1
Q
Describe Mr Craven
A
- present shortness of breath, catching breath, climbing stairs at home hairs , running for bus is hard, running for bus, slower pace on flat, no cough of phlegm or blood
- Spirometer
- Both parents smokers
- Chest infection so took amoxicillin
- 30 pack year smoking history
2
Q
What are causes of breathlessness?
A
- Lung Conditions
- Heart Conditions
- Anxiety
- Being Unfit
3
Q
Describe lung conditions
A
- Lung conditions cause breathlessness in different ways.
- Some conditions cause the airways to become inflamed and narrowed, or fill the airways with phlegm, so it’s harder for air to move in and out of the lungs.
- Others make the lungs stiff and less elastic so it’s harder for them to expand and fill with air.
4
Q
What lung conditions cause long term (chronic) breathlessness?
A
- chronic obstructive pulmonary disease (COPD) asthma
- interstitial lung disease (ILD), including pulmonary fibrosis
bronchiectasis - industrial or occupational lung diseases such as asbestosis, which is caused by being exposed to asbestos
- lung cancer
5
Q
What are some lung conditions can also cause short-term (acute) breathlessness?
A
a flare-up of asthma or COPD
1. a pulmonary embolism or blood clot on the lung
2. a lung infection such as pneumonia or tuberculosis
3 .a pneumothorax or collapsed lung
4. a build-up of fluid in your lungs or the lining of your lungs – this might be because your heart is failing to pump efficiently or may be because of liver disease, cancer or infection
6
Q
Describe heart problems
A
Some people may experience long-term breathlessness due to heart failure.
- This can be due to problems with the rhythm, valves or cardiac muscles of the heart.
- Heart failure can cause breathlessness because the heart is not able to increase its pumping strength in response to exercise, or because the lungs become congested and filled with fluid. -Often this is worse when lying flat so breathlessness due to heart failure can be worse at night or when asleep.
7
Q
What are some heart conditions that cause acute breathlessness include?
A
- a heart attack
2 .an abnormal heart rhythm. -You might feel your heart misses beats or you might experience palpitations
8
Q
Describe anxiety
A
-Some people feel short of breath when they’re anxious or afraid.
-This is a normal responseby your body to what you think is a stressful situation – your body is preparing for action.
-As you get more anxious, you may start to breathe faster and tense your breathing muscles.
-Your physical health can also impact on your mental health, especially if you are living with a lung condition.
=You might get anxious if you don’t feel in control of your condition. And if you have a condition, you may have symptoms that make you feel anxious.
-Sometimes the symptoms - like breathlessness, tightness in your chest or getting tired very easily - are similar to feelings of anxiety.
9
Q
What is a panic attack?
A
- When your body’s normal response is exaggerated, you get a rapid build-up of physical responses.
- This is a panic attack.
- As your body tries to take in more oxygen, your breathing quickens.
- Your body also releases hormones so your heart beats faster and your muscles tense.
10
Q
What happens in a panic attack?
A
During a panic attack, you might feel you can’t breathe and:
1. have a pounding heart
2. feel faint
3. sweat
4. feel sick
5. have shaky limbs
6. feel you’re not connected to your body
Panic attacks can be very frightening if you feel you can’t breathe.
11
Q
Describe being unfit
A
When we are unfit, our muscles get weaker.
This includes the muscles we use to breathe. Weaker muscles need more oxygen to work, so the weaker our muscles, the more breathless we feel.
12
Q
How can being an unhealthy weight make us feel breathless?
A
- If you’re underweight, your breathing muscles will be weaker.
- If you’re overweight, it takes more effort to breathe and move around. Having more weight around the chest and abdomen restricts how much your lungs can move.If you have a body mass indexof25 or more, you’re more likely to get breathless compared to people with a healthy weight.
13
Q
What happens to people who are severely overweight?
A
- People who are severely overweight can develop obesity hypoventilation syndrome.
- This is when poor breathing leads to lower oxygen levels and higher carbon dioxide levels in their blood.
14
Q
What are some other reasons for long term breathlessness?
