Download Asthma COPD

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Asthma &
COPD
Finals Teaching 2013
Alison Portes FY1
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Objectives
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Main features of asthma and COPD
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Focus on clinicals – history, examination, investigations,
management
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10 minutes on each
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Quiz and summary of key points
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A few added extras…
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Asthma
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Asthma
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Definition
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Pathophysiology
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History
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Examination
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Investigations
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Management
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Acute
Chronic
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Medications
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Paediatric Asthma
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Definition
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Obstructive airways disease
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Chronic
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Inflammatory
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Variable
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Reversible
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Hyperresponsiveness
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Pathophysiology
Acute asthma airway changes Airway constriction
 Mucus hypersecretion
 Eosinophils
 IgE mediated inflammatory response
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degranulation of mast cells
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histamine release
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inflammatory cell infiltration
Chronic asthma airway changes– airway
remodelling
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Smooth muscle hyperplasia / hypertrophy
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Goblet cell hyperplasia
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History
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Full respiratory history plus…
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Triggers (exercise, illness, cold, pets…)
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Diurnal variation
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Disturbed sleep
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Atopy/family history of atopy
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Occupation
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Compliance with meds
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GP/A&E/ITU attendances
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Examination
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Standard respiratory exam
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?Start at the back
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Tachypnoea
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Widespread polyphonic wheeze
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Hyperresonant percussion note
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Diminished breath sounds
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Hyperinflated chest
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Investigations
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Bedside
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Bloods
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Blood gas – when and why?
Imaging
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PEF
CXR – when and why?
Special tests
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PEF monitoring
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Spirometry - Bronchodilator challenge
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Management - chronic asthma
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BTS guidelines
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Step 1: SABA only
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Step 2: SABA & ICS 200-800 mcg/day
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Step 3: add LABA (combined)
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Step 4: ↑ ICS dose (stop LABA if no benefit), monteleukast
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Step 5: help! Oral steroids…
Asthma Medications
Beclomethasone
Salbutamol
Salmeterol
plus flixotide
Salmeterol
Mechanism?
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Acute severe asthma
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PEFR 50-33%
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RR ≥ 25
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HR ≥ 110
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Unable to complete sentences
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But SpO2 >92%
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Worse = life-threatening (silent chest, cyanosis, low SpO2)
33-92-CHEST
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Better = moderate asthma
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Management - Acute severe
asthma
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How would you like to manage this patient?
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Immediate
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A to E
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Salbutamol 5mg via oxygen driven nebuliser
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Repeat obs (SpO2, HR, RR) and PEF to assess for progression of severity
and risk to life
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If clinically stable and PEF >75%, can repeat Salbutamol nebs and
consider oral prednisolone 40-50mg
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Otherwise, add ipratropium nebs, IV hydrocortisone, consider magnesium
sulphate IV and call for help!
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Respiratory Failure
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pO2 < 8 kPa
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Type I
 Normal/low pCO2
 V/Q mismatch/diffusion limitation
 Atelectasis, pulmonary oedema, pneumonia, pneumothorax
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Type II
 ↑ pCO2
 ↓pH if acute
 Ventilatory failure
 COPD, neuromuscular disorders (GBS, MND), CNS depression
(drugs, brainstem injuries)
 Needs controlled O2 ± ventilation
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Paediatric Asthma
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Signs of chronic asthma/growth
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Inhaler technique/spacers
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Asthma vs. Viral induced wheeze
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Differences in the BTS management guidelines
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What age can a child do a peak flow?
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Don’t let them leave without…
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Communication
Please explain to Mr X how to correctly use his inhaler
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Check understanding
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If you haven’t used it for a while, spray in the air to check it works
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Shake it
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As you breathe in, simultaneously press down on the inhaler
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Continue to breathe deeply
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Hold your breath for 10 seconds or as long as you comfortably can, before
breathing out slowly.
