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Respiratory Flashcards

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1
Q

What is asthma?

A

Chronic inflammation of the airways- the smooth muscles tighten and air is trapped in alveoli
Increased airway hypersensitiveness
Reversible with salbutamol

Obstructive disease

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2
Q

What are the symptoms of asthma?

A

Wheezing, SOB, chest tightness at night/early morning

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3
Q

What can trigger asthma?

A

Antigens
Allergens
Smoke/perfumes

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4
Q

What are the problems associated with caring for those with asthma?

A
  • Still causing deaths
  • Underprescribing of preventer therapy
  • Inappropriate LABA monotherapy- guidelines do not recommend this
  • Personal action plans not provided to all patients
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5
Q

How do you diagnose asthma?

A
  • Look at symptoms and age

Lung function test: FEV1/FVC ratio < 70%

Peak expiratory flow- normal calculated score depends on age, height, gender and ethnicity. If this is significantly different, it may be asthma

Reversibility testing- give them salbutamol and see if lung function improves - should be at least 12-20%

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6
Q

What is FEV1?

A

Volume of air patient is able to exhale in 1st second of expiration
should be 70% of total lung volume

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7
Q

What is FVC?

A

Total volume of air patient can forcibly exhale in one breath

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8
Q

What is peak expiratory flow?

A

Person’s max speed of expiration

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9
Q

A patient who is thought to have asthma is given salbutamol in a reversibility test. However, lung function does not improve. What could the patient have?

A

Irreversible condition e.g. COPD

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10
Q

What are the 7 aims of asthma therapy?

A
  1. To control disease
  2. No daytime symptoms
  3. No sleep disturbances
  4. No need for rescue meds
  5. No exacerbations including infections
  6. No limitations on activity
  7. FEV1>80%
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11
Q

What are the BTS/SIGN asthma guidelines?

A

Should all be on SABA PRN

  1. Low dose ICS- regular preventer to use every day
  2. LABA/ICS combo
  3. If no response to LABA, stop and increase ICS dose OR if response to LABA, use medium dose ICS. If inadequate response, add in 3rd drug - LRTA, LAMA or SR theophylline

Steps 4 and 5 refer to specialist care:

  1. High dose ICS or add in 4th drug- LRTA, LAMA, SR theophylline or beta agonist tablet.
  2. Daily steroid oral tablet (lowest dose that controls condition) as well as maintaining high dose ICS. Consider other treatment options to minimise oral steroid tablet use
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12
Q

Theophylline is not used as much in asthma now. Why?

A

Requires therapeutic drug monitoring due to narrow therapeutic index, and it is hard to get the ideal dose for patients.

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13
Q

When is a review needed for a patient on salbutamol?

A

If they are using it >QDS regularly

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14
Q

What are the SABA options for asthma patients?

A

Salbutamol 100 mcg 2 doses PRN up to QDS

Terbutaline turbohaler 500 mcg 1 dose PRN

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15
Q

What type of inhaler is a turbohaler?

A

DPI

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16
Q

What are the ICS options for asthma patients?

A

ALL BD doses

Clenil MDI (beclomethasone) 100-200 mcg 2 doses BD

Pulmicort Turbohaler (budesonide) 100-200 mcg 2 doses BD

Flixotide MDI or accuhaler (fluticasone) 50-100 mcg BD

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17
Q

What are the ICS/LABA combination inhalers for asthma patients?

A

ALL BD doses

  • Seretide MDI or accuhaler (fluticasone/salmeterol) 500/50 mcg BD
  • Symbicort turbohaler (budesonide/formoterol) BD
  • Fostair MDI (beclomethasone/formoterol) MDI 2 doses bd
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18
Q

LABA monotherapy is recommended in asthma. True or false?

A

False- needs an ICS

Usually in a combo inhaler

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19
Q

What type of inhaler is an accuhaler?

A

DPI

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20
Q

Seretide MDI is licensed in COPD. True or false?

