therapy & management asthma & copd
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THERAPY & MANAGEMENT ASTHMA & COPD. Dr. Mike Iredale October 2010. www.brit-thoracic.org.uk www.asthma.org.uk. ASTHMA. - PowerPoint PPT PresentationTRANSCRIPT
THERAPY & MANAGEMENT
ASTHMA & COPD
Dr. Mike IredaleOctober 2010
www.brit-thoracic.org.uk
www.asthma.org.uk
ASTHMA
“a chronic inflammatory disorder of the airways….in susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.”
ACUTE ASTHMA
Assessment - able to complete sentences ? - peak expiratory flow rate - respiratory rate - pulse - oxygen saturation - arterial blood gases
ACUTE ASTHMA - Treatment
Oxygen - high flow / concentration
Nebulised (high dose) B2-agonist - salbutamol - terbutaline
ACUTE ASTHMA - Treatment (2)
Steroids - prednisolone (40-50 mg daily) - hydrocortisone (100mg qds)
no need to taper dose continue inhaled steroid
ACUTE ASTHMA - Treatment (3)
Ipratropium Bromide - nebulised 500mcg qds
- acute severe asthma - life-threatening asthma - poor initial response to nebulised B2-agonist - only for initial phase of treatment
ACUTE ASTHMA - Treatment (4)
Intravenous Magnesium Sulphate - 1.2 - 2g IV infusion over 20 min (single dose)
consider if: life-threatening or near fatal asthma acute severe asthma with poor initial response after consultation with senior medical staff
ACUTE ASTHMA - Treatment (5)
Intravenous Infusions
Aminophylline - 0.5 mg / kg / hr - omit bolus if on oral aminohylline / theophylline - check levels
B2-agonist - limited evidence - ventilated patients
ACUTE ASTHMA - Treatment (6)
Antibiotics
Routine prescription of antibiotics is NOT
indicated for acute asthma.
ACUTE ASTHMA
ITU Referral: - deteriorating peak flow - persisting / worsening hypoxia - hypercapnea - falling pH on ABG - exhaustion / feeble respiration - drowsiness, confusion, coma, cardiac arrest
ACUTE ASTHMA
Discharge: - on discharge medication for 24 hours - PEF >75% best/predicted + <25% variability - oral + inhaled steroid + bronchodilator - inhaler technique checked - PEF meter + action plan - follow up: GP 2 days, chest clinic 4 weeks
Questions ?
CHRONIC ASTHMA
Treatment Goals: - minimal symptoms during day & night - minimal need for reliever medication - no exacerbations - no limitation of physical activity - normal lung function
(FEV1 / PEF > 80% predicted or best)
CHRONIC ASTHMA
Non-Pharmacology
- smoking cessation (active / passive) - allergen avoidance - complementary / alternative medicine - weight reduction in obese - gastro-oesophageal reflux - immunotherapy
CHRONIC ASTHMA
Pharmacology
- step-wise approach - start at level appropriate to severity - step-down when control is good
- compliance, inhaler technique, trigger factors
CHRONIC ASTHMA
STEP 1: Mild Intermittent Asthma
inhaled short-acting B2-agonist - as required - reliever therapy
CHRONIC ASTHMA
STEP 2: Introduction of Regular Preventer Therapy
inhaled steroid is first choice - 400-800 mcg BDP (beclomethasone) equivalent
CHRONIC ASTHMA Inhaled Steroids:
- beclomethasone (BDP) - budesonide
- fluticasone - mometasone - ciclesonide
- large volume spacer in doses >1500 mcg BDP
CHRONIC ASTHMA
STEP 3: Add-on therapy
long-acting B2-agonist - salmeterol - formoterol
- good response - continue no response - stop
CHRONIC ASTHMA
STEP 3: Add-on therapy (2)
if control remains inadequate: - increase inhaled steroid to 800 mcg / day
CHRONIC ASTHMA
STEP 3: Add-on therapy (3)
if control remains inadequate trial of:
- leukotriene receptor antagonists - theophylline
CHRONIC ASTHMA STEP 4: Poor control on moderate dose
inhaled steroid + add-on therapy: Addition of 4th drug
- increase inhaled steroid to 2000 mcg / day - leukotriene receptor antagonists - theophylline - slow-release oral B2-agonist
CHRONIC ASTHMA
STEP 5: Continuous or Frequent use of Oral Steroid
- side-effects
- steroid sparing medication - inhaled steroid most effective - immunosuppressants
CHRONIC ASTHMA
Step Down
- patients often left over treated
- regular review - aim to maintain at lowest dose inhaled steroid that keeps asthma controlled
Questions ?
