Week 9: Asthma and COPD Flashcards

Question

step 2 in asthma mangement

Answer 1

low dose ICS e.g. prednisolone

Answer 2

add LTRA e.g. **Montelukast** or LABA e.g. salmeterol depending on guidelines

Answer 3

increase ICS to medium dose e.g. beclamethasone add LTRA stop LABA if no response

Answer 4

specialist

Answer 5

always prescribe with corticosteroid

Answer 6

* Achieve early control * Step up or down medication to enable optimum control * Lowest dose of inhale steroid possible * Check compliance e.g. taking medication and inhaler technique

Answer 7

a normal FEV1, FVC and FEV1/FVC ratio.

Answer 8

a reduced FVC but with a normal FEV1/FVC ratio. [The FEV1 is reduced in proportion to the FVC] e.g. pulmonary fibrosis

Answer 9

a normal FVC but with a reduced FEV1 and hence FEV1/FVC ratio. In obstruction, the PEFR is also reduced \<70%

Answer 10

Bronchodilator reversibility typically involves repeating spirometry testing 20 – 30 mins after administering a dose of bronchodilator (typically Salbutamol 2 x 200mcg puffs, ideally via a large volume spacer). If there is ‘reversible’ airways obstruction, there will be an improvement in the FEV1/FVC ratio.

Answer 11

MDI- pressurised metered dose inhalers DPIs- dry powder inhalers SMIs- soft mist inhalers

Answer 12

generates an ‘aerosol’ which is inhaled. 1. Test the inhaler- shake inhaler and press canister to release puff into air 2. Now check that there is nothing inside the mouth piece and shake the inhaler well 3. Sit or stand up straight and tilt your chin up 4. Breathe out gently and slowly away from the inhaler until lungs feel empty 5. Put lips around the mouthpiece to make a tight seal 6. Start to breathe in slowly and steadily and at the same time press the canister on the inhaler once 7. Continue to breathe in slowly until your lungs feel full 8. Hold breathe for 10 seconds then breathe out gently away from your inhaler 9. Repeat step 30-1 min later if required 10. If inhaler contains steroids- rinse mouth with water

Answer 13

1. SABA = Short Acting Beta Agonist 2. LABA = Long Acting Beta Agonist 3. SAMA = Short Acting Antimuscarinic (rarely used in asthma) 4. LAMA = Long Acting Antimuscarinic (rarely used in asthma) 5. ICS = Inhaled corticosteroids Some inhalers contain single agents; some are combinations. Common combinations are: 1. ICS/LABA (can be used in asthma and COPD) 2. LABA/LAMA (mainly used in COPD) 3. ICS/LABA/LAMA (mainly used in COPD)

Answer 14

**Spacers** are useful devices which can improve inhaler technique. Several options are available.

Answer 15

no features of severe asthma PEFR \>75%

Answer 16

no features of severe PEFR 50-75%

Answer 17

if any on of the following * PEFR 33-50% of best predicted * cannot complete sentences in 1 breath * RR \>35/min * HR \>110/min

Answer 18

if any one of the following * PEFR \<33% * sat \<92% of ABG pO2\<9kPa * cyanosis, poor resp effort, silent chest * exhuastion, confusion, hypotension, arrhthmias * normal pCO2

Answer 19

* rasised pCO2

Answer 20

**Acute Asthma Management:** * ABCDE * Aim for SpO2 94-98% with oxygen as needed, ABG if * sats \<92% * 5mg nebulised Salbutamol (can repeat after 15 mins) * 40mg oral Prednisolone STAT (IV Hydrocortisone if * PO not possible) **If severe:** * Nebulised Ipratropium Bromide 500 micrograms * Consider back-to-back Salbutamol **If life threatening or near fatal:** * Urgent ITU or anaesthetist assessment * Urgent portable CXR * IV Aminophylline * Consider IV Salbutamol if nebulised route ineffective

Answer 21

* COPD is an umbrella term which encompasses ***emphysema and chronic bronchitis*** * Chronic obstructive pulmonary disease (COPD) is a common, treatable (but not curable) and largely preventable lung condition. * It is characterised by persistent respiratory symptoms (such as breathlessness, cough, and sputum) and airflow obstruction (usually progressive and not fully reversible). Airflow obstruction results from chronic inflammation caused by exposure to noxious particles or gases (usually tobacco smoke but also from environmental and occupational exposures

Answer 22

* Smoking * Exposure to air pollution. * Breathing second hand smoke. * Working with chemicals, dust and fumes. * Alpha-1 deficiency. * Childhood respiratory infection.