A

False- the MDI is only licensed in asthma

Accuhaler is licensed in both

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21
Q

What is a disadvantage of a DPI?

A

Breath actuated, need to have respiratory effort for it

If not, MDI is more appropriate

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22
Q

What is the only LAMA licensed in asthma?

A
  • Tiotropium bromide Respimat (spiriva) 5mcg OD

Not the capsule one

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23
Q

When are biologics used in asthma?

A
  • Severe, last resort AND patients need to have been adherent to previous treatment
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24
Q

Why are biologics used in asthma?

What is the MOA of mepolizumab?

What is the MOA of reslizumab?

A
  • As allergens get through airway epithelium, it activates IL33 pathway
  • Mepolizumab - anti IL5 monoclonal antibody to decrease eosinophil production
  • Reslizumab interferes with IL5 binding to decrease activity and survival of eosinophil (WBC)
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25
What is some other management of asthma?
- Self-management plan and rescue pack of corticosteroids and antibiotics - Peak flow meter to see if lung function is getting worse - Smoking cessation - Flu vaccine - Review therapy every 3-6 months and adherence - Allergy avoidance - Weight control - Inhaler technique - Asthma control test
26
How do you use a peak flow meter?
1. Stand up and take a deep breath. Hold device horizontally. Make sure the pointer is on zero 2. Breath into device hard and fast 3. Take reading and repeat 3 times, taking the highest reading
27
What peak flow reading would indicate an asthma attack?
200 | call 999
28
What would an asthma patient do if their peak flow is lower than expected?
Use ICS more frequently for 2/3 days and SABA PRN.
29
What would an asthma patient do if their peak flow is higher than expected?
Continue on baseline ICS and SABA treatment
30
How can being overweight make a respiratory condition worse?
Fat pushing down on lungs - SOB
31
If an asthma has a PMH of allergies and still symptomatic despite asthma treatment, what additional diagnosis would you consider?
Rhinosinusitis
32
GORD can cause exacerbations of asthma. True or false?
True
33
What is COPD?
Chronic obstructive pulmonary disease Not fully reversible FEV1/FVC< 70% Progressive and chronic Permanently smaller lung vessels
34
What two conditions comes under COPD?
Bronchitis Emphysema
35
What is bronchitis?
Thick, sticky, mucous blocks airways instead of cleaning it Inflammation and swelling of narrow airways
36
What is emphysema?
Air exchange becomes difficult in damaged alveoli Air becomes trapped
37
What are symptoms of COPD?
SOB - MRC score Coughing up sputum- what colour? Chest tightness Persistent cough
38
How do you diagnose COPD?
- FEV1/FVC ratio < 70% - Symptoms - Occupational hazards e.g. open fires - History of smoking- pack years calculation - Chest X-Ray or CT scan - Arterial blood gas test
39
How do you calculate pack years? What number of pack years would indicate severe disease?
(no of cigs a day x 20)/No of years smoked for 100
40
What are the differences between COPD and asthma in terms of: 1. Age 2. Symptoms 3. Attack triggers 4. Smoking history 5. Freedom of symptoms between attacks 6. Night time awakening of SOB
1. Asthma <35 years and COPD > 35 years 2. Asthma- SOB, wheezing COPD - SOB, chronic cough, sputum 3. Asthma's attack triggers are common and marked whereas with COPD it is less so 4. Asthma smoking history could be anything, with COPD, smoking is common 5. Asthma has freedom of symptoms between attacks whereas COPD does not 6. Asthma- common but COPD- uncommon
41
What are the 4 stages of COPD?
