Asthma Cptp

7/23/2019 Asthma Cptp

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CPTP ASTHMA & COPDRichard Shaw, a 50 year old man who as recently moved into the area oes to reister at a

local !P s"rery# A ro"tine $"estionanaire, administered at reistration, reveals that Ric% has

a history of asthma which began when he was a child. Ric% still e'eriences sym'toms

o( breathlessness and wheezing, es'ecially early in the morning, and also has a

chronic cough# He has never )een hos'italised d"e to his asthma )"t has lost days at wor%

d"e to chest 'ro)lems# He has occasional exacerbations of breathlessness,

associated with a cough productive of purulent sputum. These e'isodes are "s"ally

treated with anti)iotics and short co"rses o( 'rednisolone# His only c"rrent asthma treatment

is a salbutamol inhaler which he uses "when he feels he needs it *, which is often as

much as eight times a day. He has occasionally had courses of oral and inhaled

steroids in the past but has not continued with inhaled steroids as he does not

notice any e+ect on his sym'toms# Ric% had a myocardial infarction 2 years ago and

ta%es aspirin 75 mg daily and simvastatin 20mg daily# His only other 'ast medical

history is glaucoma for which he uses timolol eye drops.

Q1) List the types of drug treatment available for asthma.

The main aim o( treatment is

a) Controller medications

They 'revent asthma attac%

Airways )ecome less inamed and less li%ely to react to triers

b) Quick-relief medications

Rela the m"scles aro"nd the airway

O(ten called the resc"e medications



Two )asic ty'es o( dr"s-

1. Bronchodilators

Relieve the sym'toms o( asthma )y relain the m"scles that can

tihten aro"nd the airways

.t hel's o'en "' the airways

Short- acting bronchodilator:

• O(ten re(erred to as resc"e inhalers and "sed $"ic%ly relieve

co"h, whee/e, chest tihtness and SO ca"sed )y asthma

• They may )e also "sed 'rior to eercise (or 'eo'le with eercise

1ind"ced asthma

• They sho"ld not )e "sed daily in the daily ro"tine#

• .2 the "sae o( short3 actin )ronchodilator as resc"e inhaler is"se more than twice a wee%, then asthma may not )e o'timally

controlled#

Long-acting bronchodilator:

• Sometimes "sed in com)ination with inhaled steroids (or control

o( asthma sym'toms or when someone have onoin asthma

sym'toms des'ite treatment with daily inhaled steroids#



4# Anti3inammatory dr"s inhaled steroids6

These medications 'revent asthma attac%s and wor% )y red"cin

swellin and m"c"s 'rod"ction in the airways#

Airways there(ore )ecome less sensitive and less li%ely to react to

asthma triers and ca"se asthma sym'toms

Q2) What would be the most appropriate management plan for this patient?

Contin"e 'rn inhaled sal)"tamol and add 'rn inhaled "ticasone

Contin"e 'rn inhaled sal)"tamol and add 'rn inhaled i'ratro'i"m

ontinue prn inhaled salbutamol and add regular inhaled !uticasone

Sto' 'rn inhaled sal)"tamol and s")stit"te 'rn inhaled salmeterol

Sto' 'rn inhaled sal)"tamol and s")stit"te re"lar inhaled salmeterol

0



Rick is

married

and

works as

avan

driver.

He has

smoked

40

cigarettes daily since his teens and drinks about16 units of alcohol a week.



The general practitioner examines Rick and the only abnormality he discovers is asparse scattered

polyphonic wheeze on chest auscultation. Rick'stemperature is normal, hisSpO 2 95% and his peak flow is

330 l/min (predicted 560) butincreases to 370 after 200 mcg inhaled salbutamol

#The reversibility is only 12% (target in asthma is > 15%)

Q3)o! should this patient be managed"

• Ste' "' to ste' 4

Q#)$re steroids appropriate and% if so% ho! should they be

administered"

• Steroids are a''ro'riate as his sym'toms 7 asthma is not '"rely controlled#

• .nhaled corticosteroid

Q&)Comment on his other drug treatment. 'hat changes to this

might be helpful"

