ASTHMA & COPDBy Laura Parker

Learning Objectives To be able to define Asthma and COPD To have an understanding of the

pathogenesis of each disease and the common causes / risk factors associated

To be able to recognise the presentation of patient with Asthma or COPD

To be able to manage an acute exacerbation of Asthma / COPD

To understand the long term management options available for clinicians for Asthma / COPD

ASTHMA

Definition Asthma: chronic inflammatory disease of the lungs

characterised by airway obstruction that is reversible

Extrinsic Immune Onset childhood Eosiniphilia blood & sputum

Intrinsic Abnormal autonomic reulation of airways Onset Adulthood Eosinophilia sputum Assoc w/ chronic bronchitis

Pathogenesis

Incidence & Aetiology• 5.4 million receive treatment UK (~5%)• Most common chronic medical condition

in children

• Risk Factors• Personal history of atopy• Family history of asthma or atopy

PresentationSYMTPOMS SIGNS• Wheeze• Cough• Difficulty breathing• Chest tightness• ?diurnal variation• ?triggers• ?atopy

• Normal between attacks

• Prolonged expiration• Wheeze

Respiratory distress

Recognising a sick patient…

Differentials I G V I T A M I N D

Idiopathic or Iatrogenic

Genetic: Vascular: Infective: Trauma: Autoimmune: Metabollic: Inflammatory: Neoplastic: Degenerative:

Differentials Anaphylaxis eg penicillin allergic patient given

penicillin alpha 1 Antitrypsin disease PE, Anaemia Pneumonia, Bronchiectasis Tension pneumothorax Autoimmune: Metabollic: COPD, Asthma Lung Ca Fibrosis

InvestigationsInpatient• Peak flow• Sputum • Urine• Bloods• ABG• ECG• CXR• Pulmonary Function Tests• +/- further imaging ( CT, HRCT)

Investigations

Management: Acute Exacerbation

A,B,C,D,E…• OXYGEN

• Sats 94-98%

• NEBS• BETA AGONIST• IPRATROPIUM

• STERIODSoral / IV • +/-

• IV MgSO4• ABX if suspicious infective exacerbation

Long Term Management Asthma

Aims: No symptoms during the day No waking at night due to symptoms No exacerbations No need for rescue medication No exercise limitation Normal lung function

Long Term Management Asthma

Yearly Asthma Review Smoking status Triggers and avoidance Concordance Inhaler technique Stepwise approach….

Long Term Management Asthma

COPD

Definitions Chronic Obstructive Pulmonary Disease

(COPD): collective term for an inflammatory lung disease in which airway obstruction is progressive and only partially reversible by bronchodilators

Chronic Bronchitis: persistent cough with sputum production for > 3months/year for 2 years

Emphysema: permanent enlargement of air spaces distal to the terminal bronchiole due to alveolar septal destruction

Pathophysiology

Incidence & Aetiology Est 3 million people UK Prevalence 1.5% population

Risk factors• SMOKING (effects approx 15% smokers)• Increases with age• More common in men• More common deprived communities

PresentationSYMPTOMS SIGNS• Wheeze• Chronic cough• SOBOE• Regular sputum

production• Frequent winter

'bronchitis”• ? >35yrs old• ?hx of smoking

• Pink puffers / blue bloaters

• Respiratory distress• Hyper-expansion• Hyper-resonant• Prolonged expiration• Wheeze

Differentials Anaphylaxis eg penicillin allergic patient given

penicillin alpha-1 Antitrypsin PE, Anaemia Pneumonia, Bronchiectasis Tension pneumothorax Autoimmune: Metabollic: COPD, Asthma Lung Ca Fibrosis

Investigations Inpatient• Peak flow• Sputum • Urine• Bloods• ABG• ECG• CXR• Pulmonary Function Tests• +/- further imaging ( CT, HRCT)

Acute Exacerbation COPDA,B,C,D,E Controlled oxygen therapy

Aim Saturations 88-92% Nebulised bronchodilators Oral corticosteroids

+/- ABX  NIV

Long Term Management of COPD

Multi-Disciplinary Smoking CessationVaccination

Long Term Management COPD Mucolytics

Oral bronchodilators eg theophylline (nb narrow therapeutic window)

therapeutic range of theophylline is 10-20 mg/litre

Oxygen LTOT / SBOT

NIV

Surgery: bullectomy, lung volume reduction surgery and lung transplantation

Learning Objectives To be able to define Asthma and COPD To have an understanding of the

pathogenesis of each disease and the common causes / risk factors associated

To be able to recognise the presentation of patient with Asthma or COPD

To be able to manage an acute exacerbation of Asthma / COPD

To understand the long term management options available for clinicians for Asthma / COPD

How to Use an Inhaler1. Remove cap 2. Shake the device3. If you have not used the inhaler for a week or more, or it is the first

time you have used the inhaler, spray it into the air before using to check that it works

4. Hold the inhaler upright with you forefinger on the top5. Big breath out6. Place the mouthpiece in your mouth between your teeth, and close

your lips around it7. Start to breathe in slowly and deeply, at the same time, press down

on the canister releasing a “mist”8. Hold your breath for as long as is comfortable, then breathe out as

normal. 9. If you need 2 puffs, wait 30 seconds then repeat10. Do not release two puffs at the same time11. Replace cap

SmokingAccurate HistoryPack year = no. cigarettes smoked per day X no. years smoked20

Assess “readiness to change”Cessation

Nicotine Replacement Therapy• Patches

• Bupropion (nb reduces seizure threshold)• Varenicline (champix) (nb use in caution in a Pt w/

psych hx)• E-cigarettes: evidence controversial, recent BMJ

article suggest they encourage and glamourize smoking, not available by prescription at present

Case Study (1)A 64 year old gentleman presents to A&E with increasing SOB over the last 3 days. This is associated with a cough productive of thick, green sputum. He has a past medical history of “asthma”, but he has smoked 50 cigarettes a day for the past 40 years. Obs: RR 30 O2 sats 85% on 21% HR 120 BP 138/82. O/E he is using his accessory muscles to breathe, bilateral diffuse coarse crepitations and widespread wheeze

Questions Differential diagnoses? Initial management? Investigations? Treatment?

Case Study (2)Patient is successfully treated for infective exacerbation of COPD and discharged from hospital. You see him in your GP surgery a few weeks later for a medication review. How may you optimise the management of this patient?

References http://emedicine.medscape.com/article/296301-overview http://www.patient.co.uk/doctor/bronchial-asthma British Guideline on the Management of Asthma. British Thoracic

Society and the Scottish Intercollegiate Guidelines Network. (Revised January 2012). Available online at http://www.brit-thoracic.org.uk 

Regulation in chronic obstructive pulmonary disease: the role of regulatory T-cells and Th17 cells: Nina Lane*, R. Adrian Robins*, Jonathan Corne† and Lucy Fairclough* Clinical Science (2010) 119, (75–86)

Chronic Obstructive Pulmonary Disease (2010). Clinical Gudeline 101. National Institute for Health and Care Excellence. Available online athttp://www.nice.org.uk/CG101 

How to use inhaled devices: http://www.medicines.org.uk/guides/pages/how-to-use-your-inhaler-videos

BNF

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