+ asthma & copd finals teaching 2013 alison portes fy1
TRANSCRIPT
+Objectives
Main features of asthma and COPD
Focus on clinicals – history, examination, investigations, management
10 minutes on each
Quiz and summary of key points
A few added extras…
+Asthma
Definition
Pathophysiology
History
Examination
Investigations
Management Acute Chronic
Medications
Paediatric Asthma
+Definition
Obstructive airways disease
Chronic
Inflammatory
Variable
Reversible
Hyperresponsiveness
+Pathophysiology
Acute asthma airway changes- Airway constriction Mucus hypersecretion Eosinophils IgE mediated inflammatory response
degranulation of mast cells histamine release inflammatory cell infiltration
Chronic asthma airway changes– airway remodelling
Smooth muscle hyperplasia / hypertrophy
Goblet cell hyperplasia
+History
Full respiratory history plus…
Triggers (exercise, illness, cold, pets…)
Diurnal variation
Disturbed sleep
Atopy/family history of atopy
Occupation
Compliance with meds
GP/A&E/ITU attendances
+Examination
Standard respiratory exam
?Start at the back
Tachypnoea
Widespread polyphonic wheeze
Hyperresonant percussion note
Diminished breath sounds
Hyperinflated chest
+Investigations
Bedside PEF
Bloods Blood gas – when and why?
Imaging CXR – when and why?
Special tests PEF monitoring Spirometry - Bronchodilator challenge
+Management - chronic asthma
BTS guidelines
Step 1: SABA only
Step 2: SABA & ICS 200-800 mcg/day
Step 3: add LABA (combined)
Step 4: ↑ ICS dose (stop LABA if no benefit), monteleukast
Step 5: help! Oral steroids…
+Acute severe asthma
PEFR 50-33%
RR ≥ 25
HR ≥ 110
Unable to complete sentences
But SpO2 >92%
Worse = life-threatening (silent chest, cyanosis, low SpO2) 33-92-CHEST
Better = moderate asthma
+Management - Acute severe asthma
How would you like to manage this patient?
Immediate A to E Salbutamol 5mg via oxygen driven nebuliser Repeat obs (SpO2, HR, RR) and PEF to assess for progression of
severity and risk to life If clinically stable and PEF >75%, can repeat Salbutamol nebs and
consider oral prednisolone 40-50mg Otherwise, add ipratropium nebs, IV hydrocortisone, consider
magnesium sulphate IV and call for help!
+Respiratory Failure
pO2 < 8 kPa
Type I Normal/low pCO2 V/Q mismatch/diffusion limitation Atelectasis, pulmonary oedema, pneumonia, pneumothorax
Type II ↑ pCO2 ↓pH if acute Ventilatory failure COPD, neuromuscular disorders (GBS, MND), CNS depression
(drugs, brainstem injuries) Needs controlled O2 ± ventilation
+Paediatric Asthma
Signs of chronic asthma/growth
Inhaler technique/spacers
Asthma vs. Viral induced wheeze
Differences in the BTS management guidelines
What age can a child do a peak flow?
Don’t let them leave without…
+Communication
Please explain to Mr X how to correctly use his inhaler
Check understanding If you haven’t used it for a while, spray in the air to check it works Shake it As you breathe in, simultaneously press down on the inhaler Continue to breathe deeply Hold your breath for 10 seconds or as long as you comfortably can,
before breathing out slowly. If you need to take another puff, wait for 30 seconds, shake your
inhaler again then repeat Advise on using a spacer
+COPD
Definition
Pathophysiology
History
Examination
Investigations
Management Chronic Acute Exacerbation
+Definition
Umbrella term – chronic bronchitis and /or emphysema
Airflow obstruction (FEV1/FVC < 0.7)
Usually progressive
Not fully reversible
Doesn’t change markedly over few months
Predominantly caused by cigarette smoking
Differentiation from asthma
+Pathophysiology
Chronic bronchitis Clinical diagnosis - chronic cough and sputum production on most
days for at least 3 months per year for 2 years Airway narrowing due to bronchiole inflammation, mucosal oedema
and mucus hypersecretion
Emphysema Pathological diagnosis - permanent destructive enlargement of
distal air spaces Destruction and enlargement of alveoli that reduces elastic recoil
and results in bullae
+History
Full respiratory history plus…
Smoking, smoking, smoking!!
Consider your differentials – ILD, bronchiectasis, malignancy, heart failure – and rule them out
Red flag symptoms
+Investigations
Bedside Sputum, ECG
Bloods FBC, U&E, CRP, blood cultures, ABG
Imaging CXR Echo
Special tests Spirometry α1-antitrypsin levels
+Management of Chronic COPD
Long term Conservative – smoking cessation, pulmonary rehabilitation, flu
vaccination Medical – LTOT (only if not smoking), bronchodilators,
antimuscarinics, home nebulisers, steroids (can consider if more than 2 infective exacerbations/year), prophylactic antibiotics
Surgical – Transplant, lobectomy, bullectomy
LTOT criteria PaO2 <7.3 kPa on air during period of clinical stability PaO2 7.3-8.0 kPa and signs of secondary polycythaemia, nocturnal
hypoxaemia, peripheral oedema or pulmonary hypertension At least 15 hours a day
+Acute Exacerbation of COPD
Sustained worsening of symptoms from usual state
Beyond daily day-day variation
Acute in onset
Often associated with ↑ SOB, ↑ cough, ↑ sputum volume, ↑ sputum purulence
Not pneumonia!
+Management – exacerbation of COPD
How would you like to manage this patient?
Immediate A to E Maintain sats 88-92% (titrate to ABG) – O2 via Venturi mask Corticosteroids (oral/IV) Empirical antibiotics if purulent sputum Salbutamol 5mg and Ipratropium via O2 driven nebulisers Consider need for NIV – if desaturating/decompensating Admit, chest physiotherapy
+FEV1/FVC
Determines the severity of COPD Describes the proportion of a person’s vital capacity (maximum air
expelled after maximum inhalation) that can be expired in the first second.
Normal ~ 70% Mild 50-70% Moderate 30-50% Severe <30%
+Quiz
What is in a brown inhaler?
What are the features of life-threatening asthma?
List 4 classes of drug used to treat Asthma/COPD?
What are the criteria for LTOT?
What is the 2nd step in the BTS asthma ladder? And the 4th?
What level SpO2 should you aim for in COPD patients?
What is Spiriva?
+Key Points
History and Examination – concentrate on doing the basics well
Investigations – what differential will it rule out?
Learn the essentials now and keep repeating them… Acute severe/life-threatening asthma criteria BTS asthma guidelines – the ladder T1 vs T2 respiratory failure LTOT criteria
Practice communication task – PEF, inhalers
Questions?
Reading Chest X-RaysRIP...ABCDE
Adequacy:- Rotation
(symmetry of clavicles)
- Inspiration (ribs)- Penetration
(vertebral bodies)- Mention central
lines, NG tubes, pacemakers etc
- Airway: is the trachea central?
- Boundaries and Both lungs: lung borders, consolidation, hazy etc
- Cardiac: Heart size- Diaphragm- Everything else:
soft tissue mass, fractures