A
- smoking
- conditions that affect how your muscles work, such asmuscular dystrophy, myasthenia gravis or motor neurone disease
- postural conditions that alter the shape of your spine, and affect how your ribs and how your lungs expand. For example scoliosis and kyphosis
- anaemia, when a lack of iron in the body leads to few red blood cells
- kidney disease
- thyroid disease
15
Q
What happens when you visit the doctor?
A
- You may not actually feel out of breath when you see your doctor - you’ll be sitting down and may have only walked a short distance.
- So think about how you’ll describe your breathlessness. Maybe bring someone with you who can help.
- Your doctor should show you the MRC breathlessness scale to help describe how breathless you get.
16
Q
What is the MRC breathlessness scale?
A
- The scale health care professionals usually use to measure breathlessness is the Medical Research Council (MRC) breathlessness scale
- The MRC scale does not recognise other aspects of breathlessness – such as how you think or feel about getting out of breath.
- It shows what your breathlessness stops you doing.
- Your grade is the one that describes you when you’re at your best.
17
Q
What are the grades in MRC breathlessness scale?
A
1: not troubled by breathlessness except on strenuous excursive
2: Short of breath when hurrying on the level or walking up a slight hill
3: Walks sower than most people on the level, stops after a mile or so, or stops after 15 mins walking past own pace
4: stops for breath after walking about 100 yards or after a few mins on level ground
5: too breathless to leave house or breathless when undressing
18
Q
What should the doctor also hear?
A
- what you used to be able to do that you can’t do any more
- what people of your age around you do that you think you should be able to do
- what your personal goals are for your day-to-day activity
You might find it useful to use local landmarks such as bus stops, shops and hills to help you describe these things.
If you have a phone with a camera, you could record the sort of activities that make you out of breath so you can show your doctor what it looks or sounds like.
19
Q
What doctors could you ask as the doctor?
A
- How long have you been feeling breathless and how quickly did it come on?
- Does it come and go or is it there all the time?
- Is there any pattern to your breathlessness?
- Does it start or get worse at any particular time of day?
- Does it come on or get worse when you lie flat?
- Does anything bring it on? For example, pollen, pets or medication?
- Do you smoke?
- Do you also have a cough, or bring up phlegm?
- Do you get chest pain, palpitations or ankle swelling?
- How active are you usually?
- What’s your job or occupation?
- Is your breathlessness related to certain times at work?
- Do you have a history of heart, lung or thyroid disease or of anaemia?
- Have you made any changes in your life because of your shortness of breath?
- Do you feel worried or frightened, depressed or hopeless?
- What have you done to help you cope with the way you’re feeling?
20
Q
What tests would the doctor do?
A
- do some breathing and lung function tests
- check the number of breaths you take every minute, listen to your chest, and look and feel how your chest moves as you breathe
- check your heart rate and rhythm and check if fluid is building up in your ankles or lungs
- check your blood pressure and temperature
- check your height, weight, waist and body mass index
- examine your head, neck and armpits to see if your lymph glands are swollen
- look at your eyes, nails, skin and joints
- check your blood oxygen levels with a pulse oximeter
21
Q
What extra tests may they do?
A
- a chest X-ray
- a spirometry test
- an electrocardiogram or ECG. If your breathlessness is intermittent you might be asked to wear a portable recorder for 24 hours, or seven days, to record your heart’s electrical activity
- an echocardiogram. This is a non-invasive ultrasound of your heart which can tell how well it’s working.
- blood tests to detect anaemia, allergies or any thyroid, liver, kidney or heart problems
22
Q
How long would it take to get a diagnosis?
A
- Getting a diagnosis for daily long-term breathlessness can take some time.
- Your health care professional must consider all possible causes.
- You may need to take repeated tests and try various treatments before the cause is identified.
23
Q
What investigations would they do in emergency admission?
A
- Chest radiography - to look for signs of heart failure and pulmonary pathology (including pleural effusion).
- Electrocardiography (ECG) - to look for signs of heart failure, arrhythmia, and pulmonary embolism.
- Spirometry - to look for signs of obstructive airway disease or a restrictive pattern associated with interstitial lung disease (such as idiopathic pulmonary fibrosis, sarcoidosis, pneumoconiosis, or extrinsic allergic alveolitis).
- Full blood count - to check for anaemia.