COPD
..is a chronic, slowly progressive disorder characterised by airflow obstruction (reduced FEV1 and FEV1/VC ratio) that does not change markedly over several months. Most of the lung function impairment is fixed, although some reversibility can be produced by bronchodilator (or other) therapy.
COPD - Treatment
SMOKING CESSATION
..is the single most important way of affecting outcome in patients at all stages of COPD
COPD - Treatment (2) Bronchodilators (BD)
- stepwise approach - stop therapy if ineffective
short acting as needed (B2-agonist or AC)
combination short acting BD
long-acting BD (B2-agonist or AC)
COPD - Treatment (2)
Bronchodilators - Mod/severe COPD: consider -
combination long-acting BD + inhaled steroid
theophylline
COPD - Treatment (3)
Frequent exacerbations:
optimise BD therapy with one or more long-acting BD (B2-agonist or AC)
inhaled steroid - if FEV1 < 50% + 2 exacerbations in last year
COPD - Treatment (4)
Other measures:- nutrition- vaccination- pulmonary rehabilitation- breathlessness treatment- surgery- mucolytic therapy- depression
COPD - Treatment (5)
Long Term Oxygen Therapy (LTOT):
- improved survival (25% - 41% 5 yr) - less secondary polycythaemia - prevents progression of pulmonary hypertension - better neuropsychological health
COPD - Treatment (5)
Long Term Oxygen Therapy (LTOT):
- FEV1 < 1.5 l - paO2 < 7.3 kPa, on 2 occasions 3 weeks apart - at least 15 hrs each day - no benefit if continue to smoke
Questions ?
COPD - Acute Exacerbation
Presentation: Important symptoms include
- increased sputum purulence - increased sputum volume - increased dyspnoea - increased wheeze - chest tightness - fluid retention
COPD - Acute Exacerbation
Treatment: Bronchodilators
- nebulised in hospital + regular - B2-agonist / anticholinergic
- acute response does not imply long-term benefit
- iv aminophylline if severe and not responding
COPD - Acute Exacerbation
Treatment: Antibiotic
if 2 or more of - increased breathlessness - increased sputum volume - development of purulent sputum
COPD - Acute Exacerbation
Treatment: Antibiotic
commonest bacterial causes - Haemophilus influenzae - Streptococcus pneumoniae
amoxycillin first choice for most patients
COPD - Acute Exacerbation
Treatment: Steroid - common practice but value unclear
Justified if: - already on oral steroid - previous documented response - first presentation of airways obstruction - AFO fails to respond to increase bronchodilator
COPD - Acute Exacerbation
Treatment:
Diuretic - peripheral oedema - raised JVP
Anticoagulant - prophylactic clexane for acute on chronic respiratory failure
COPD - Acute Exacerbation
Treatment: OXYGEN
? resp. failure - oxygen saturation - pO2 < 8 kPa, SaO2 < 92%
? type of resp failure - ABG - type 1: normal or low pCO2
- type 2: raised pCO2
COPD - Acute Exacerbation
Treatment: OXYGEN
type 1 - high concentration oxygen
- monitor with SaO2 unless patient deteriorates
- aim to keep SaO2 >94-98 %
COPD - Acute Exacerbation
Treatment: OXYGEN type 2 - controlled oxygen therapy
- 24 % FiO2 , repeat ABG after 60 min
- if pO2 > 8 kPa + pCO2 & pH ISQ - no change - if pO2 < 8 kPa + pCO2 & pH ISQ - increase to 28% - if pCO2 increases & pH falls - alternative strategy
COPD - Acute Exacerbation
Alternative strategies for COPD & respiratory failure:
- non-invasive ventilation (NIV)(pH < 7.35, pCO2 > 6)
- intubation and ventilation
(- iv doxapram)
Questions ?
www.brit-thoracic.org.uk
www.asthma.org.uk