$spirin

803409 o( ad"lts with asthma have sensitivity to as'irin or to :SA.DS

Asthma attac%s ca"sed )y any o( these medications can )e severe and

even (atal Prod"cts with acetamino'hen is sa(er alternative (or 'ain reliever (or

as'irin3ind"ce asthma 'atient Some 'eo'le with asthma cannot ta%e as'irin or :SA.DS )eca"se o(

what;s %now as <SAMST=R;S TR.AD>

Asthma

As'irin sensitivity

:asal 'olys

Beta-blockers Commonly "sed to treat n"mero"s condition incl"din heart conditions,

hih )lood 'ress"re, miraine headache, and eye dro' la"coma6 Patient is ta%in Timolol non3selective )eta3)loc%er , treatment (or

la"coma6



:2- eta )loc%ers sho"ld not )e "sed in 'atients with-

a6 Asthma)6 COPD

:2 on timolol- systemic a)sor'tion can (ollow to'ical a''lication to the

eyes, there(ore eye dro's containin a )eta3)loc%ers are contra3indicated

in 'atient with )radycardia, heart )loc% and "ncontrolled heart (ail"re and

asthma

Chane to other o'tion-

. #rostaglandin analogue2. $ympathomimetics

o .s a selective

al'ha 4

adrenorece'tor aonisto .s licensed (or the

red"ction o(

intra3oc"lar 'ress"re in 'atients (or whom )eta3)loc%ersare not s"ita)le

%. arbonic anhydrase

inhibitorso Dor/olamide &

)rin/olamide are to'ical carvonic anhydrase inhi)itorso Are licensed (or "se in 'atients resistant to )eta3

)loc%ers or those who are contraindicated with )eta

)loc%ers#

$C(-nhibitor

!enerally, it is sa(e in asthmatic 'atient# "t, it can ca"se co"hs in a)o"t 809 o( the 'atients who "se them#

This may not )e asthma )"t, it can )e con("sed with asthma#

.( the co"h is ca"sed )y AC=., it will "s"ally o away a wee% or so

a(ter the AC=. is sto''ed# ?hen co"h, then it may lead to case o( "nsta)le airways, may trier

asthma sym'toms#

The !P ad@"sts Ric%s medication in line with TS "idelines# $ix wee&s later Ric%ret"rns to the 'ractice (or review of his treatment # He is (eelin )etter# 'is pea&

!ow is %(0 l)min *rst thing in the morning and +%5 l)min in the evening his

best *gure-. He is still breathless on exertion and occasionally wa&es in the

early morning with coughing and a chest that feels tight.

The !P considers ("rther modi(yin Ric%s treatment#

Q*) 'hat further management !ould you recommend"

Chec% com'liance

Chec% dosae

Chec% inhaler techni$"e

Chec% & eliminate trier (actors smo%in smo%in cessation6

Chane 7 ste' "' to ste' B AA6

http://www.webmd.com/first-aid/coughs

http://www.webmd.com/first-aid/coughs



$ix months later Ric% is rihtly or wronly6 being prescribed inhaled salbutamol as

reuired he usually ta&es usually 200 mcg 2/% times daily-, regular inhaled

beclometasone 00 mcg)day- inhaled salmeterol 50 mcg twice daily- and oral

theophylline +50 mg daily. He has been well , witho"t morning wa&ing due to

breathlessness. 'e occasionally coughs, sometimes producing mucoid sputum. He

still smo&es# A chest 1/ray shows hyper/expanded lungs )"t no *brosis or other

a)normalities# His best pea& !ow is 500 )min#

One evenin he comes to the evenin s"rery with an exacerbation of his breathlessness

associated with a cough productive of purulent sputum. He is seen )y a loc"m !P who

on eaminin Ric% hears wheezes throughout both lung *elds# ?hen meas"red, 3ic&4s

pea& !ow is 275 l)min. E9 severe attac%6

Q+)'hat management is re,uired no!"

• Admit 'atient

•

• Hih ow oyen



• :e)"lised SAA

•

• Oral Prednisolone

• Monitor 'atient

2ollowin B days treatment the !P is called to review Ric% at home# Ric%s sym'toms have not

im'roved, indeed his 'ea% ow has (allen to 400 l7min and he (eels very )reathless at rest# His

res'iratory rate is B5 7min and '"lse is 8B 7min# ?hen tal%in he is "na)le to com'lete a ("ll

sentence#

The !P calls an am)"lance to ta%e Ric% to hos'ital and re(ers him to the Medical Admissions

Fnit where he is admitted "nder the care o( Dr Gac%son, the eneral 'hysician on call# A chest