- Urea and electrolytes, and random blood glucose level - to test for renal failure and diabetes as causes of metabolic acidosis and breathlessness.
- Thyroid function tests - to detect thyroid disease as a cause of breathlessness.
- B-type natriuretic peptide (BNP)or N-terminal pro-B-type natriuretic peptide (NTproBNP) - to assess for heart failure.
If initial investigations do not identify the cause of breathlessness
-Reassess for risk factors and clinical features ofpulmonary embolism. If this is suspected, arrange urgent referral for further investigations.
24
Q
How do you distinguish asthma from COPD?
A
- Smoking history - almost always present in people with COPD.
- Age - usually older than 35 years of age for COPD.
- Chronic productive cough - common with COPD, uncommon with asthma.
- Breathlessness - progressive with COPD, variable with asthma.
- Variability of symptoms - common with asthma, uncommon with COPD.
- Night time wakening with wheeze and breathlessness - common with asthma, uncommon with COPD.
25
What are other distinguishers?
-If asthma and COPD cannot be distinguished based on clinical features, consider the following:
a large response (greater than 400 mL) to bronchodilators or prednisolone (30 mg orally per day, for 14 days) is characteristic of asthma.
-If FEV1 and the FEV1/FVC ratio return to normal with drug therapy, clinically significantly COPD is not present.
-Significant diurnal or day-to-day variability of serial peak flow measurements suggest asthma.
If doubt still remains, refer the person for a specialist's opinion.
-For people with COPD, arrange chest radiography to exclude other serious lung pathology (such as lung cancer) and check the full blood count to identify anaemia or polycythaemia.
26
What do you do if suspected heart failure?
- Perform an ECG for all people with suspected heart failure.
- For people without a history of MI, check B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NTproBNP) and refer to specialist assessment and echocardiography appropriately if raised above agreed levels for referral.
- For people with a history of MI, refer directly for urgent specialist assessment (to be seen within 2 weeks)
27
What do you do for suspect bronchiectasis?
1. Arrange chest radiography to exclude other causes for the symptoms
2. Refer all people with suspected bronchiectasis to a respiratory specialist for confirmation of the diagnosis (by high resolution computed tomography scanning).
3. See CKS topic Bronchiectasis
28
What happens if suspected lung/pleural cancer?
- Arrange an urgent chest X-ray (to be performed within 2 weeks) in people aged 40 years and over with breathlessness if:
- They have ever smoked; or
- They have been exposed to asbestos; or
- They have any of the following unexplained symptoms; cough, fatigue, chest pain, weight loss, appetite loss
29
When else should an urgent chest X-ray (to be performed within 2 weeks) should also be considered in people aged 40 years and over?
1. Persistent or recurrent chest infection.
2. Finger clubbing.
3 .Supraclavicular lymphadenopathy or persistent cervical lymphadenopathy.
4. Chest signs consistent with lung cancer or pleural disease.
5. Thrombocytosis.
6. Suspected abdominal splinting secondary to ascites.
7. Arrange an abdominal ultrasound scan to confirm the presence of ascites and to exclude or confirm liver cirrhosis and peritoneal cancer.
8. Arrange other investigations guided by clinical findings (for example liver function tests or erythrocyte sedimentation rate; for signs of cancer).
9. Awaiting results of investigations should not delay urgent referral if cancer is suspected.
30
What are the possible respiratory differential diagnosis?
1. Asthma
2. COPD
3. Pulmonary fibrosis
4. Lung Cancer
5. Pulmonary embolism
6. Pneumothorax
7. Lower respiratory tract infection
31
What are the possible cardiovascular / systemic differential diagnosis?
1. Congestive heart failure
2. Pulmonary oedema
3. Valvular defects
4. Acute coronary syndrome
5. Anaemia
6. Renal or liver failure
7. Deconditioning
8. Arrythmia
9. Postural conditions e.g. scoliosis
10. Conditions affects muscles
32
What happens in obstructive chronic bronchitis?
1. Inflammation and swelling further narrows airway
| 2. Thick and sticky mucus blocks up the airways rather than clears
33
What happens in emphysema?
1. Air becomes trapped
| 2. Air exchange becomes difficult in damaged alveoli
34
What are the signs of hyperinflation?
