting in minimal systemic anticholinergic side-effects. Glycopyrronium bromide (Seebri breezehaler) Umeclidinium (Incruse Ellipta)

Answer 81

New recommendation 2010 Fostair: beclomethasone diproprionate 100mcg with formoterol fumarate 6 mcg Symbicort: budesonide 100mcg with formoterol fumarate 6 mcg If ICS not tolerated or declined an alternative option is to combine LABA and LAMA e.g. formoterol with Tiotropium

Answer 82

Quality statement 2: Inhaler technique (patients should have this assessed when starting treatment and then regularly during treatment) Hand held best if can be used. Consider a spacer MDI first option but can try other inhaler types Spacers must be compatible with inhaler and do not over clean Nebulisers when patients disabled by breathlessness despite max use of inhalers Review and do not continue without evidence of benefit

Answer 83

Oral steroids are NOT advised. In advanced COPD may need low dose oral maintenance – dose as low as possible. Watch for SE. ICS not licensed for use alone in COPD - prescribers responsible Oral reversibility tests do not predict inhaled therapy responses and should not be used ICS are to reduce progression of disease and control exacerbations not to improve lung function per se Risk of osteoporosis and other side effects with long term high dose ICS

Answer 84

No longer recommended agent – narrow therapeutic index - toxicity Should only be used for patients that cannot use inhaled therapy or if symptoms persist. Offer only after trials of SABA and LABA Can be combined with beta-agonists and muscarinic antagonists No advantage over SABA or LABA and poor side- effect profile-need to monitor plasma levels and interactions

Answer 85

Inappropriate use - respiratory depression possible LTOT for patients PaO2 <7.3kPa (55mmHg) or <8kPa with polycythaemia or nocturnal hypoxaemia (PaO2 < 90% for 30% of time) Consider if FEV1 30-49% predicted. To benefit from LTOT, give for 15hrs/day Need to assess benefit – including arterial blood gas on 2 occasions at least 3 weeks apart for patients who are stable. Ambulatory O2 prescribed when on LTOT to allow movement outside home – may also use short burst O2

Answer 86

Phosphodiesterase type-4 inhibitor Maintenance therapy for COPD particularly associated with recurrent bronchitis with history of frequent exacerbations NICE – currently recommended only as part of a research study in COPD as an add on to bronchodilator therapy NICE recommend that patients should be allowed to continue therapy if benefit is found

Answer 87

Considered for patients with a chronic productive cough Facilitate expectoration by reducing sputum viscosity (thickness) Can reduce exacerbations Should be stopped if there is no benefit after a 4-week trial

Answer 88

angioedema, arrhythmias, headaches hyperglycaemia (when given IV), hypokalaemia (with high doses)

Answer 89

constipation, cough, dry mouth, gastro- intestinal-motility-disorder

Answer 90

hoarse voice, oral thrush. Need to reduce the risk by using inhalers correctly and rinsing mouth out with water after using inhaler

Answer 91

Patients with severe COPD who remain breathless with marked restrictions of their activities of daily living, despite maximal therapy (including rehabilitation), should be referred for consideration of lung volume reduction surgery if they meet all of the following criteria: 1. FEV1 more than 20% predicted 2. PaCO2 less than 7.3 kPa 3. Upper lobe predominant emphysema 4. TLCO more than 20% predicted

Answer 92

Anti-oxidant therapy – alpha-tocopherol (guess what it is) and beta-carotene (guess what it is) supplements Anti-tussive therapy Prophylactic antibiotic therapy (insufficient evidence) Anti-oxidant therapy – alpha-tocopherol (vit E) and beta-carotene (carrots!) supplements Anti-tussive therapy Prophylactic antibiotic therapy (insufficient evidence) Mucolytics should not be used routinely. Consider in people with productive chronic cough who respond.

Answer 93

Symptoms: worsening breathlessness, cough, increased sputum production and change in sputum colour Give bronchodilator therapy via nebuliser +/- oxygen IV aminophylline given if response to nebulised bronchodilators is poor (take levels within 24 hours) Short course of oral steroids (prednisolone 30mg for 5 days) - if increased breathlessness interferes with daily activities Antibiotics – if sputum becomes more purulent or if other signs of infection (usually a macrolide, or a tetracycline)

Answer 94

1. Exercise and pulmonary rehabilitation 2. Controlling breathing (breathing gently, using the least effort, with shoulders supported and relaxed) 3. Eating well and maintaining healthy weight 4. Vaccination (against pneumococcal infection -have this once, and the annual influenza vaccine) 5. Managing flare ups (exacerbations) Top Tip: STOP SMOKING

the patient Flashcards

(120 cards)