3ray ta%en on admission shows left basal consolidation and )lood tests show-



Haemolo)in 8#4 7d 8B18I6

?hite Cell Co"nt 8J#I 80E7 1886 high6

Platelet Co"nt 8E5 80E7 8501006

Ser"m sodi"m 8BE mmol7 8BJ186

Ser"m 'otassi"m #4 mmol7 B#51#E6

Ser"m "rea K#8 mmol7 4#51J#06

Ser"m creatinine 80J Lmol7 K018806

Ser"m l"cose J#B mmol7 #3J#J6

CRP BJ m7 56 high6

Arterial lood !ases show-

'H J#B

PaO4 J#E %Pa less than I is li(e threatenin6

PaCO4 5#5 %Pa

HCOB3

remain mystery6 )"t we thin% it sho"ld )e increase

How wo"ld Ric%s asthma )est )e descri)ed at this staeN

Ac"te Severe

i(e Threatenin

Mild

Moderate

:ear 2atal

iscussion oint

How sho"ld this eacer)ation )e manaedN

• Same as manaement severe attac%

• Add inhaled i'ratro'i"m

• Consider Add anti)iotic

?hat are the li%ely in(ectin oranismsN

Stre'# Pne"monia

Haemo'hil"s .n"en/a

0



Sho"ld Ric% )e iven anti)ioticsN .( so which anti)iotics wo"ld )e a''ro'riateN

Consider

Amoicillin o(ord tet)oo%6

Macrolides anti)iotic inter(ere with theo'hylline meta)olism clinical 'harmacoloy

tet)oo%6

Ric%s sym'toms do not res'ond ade$"ately to the initial treatment with sal)"tamol,i'ratro'i"m and hydrocortisone and the admittin doctor decides to add a manesi"m

in("sion#

'ri/k( 0ask

?rite a 'rescri'tion (or an a''ro'riate initial in("sion o( manesi"m#

Rick makes a good recovery and is discharged from hospital. While he is admitted he is reviewed by the

respiratory medicine team who revise his chronic treatment.

2ive years later, Ric% oes to see his !P# He has had worsenin )reathlessness and whee/in

over the 'recedin 4 months, )oth o( which are worse on on eertion# He also has a daily

co"h 'rod"ctive o( o+3white s'"t"m# He has also noticed and increasin le oedema

'"lmonary Hy'ertension secondary to COPD6# He has contin"ed to smo%e 0 ciarettes a

day#

Ric% is a'yreial# On res'iratory a"sc"ltation the !P hears a (ew 'oly'honic whee/es# Physical

eamination is otherwise "nremar%a)le# Ric%s 'ea% ow is 4I0 l7min 'redicted 5K06 and his

oyen sat"ration on room air is EB9#

Altho"h the !P does not thin% that Ric% has an ac"te in(ection he sends )lood (or ("ll )lood

co"nt and "rea and electrolytes# The res"lts, when availa)le 4 days later, are normal# He also

sends Ric% to the local hos'ital (or s'irometry which shows Ric% to have an 2=8 09 o(

'redicted and 2=872C ratio 'ost3)ronchodilator o( 0#K#

s ick2s primary problem no! still asthma"

• COPD N P"lmonary hy'ertension, heart (ail"re, electrolyte im)alance6

dianosis o( COPD i( 2=872C 0#J Ratio 'ost3)ronchodilator o( 0#K less than 0#J6

Q B5 years old li%ely to )e COPD

Heavy smo%er

Chronic co"h with white s'"t"m

:.C=-

A dianosis o( COPD sho"ld )e considered in 'atients over the ae o( B5

who have ris% (actor smo%in6 and who 'resent with one or more o( the

(ollowin sym'toms-

8# =ertional )reathlessness4# Chronic co"hB# Re"lar s'"t"m 'rod"ction# 2re$"ent winter )ronchitis



5# ?hee/e

o!

should this

patient be managedN

• Smo%in cessation

• Consider vaccination 'ne"mococcal and in"en/a6

$re inhaled bronchodilators and steroids appropriate"

• es :.C= "ideline

• Add i'ratro'i"m

• M"colytic

• Sto' theo'hylline

'hat are the risks of inhaled steroids in this patient"