1. More than 7 anterior rubs visible in mid clavicular line (although this is not particularly sensitive)
2. Flattening of the diaphragm (may be more sensitive sign)
3. Heart may appear small and arrow sometimes with air visible below the inferior border (floating hear sign)
35
What are bullae?
- Air filled applies with thin walls, bordered only by remnants of alveolar septa or pleura
- Often caused by emphysema
36
How to look for bullae?
- Areas of low density (black = lots of air
| - May be outlined resembling bubbles
37
What are the two types of rescue therapy?
1. Short acting beta agonists (SABA)
- Salbutmaol (Ventolin)
2. Short acting muscasrinic antagonists (SAMA)
- Ipratropium bromide (Atrovent)
38
What are two types of maintenance therapy?
1. Long acting beta agonists (LABA)
- Formoterol, salmeterol (Serevent)
2. Long acting muscarinic antagonists (LAMA)
- Tiotropium (Spiriva) Glycopyrronium
39
What are inhaled corticosteroids (ICS)?
1. Alone - not licensed in COPD (Beclometasone, Fluticasone (Flixotide))
2. in combo e.g. with a LABA
Flutcsone + vilaterol (together = Relvar
40
What are the different combinations?
- Numerous different inhaler devices exist
- Numerous dirt combinations exist within a single inhaler
1. SABA + SAMA
2. LABA + LAMA
3. LABA + ICS
4. LABA + LAMA + ICS
41
What are some withdrawal symptoms of smoking cessation?
1. nicotine cravings
2. irritability
3. depression
4. restlessness
5. poor concentration
6. light-headedness
7. sleep disturbances
8. increased appetite
42
What is non-drug treatment?
-Abrupt putting offers best chance of success with combo drug treatment and behavioural support
43
What is drug treatment?
1. Nicotine replacement therapy (NRT)
2. varenicline
3. bupropion hydrochloride
44
What are the most effective treatments?
1. Varenicline
2. mbination of long-acting NRT (transdermal patch) and short-acting NRT (lozenges, gum, sublingual tablets, inhalator, nasal spray and oral spray)
3. If these options are not appropriate, bupropion hydrochloride or single therapy NRT should be considered instead.
45
What are different patches?
- Nicotine transdermal patches are generally applied for 16 hours, with the patch removed overnight; if smokers experience strong nicotine cravings upon waking, a 24-hour patch can be used instead
- Short-acting nicotine preparations are used whenever the urge to smoke occurs or to prevent cravings; there is no evidence that one form of NRT is more effective than another. 1. The use of NRT combined with varenicline or bupropion hydrochloride is not recommended, and both varenicline and bupropion hydrochloride should not be prescribed together.
46
What is harm reduction approach?
1. Harm reduction approaches include stopping smoking whilst using NRT to prevent relapse, and smoking reduction or temporary abstinence with or without the use of NRT
2. These smokers should be advised that NRT will make it easier to reduce how much they smoke and improve their chance of stopping smoking in the long-term.
47
What are E cigarettes?
1. E-cigarettes deliver nicotine without the toxins found in tobacco smoke
3. Evidence suggests that e-cigarettes are substantially less harmful to health than tobacco smoking, but long-term effects are still largely unknown
3. Cannot be prescribed or supplied by smoking cessation services
4. not licensed drugs, they are regulated by the Tobacco and Related Products Regulations 2016. (18 age)
48
How is pregnancy important?
1. Pregnant females should be advised to stop smoking completely, and be informed about the risks to the unborn child of smoking during pregnancy, and the harmful effects of exposure to second-hand smoke for both mother and baby
2. All pregnant females who smoke or have stopped smoking in the last 2 weeks should be referred to their local NHS Stop Smoking Services, and ongoing support should be offered during and following pregnancy.
4. Smoking cessation should also be encouraged for all members of the household.
49
When should NRT be used in pregnancy?
1. NRT should only be used in pregnant females if non-drug treatment options have failed
2. Clinical judgement should be used when deciding whether to prescribe NRT following a discussion about its risks and benefits
3. Subsequent prescriptions should only be given to pregnant females who have demonstrated they are still not smoking.
50
What re concomitant drugs?