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If you need to take another puff, wait for 30 seconds, shake your inhaler
again then repeat
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Advise on using a spacer
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COPD
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COPD
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Definition
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Pathophysiology
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History
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Examination
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Investigations
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Management
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Chronic
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Acute Exacerbation
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Definition
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Umbrella term – chronic bronchitis and /or emphysema
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Airflow obstruction (FEV1/FVC < 0.7)
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Usually progressive
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Not fully reversible
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Doesn’t change markedly over few months
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Predominantly caused by cigarette smoking
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Differentiation from asthma
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Pathophysiology
Chronic bronchitis
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Clinical diagnosis - chronic cough and sputum production on most days for
at least 3 months per year for 2 years
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Airway narrowing due to bronchiole inflammation, mucosal oedema and
mucus hypersecretion
Emphysema
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Pathological diagnosis - permanent destructive enlargement of distal air
spaces
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Destruction and enlargement of alveoli that reduces elastic recoil and
results in bullae
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History
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Full respiratory history plus…
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Smoking, smoking, smoking!!
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Consider your differentials – ILD, bronchiectasis, malignancy,
heart failure – and rule them out
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Red flag symptoms
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Examination
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Look and comment!
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Tar stains
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Accessory muscles
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Barrel chest
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Crepitations
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Wheeze
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Investigations
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Bedside
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Bloods
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FBC, U&E, CRP, blood cultures, ABG
Imaging
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Sputum, ECG
CXR
Echo
Special tests
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Spirometry
α1-antitrypsin levels
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Management of Chronic COPD
Long term
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Conservative – smoking cessation, pulmonary rehabilitation, flu
vaccination
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Medical – LTOT (only if not smoking), bronchodilators, antimuscarinics,
home nebulisers, steroids (can consider if more than 2 infective
exacerbations/year), prophylactic antibiotics
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Surgical – Transplant, lobectomy, bullectomy
LTOT criteria
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PaO2 <7.3 kPa on air during period of clinical stability
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PaO2 7.3-8.0 kPa and signs of secondary polycythaemia, nocturnal
hypoxaemia, peripheral oedema or pulmonary hypertension
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At least 15 hours a day
Antimuscarinics
Long-acting
Short-acting
Ipratropium
Tiotropium
Mechanism?
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Acute Exacerbation of COPD
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Sustained worsening of symptoms from usual state
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Beyond daily day-day variation
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Acute in onset
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Often associated with
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↑ SOB, ↑ cough, ↑ sputum volume, ↑ sputum purulence
Not pneumonia!
+Management – exacerbation of COPD
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How would you like to manage this patient?
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Immediate
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A to E
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Maintain sats 88-92% (titrate to ABG) – O2 via Venturi mask
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Corticosteroids (oral/IV)
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Empirical antibiotics if purulent sputum
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Salbutamol 5mg and Ipratropium via O2 driven nebulisers
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Consider need for NIV – if desaturating/decompensating
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Admit, chest physiotherapy
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FEV1/FVC
Determines the severity of COPD
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Describes the proportion of a person’s vital capacity (maximum air
expelled after maximum inhalation) that can be expired in the first second.
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Normal ~ 70%
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Mild 50-70%
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Moderate 30-50%
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Severe <30%
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Quiz
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What is in a brown inhaler?
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What are the features of life-threatening asthma?
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List 4 classes of drug used to treat Asthma/COPD?
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What are the criteria for LTOT?
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What is the 2nd step in the BTS asthma ladder? And the 4th?
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What level SpO2 should you aim for in COPD patients?
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What is Spiriva?
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Key Points
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History and Examination – concentrate on doing the basics well
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Investigations – what differential will it rule out?
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Learn the essentials now and keep repeating them…
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Acute severe/life-threatening asthma criteria
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BTS asthma guidelines – the ladder
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T1 vs T2 respiratory failure
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LTOT criteria
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Practice communication task – PEF, inhalers
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Questions?
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Extras
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Typical graphs
Reading Chest X-Rays
RIP...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