Answer 23

* FEV1/FVC ratio is below \<70% - non reversible with bronchodilators * Chronic cough w or without sputum * Shortness of breath during activity * Wheezing * Ankle oedema * Cor pulmonale

Answer 24

* Spirometry * CXR- can see bigger alveoli à air trapping à shows up as hyperdense * Hyperinflated chest, flat diaphragm * Severity of COPD is based on decreased FEV1 * Can use MRC dyspnoea scale (symptomatic test) * Other tests * Alpha 1 antitrypsin level (genetic condition causing early onset COPD, even in people with no risk factors) * Investigations for heart disease (e.g. ECG, natriuretic peptide, echocardiogram) * Investigations for other lung disease (e.g. CT thorax, sputum culture) * Oxygen saturations (to check for hypoxia)

Answer 25

Emphysema refers to a radiological/pathological change: *“a condition of the lung characterized by abnormal, permanent enlargement of airspaces distal to the terminal bronchiole, accompanied by the destruction of their walls, and without obvious fibrosis”* * Damage to walls of alveoli * Rather than lots of small alveoli, they breakdown forming larger alveoli à unable to support bronchioles * Bronchioles collapse and trap air inside the lungs * Changes in emphysema are irreversible

Answer 26

* Smoking (must stop smoking to stop it getting worse) * **Alpha 1- antitrypsin deficiency**

Answer 27

Chronic bronchitis is the clinical term for cough and sputum production for at least 3 months in each of 2 consecutive years. 1. Chronic inflammation of the bronchioles 2. Inflammatory changes like asthma 3. Instead of responding to allergen, it responds to irritants like cigarette smoke * Not T1 hypersensitivity 4. Non-reversible 5. Increased mucus and inflammation that causes narrowing of the airway → not bronchoconstriction

Answer 28

* Smoking cessation advice e.g. nicotine replacement therapy * Vaccinations e.g. annual influenzas and pneumococcal * Pulmonary rehabilitation * pharmacological * inhaled treatment * prophylactic antibiotics * LTOT * mucolytics

Answer 29

* Increase exercise tolerance * Anxiety management * Breathing technique * Teaching of how to clear chest of sputum

Answer 30

*Make sure patient has correct inhalation technique. Nebulised treatment should be considered for patients with distressing or disabling breathlessness* * Initial treatment: SABA or SAMA * Step up treatment for patient *without* asthmatic features or features suggesting steroid responsiveness: LABA and a LAMA (discontinue SAMA if LAMA given) * SABA continued throughout all stages of treatment * Patients on LAMA and LABA who have severe exacerbations or at least 2 moderate exacerbations, consider addition of ICS INHALER (TRIPLE THERAPY) * Step up treatment for patient *with* asthmatic features or features suggesting steroid responsiveness * LABA and ICS * Patients on LABA and ICS who have severe exacerbations or at least 2 moderate exacerbations, consider addition of LAMA

Answer 31

azithromycin to reduce risk of exacerbation in patients who are non-smokers, have had all other treatment option optimised and have prolonged or frequent exacerbation with sputum production or resulting in hospitalisation- ensure sputum culture and sensitivity

Answer 32

carbocyteine

Answer 33

* Extended periods of hypoxia cause renal and cardiac damage – can be prevented by LTOT * LTOT to be used at least 16 hours/day for a survival benefit * LTOT offered if pO2 consistently below 7.3 kPa, or below 8 kPa with cor pulmonale * Patients must be non-smokers and not retain high levels of CO2 * O2 needs should be balanced with loss of independence and reduced activity which may occur * **Note: oxygen is not a treatment for breathlessness; it is a treatment to help prevent organ hypoxia**

Answer 34

* Stop CO2 retention

Answer 35

NICE calls this “Asthmatic features/features suggesting steroid responsiveness” This includes any previous, secure diagnosis of asthma or of atopy, a higher blood eosinophil count, substantial variation in FEV1 over time (at least 400 ml) or substantial diurnal variation in peak expiratory flow (at least 20%). This might happen when: * A person has ‘confirmed’ asthma (i.e. has been investigated as recommended in topic 3) but continues to smoke (or is exposed to occupational risk factors) * A person has other atopic conditions and develops COPD. * A person with COPD is noted to have a raised eosinophil count.

Answer 36

eosinophil count

Answer 37

* Exacerbations of **COPD** * **Cor pulmonale** * **Type 1 respiratory failure** (‘hypoxic’ respiratory failure) * **Type 2 respiratory failure** (‘hypercapnic’ respiratory failure) * Blue bloaters * Secondary polycythaemia- chronic hypoxia * Anxiety and depression

Answer 38

* right sided heart failure * due to pulmonary hypertension à hypoxia causes vasoconstriction of pulmonary BV * pulmonary hypertension results from hypoxia, inflammation, and loss of alveolar capillaries (related to emphysematous change). * *increased pressure In the right ventricles due to pulmonary hypertension due to chronic hypoxiaà blood flow back to the RA reduced- ankle oedema*

Answer 39

Bronchitis * CO2 retention (insensitive to it * Type 2- hypercapnic resp failure

Week 9: Asthma and COPD Flashcards

(64 cards)