1. Polycyclic aromatic hydrocarbons found in tobacco smoke increase the metabolism of some drugs by inducing hepatic enzymes, often requiring an increase in dose
2. Information about drugs interacting with tobacco smoke can be found under Interactions of the relevant drug monograph.
51
What is NRT?
1. The main reason that people smoke is because they are addicted to nicotine.
2. NRT is a medication that provides you with a low level of nicotine, without the tar, carbon monoxide and other poisonous chemicals present in tobacco smoke.
3. It can help reduce unpleasant withdrawal effects, such as bad moods and cravings, which may occur when you stop smoking.
52
Where do you get NRT from and how do you use it?
1. NRT can be bought from pharmacies and some shops
| 2. It's also available on prescription from a doctor or NHS stop smoking service
53
What is NRT available as?
1. skin patches
2. chewing gum
3. inhalators (which look like plastic cigarettes)
4. tablets, oral strips and lozenges
nasal and mouth spray
54
What re the different types of NRT used as?
1. Patches release nicotine slowly. Some are worn all the time and some should be taken off at night
2. Inhalators, gum and sprays act more quickly and may be better for helping with cravings.
3. There’s no evidence that any single type of NRT is more effective than another. But there is good evidence to show that using a combination of NRT is more effective than using a single product.
4. Often the best way to use NRT is to combine a patch with a faster acting form such as gum, inhalator or nasal spray.
5. Treatment with NRT usually lasts 8-12 weeks, before you gradually reduce the dose and eventually stop.
55
Who can use NRT?
Most people are able to use NRT, including:
1. adults and children over 12 years of age – although children under 18 should not use the lozenges without getting medical advice first
2. pregnant women – your doctor may suggest NRT if they think it would help you quit; read more about stopping smoking in pregnancy
breastfeeding women – your doctor can advise you how to do this safely
3. Always read the packet or leaflet before using NRT to check whether it's suitable for you.
4. Sometimes it may be advisable to get medical advice first, for example if you have kidney or liver problems, or you've recently had a heart attack or stroke.
56
What are the possible side effects of NRT?
1. skin irritation when using patches
2. irritation of nose, throat or eyes when using a nasal spray
3. difficulty sleeping (insomnia), sometimes with vivid dreams
4. an upset stomach
5. dizziness
6. headaches
Any side effects are usually mild. But if they're particularly troublesome, contact your GP as the dose or type of NRT may need to be changed.
57
What is Vareicline (champix)?
- Varenicline (brand name Champix) is a medicine that works in 2 ways. It reduces cravings for nicotine like NRT, but it also blocks the rewarding and reinforcing effects of smoking.
- Evidence suggests it's the most effective medicine for helping people stop smoking.
58
Where do you get Vareicline and how do you use it?
- Varenicline is only available on prescription, so you'll usually need to see your GP or contact an NHS stop smoking service to get it.
- It's taken as 1 to 2 tablets a day. -You should start taking it a week or 2 before you try to quit.
- A course of treatment usually lasts around 12 weeks, but it can be continued for longer if necessary.
59
Who can use Vareicline?
```
-Varenicline is safe for most people to take, although there are some situations when it's not recommended.
For example, it's not suitable for:
1. children under 18 years of age
women who are pregnant or breastfeeding
2. people with severe kidney problems
```
60
What are possible side effects of Vareicline?
Side effects of varenicline can include:
1. feeling and being sick
2. difficulty sleeping (insomnia)
3. sometimes with vivid dreams
4. dry mouth
5. constipation or diarrhoea
6. headaches
7. drowsiness
8. dizziness
9. Speak to your GP if you experience any troublesome side effects.
61
What is Bupropion (Zyban)?
- Bupropion (brand name Zyban) is a medicine originally used to treat depression, but it has since been found to help people quit smoking.
- It's not clear exactly how it works, but it's thought to have an effect on the parts of the brain involved in addictive behaviour.
62
Where do you get Bupropion (Zyban)?
- Bupropion is only available on prescription, so you'll usually need to see your GP or contact an NHS stop smoking service to get it.
- It's taken as 1 to 2 tablets a day. You should start taking it a week or 2 before you try to quit.
- A course of treatment usually lasts around 7 to 9 weeks.
63
Who can use Bupropion (Zyban)?