• Side e+ect o( steroids <ST=RO.DS>6 Oral candida & hoarseness

Stomach "lcer

Thin s%in



=dema

Riht and le(t heart (ail"re

Osteo'orosis

.n(ection lower res'iratory tract6

Dia)etes

Syndrome o( C"shin

Si wee%s a(ter seein his !P, Ric% is admitted to hos'ital havin 'resented to the emerency

de'artment with a B day history o( le(t3sided 'le"ritic chest 'ain and a co"h 'rod"ctive o(

reen s'"t"m# On arrival in the =D he was )reathless )"t not cyanosed, a)le to s'ea% in ("ll

sentences oyen sat"ration on room air was E09, res'iratory rate B07min"te and chest

a"sc"ltation reveals wides'read e'iratory whee/e# Ric%s GP was noted to )e elevated and

he had 'ittin oedema to the %nees# Once aain he was admitted to the medical ward "nder

Dr Gac%sons care#

The 'resence o( which clinical ndin ives the stronest indication o( the need (or hos'ital

admissionN

!reen s'"t"m

Pittin oedema to the %nee

Ple"ritic chest 'ain

Res'iratory Rate B0 7min

S'O4 E09

0



iscussion oint

?hat is yo"r di+erential dianosis o( the ac"te 'ro)lemN

• Cor '"lmonale

• Pne"monia

• Heart 2ail"re

How wo"ld yo" manae this ac"te 'resentationN

• Ta%e A!

• Chest 3ray

• lood c"lt"re

• 2"ll lood co"nt

• S'"t"m C"lt"re

• =C!

• Theo'hylline level

• F&= %idney ("nction

How wo"ld yo" treat the hy'oiaN• !ive slowly oyen II3E4 9 is the taret o( S'o46 & monitor



Ric%s admission chest 3ray is shown )elow-

3ray ndin-

• Plain Chest Radiora'h

• :ot s"re a)o"t AP7 PA

• Trachea is centrally located

• Hil"m dilated '"lmonary vessels

• "n /ones clear

• Ple"ra normal

• Costo'hrenic anle normal

• Dia'hram 2lattened Dia'hram e(t side hemidia'hram

• Heart t")"lar which indicatin heart miht )e com'ressed

• Mediastin"m not shi(ted

• one and so(t tiss"e normal

• Hy'er inated l"n I anterior ri)s6

Arterial )lood ases on 49 oyen show-

'H J#B8

Po4 K#I %Pa

Pco4 J# %Pa

HCOB3 B mmol7

iscussion oint

?hat do the )lood ases indicateN



8# Ty'e 4 res'iratory (ail"re4# Com'ensated Res'iratory Acidosis

?hat ("rther manaement sho"ld )e consideredN

• :oninvasive 'ositive3'ress"re ventilation sometimes called CPAP or iPAP6 or a

)reathin machine, i( needed#

?hat wo"ld )e the )est initial manaement ste' (or the admittin doctor to ta%e in this

caseN

!ive i'ratro'i"m )romide 500mc )y ne)"liser#

!ive sal)"tamol 500mc )y ne)"liser#

Ma%e an "rent re(erral to .CF (or non3invasive ventilation#

Prescri)e 'rednisolone 0m orally#

Start s"''lemental oyen K09 )y vent"ri mas%#

Rick recieves non-invasive ventilation in addition to bronchodilator, steroid and antibiotic therapy and makes a

good recovery from the acute exacerbation.During his convalescence Rick enquires about the possibility of having a nebuliser at home, as he has found

his nebuliser treatment very effective during his hospital stay.

Discussion Point

What are the advantages and disadvantages of home nebuliser therapy?

• Advantages:

Patient is treated at home

Continue daily activity normally

Little skill is required• Disadvantages:

Compliance

High doses bronchodilator may cause systemic effects

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Expensive

Regular maintenance

May delay seeking medical advice in a severe attack

Not portable

What alternatives are available?

• Spacer

How might he be assessed for home nebuliser therapy?

The following week Rick attends his GP's surgery for review. The GP wonders whether he might be a

candidate for long term oxygen therapy (LTOT) and resolves to discuss the possibility with the respiratory

medicine consultant.

What would be the most appropriate advice for the respiratory physician to give the GP?

LTOT is contraindicated as the patient is reliant on hypoxic drive to stimulate breathing.

LTOT is contraindicated as the patient is still smoking.

LTOT is indicated as the patient's Pao2 was <7.3 kPa during his hospital admission.

The patient should be reassessed for LTOT after a period without acute exacerbations.

The patient should receive LTOT only at night.

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