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Asthma &COPDFinals Teaching 2013Alison Portes FY1

+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…

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Asthma

+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…

Asthma Medications

Salbutamol

Salmeterol

Mechanism?

Beclomethasone

Salmeterol plus flixotide

+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

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COPD

+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

+Examination

Look and comment!

Tar stains

Accessory muscles

Barrel chest

Crepitations

Wheeze

+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

Antimuscarinics

Ipratropium

Short-acting

Tiotropium

Long-acting

Mechanism?

+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?

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Extras

+Typical graphs

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