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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