1. Bupropion is safe for most people to take, although there are some situations when it's not recommended.
2. For example, it's not suitable for:
- children under 18 years of age
- women who are pregnant or breastfeeding
- people with epilepsy, bipolar disorder or eating disorders
64
What are the possible side effect of bupropion?
1. dry mouth
2. difficulty sleeping (insomnia)
3. headaches
4. feeling and being sick
5. constipation
6. difficulty concentrating
7. dizziness
65
How might E Cigarettes affect you?
1. An e-cigarette is an electronic device that delivers nicotine in a vapour.
2. This allows you to inhale nicotine without most of the harmful effects of smoking, as the vapour contains no tar or carbon monoxide.
3. As with other approaches, they're most effective if used with support from an NHS stop smoking service.
4. There are no e-cigarettes currently available on prescription.
5. For now, if you want to use an e-cigarette to help you quit, you'll have to buy one. Costs of e-cigarettes can vary, but generally they're much cheaper than cigarettes.
66
What some questions you would ask to identify if respiratory / systemic?
1. Productive cough? If yes, blood in sputum?
- Lung cancer, fibrosis, chronic infection
2. Chest pain?
- Cardiovascular problems, pulmonary embolism, pneumothorax
3. Breathless when laid down? Waking at night due to breathlessness?
- Congestive heart failure, pulmonary oedema
4. Swelling of the ankles?
- Congestive heart failure
5. Family history of heart disease?
67
What are some things you would notice with physical visual examination?
- Pale
- Cyanosis (blue tinge to lips) – hypoxia
- Breathing rate – panting?
- Hyperinflated chest
- JV pulsations – should be <5cm above the suprasternal notch, higher if problems in right heart
68
What are some things you would notice with physical visual examination?
- Feeling with hands
- Auscultations of heart and breath sounds
1. Crackles (indicates bronchitis, heart failure, infections)
2. Wheezes (due to turbulence of air, indicates bronchoconstriction)
3. Added valvular sounds
4. Heart murmurs
69
What tests/investigations would be carried out?
1. Spirometry
- Obstructive airway disease or restrictive patterns associated with interstitial lung disease
2. Chest radiography
- Congestive heart failure and pulmonary effusion
3. ECG
- Heart failure, arrhythmia and pulmonary embolism
4. Full blood count
- Anaemia, polycythaemia, inflammatory markers (CRP), signs of infection (neutrophilia)
5. Urea and electrolytes, and random blood glucose
- Renal failure and diabetes
6. Thyroid function tests
- Thyroid disease
7. B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NTproBNP)
- Heart failure
70
What are Mr Craven's spirometry results?
• Mr Craven’s spirometry FEV1 = 2.2L, FVC = 4L. FEV1/FVC ratio = 0.55
-Indicates obstructive disease
71
What are signs of restrictive diseases?
low FEV1 and FVC, normal FEV1/FVC ratio
72
What are examples of restrictive disease?
```
o Obesity
o Neuromuscular conditions stopping chest wall movement
o Pneumothorax or pleural effusion
o Oedema
o Scoliosis
o Cancer
o Pulmonary fibrosis
```
73
What are signs of obstructive disease?
low FEV1 and FVC, low FEV1/FVC ratio
74
What are examples of obstructive disease?
o Narrowing of airways obstructs air flowing out
| o COPD, asthma, cystic fibrosis, bronchiectasis
75
What is COPD?
a group of lung conditions that make it difficult to remove air from the lungs due to narrowing of the airways
76
What is chronic bronchitis?
chronic inflammation of the bronchi (macrophages, T cells and plasma cells present, hyperplasia of goblet cells and smooth muscle)
77
What is emphysema?
breakdown of alveolar walls (due to the enzymatic action of inflammatory response)
78
What is the narrowing of airways caused by?
- Damage to lung tissue – less pull on the airways
- Blocked by mucus
- Inflammation and swelling of the airway linings
79
What are the risk factors of COPD?
1. Smoking
2. Age (>35)
3. History of chest problems as a child
4. α1-antitrypsin deficiency (rare genetic condition – emphysema)
5. Air pollution
6. Jobs that expose you to dust/fumes/chemicals
80
What is the diagnosis of spirometry?
o FEV1 less than 80% of the predicted value
| o FEV1/FVC ratio less than 70% of the predicted value
81
What is the diagnosis of X rays?
o Hyperinflation
-Flattened angle of clavicle
-Depressed diaphragm
o Bullae – air-filled spaces with thin walls, bordered only by remnants of alveolar septae or pleura (often caused by emphysema)
82
What is COPD vs asthma based on clinical features?
o Smoking history common with COPD
o Age (usually older than 35)
o Chronic productive cough common with COPD
o Progressive breathlessness in COPD (variable in asthma)
o Night time wakening from wheezing and breathlessness is uncommon with COPD
83
What are other ways to distinguish between COPD and asthma?
o Asthma typically shows a large response (>400mL) to bronchodilators or prednisolone
o With COPD, drug therapy will not cause the FEV1 and FEV1/FVC ratio to return to normal
o Significant diurnal variability in peak flow suggests asthma
84
What are the different ways to treat COPD?
1. Support to stop smoking
- Nicotine patches, gum, counselling/support
2. Annual flu jab and pneumonia vaccination
- At greater risk of diseases such as flu and pneumonia
3. Pulmonary rehabilitation (exercise and education programme)
- 6-8 weeks
- Exercise, breathing techniques, stress management, healthy eating, how to use inhalers and other medications, what to do if unwell
4. Development of a self-management plan
5. Diet/nutrition
- Ensure a healthy weight is maintained – may have unintended weight loss and muscle wastage, or may be overweight already so need to lose weight
6. Keeping well in the cold
- Try to keep warm to minimize temperature changes
- Keep humidification higher
7. Managing comorbidities
- Heart disease, diabetes, muscle and joint problems, anxiety and depression are common comorbidities
8. Medications
9. Oxygen therapy
10. Non-invasive ventilation
11. Surgery
- Lung volume reduction (emphysema) to reduce the amount of air trapped in the lungs
- Lung transplants
85
What mediations could be used?
o Inhaled bronchodilators
-Short acting beta agonists – salbutamol (Ventolin)
-Short acting muscarinic antagonists – ipratropium bromide (Atrovent)
-Long acting beta agonists – formoterol, salmeterol (Serevent)
-Long acting muscarinic antagonists – tiotropium (Spirivia), glycopyrronium
o Inhaled corticosteroids
o Mucolytic drugs
86
What are the fundamentals of COPD?
* Offer treatment and support to stop smoking
* Offer pneumococcal and influenza vaccinations • Offer pulmonary rehabilitation if indicated
* Co-develop a personalised self-management plan
* Optimise treatment for comorbidities
87
When do you start inhaled therapies?
- all the above interventions have been offered
(if appropriate), and
• inhaled therapies are needed to relieve breathlessness
and exercise limitation, and
• people have been trained to use inhalers and can
demonstrate satisfactory technique
-OFFER SABA OR SAMA TO USE AS NEEDED
88
What happens when the person is limited by symptoms or has exacerbations despite treatment?
1. No asthmatic features or features suggesting steroid responsiveness (Asthmatic features/features suggesting steroid responsiveness in this context include any previous secure xxdiagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time (at least 400 ml) or substantial diurnal variation in peak expiratory flow (at least 20%).
- Offer LABA and LAMA
2. Asthmatic features or features a suggesting steroid responsiveness
- Consider LABA + ICSb
89
What happens when offer LABA and LAMA?
1. Person has day-to-day symptoms that adversely impact quality of life
-Consider
3-month trial of b,c LABA + LAMA + ICS
If no improvement, revert to
LABA + LAMA
2. Person has 1 severe or 2 moderate exacerbations within a year
-Consider b,c LABA + LAMA + ICS
90
What happens after offering LABA + ICSb?
1. Person has day-to-day symptoms that adversely impact quality of life, or has 1 severe or 2 moderate exacerbations within a year
-Offer LABA + LAMA + ICS (Be aware of an increased risk of side effects (including pneumonia) in people who take ICS, Document in clinical records the reason for continuing ICS treatment.)
(Explore further treatment options if still limited by breathlessness or subject to frequent exacerbations (see guideline for more details)
Z YEAR 1 CSI Cases
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Decks in class (11)
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