Mild COPD or Stage 1—Mild COPD with a FEV1 about 80 percent or more of normal. Moderate COPD or Stage 2—Moderate COPD with a FEV1 between 50 and 80 percent of normal. Severe COPD or Stage 3—Severe emphysema with a FEV1 between 30 and 50 percent of normal. Very Severe COPD or Stage 4—Very severe or End-Stage COPD with a lower FEV1 than Stage 3, or people with low blood oxygen levels and a Stage 3 FEV1 Ratio < 30 %
42
What is a disadvantage of NICE guidelines for COPD treatment?
Do not take into account the phenotypes (breathlessness and frequent exacerbation)
43
What do you need to consider for exacerbations in COPD?
- How far apart are they? If close together, they may just be one exacerbation - ICS only for exacerbations not SOB
44
What is the MRC dyspnoea score?
SOB when: 1. Strenuous exercise 2. When uphill 3. Walks slower because of SOB 4. Stops after 100m walking 5. Too SOB to leave house and do daily activities e.g. dressing
45
What are the 4 aims of COPD treatment?
1. Manage symptoms 2. Decrease frequency and severity of exacerbations 3. Slow decline in lung function 4. Prolong quality of life
46
What are the SABA options in COPD?
Salbutamol 100 mcg 2 doses PRN up to QDS Terbutaline turbohaler 500 mcg 1 dose PRN
47
What is the SAMA option in COPD?
Ipratropium
48
Indacaterol breezhaler is what type of agonist? It is only licensed in COPD. True or false?
LABA True
49
What are the LABA options in COPD?
Indacaterol Breezhaler 150-300mcg OD Salmeterol MDI or accuhaler 50 mcg BD Formoterol Turbohaler 12 mcg BD
50
What is the best LAMA option in COPD and why, and what must you do if the patient is on a SAMA?
Stop SAMA Tiotropium respimat Spirivia 5 mcg OD - only one not a DPI. COPD patients have a low respiratory effort so DPI may not be appropriate
51
What are the ICS/LABA combo options in COPD?
1st line- Relvar elipta (fluticasone/vilanterol) OD dose ``` Seretide accuhaler (fluticasone/salmeterol) 500/50 mcg BD MDI is not licensed ```
52
What are the LAMA/LABA combo options in COPD?
1st line- Ultibro (glycopyronium/indacaterol) breezhaler DPI Spiolto respimat (tiotropium/olodaterol) - only one not a DPI
53
What do the guidelines say about ICS monotherapy in COPD?
- No benefit - Always needs to be with a LABA combo - Increased risk of side effects and pneumonia
54
What is the other management points for COPD?
- Flu vaccines - Smoking cessation - Hypoxia can occur in COPD - oxygen therapy - Pulmonary rehab - Self management plan - COPD assessment test (CAT) - 10 point questionnaire to show how well symptoms are being managed
55
How many hours in the day do you have oxygen therapy in COPD? What are the oxygen sats target compared to a healthy person and why?
Minimum 15 hrs/day 88-92% compared to 98% to decrease risk of hypercapnia (too much carbon dioxide, acidosis)
56
What is pulmonary rehab? How bad does the COPD have to be?
- 8 week course with personalised exercises to increase QOL and exercise capacity - Can help SOB - MRC of at least 3 or hospital admission exacerbation
57
What can be used in COPD patients where sputum production is a problem? What do they do?
Mucolytics e.g. carbocysteine,NAC Decreases sputum viscosity and aids expectoration
58
What do you need to consider when prescribing inhalers?
- Is it licensed for the indication? - Cost - What spacers are licensed - Can they use an inhaler? e.g. Arthritis - Patient's preference - Prescribe by brand
59
What is Anna Murphy's 7 steps for inhaler use?
1. Prepare inhaler device 2. Prepare load dose 3. Breathe out 4. Put lips around mouthpiece 5. Breathe in correctly 6. Remove inhaler from mouth and hold and breath in for 5-10 seconds 7. Repeat as directed and finish
60
What is a disadvantage of MDI?
Need to coordinate breath in and using inhaler which is not easy to do during an asthma attack
61
What breathing technique do you need for an MDI?
Slow and steady Coordinate breath in and pressing inhaler
62
What breathing technique do you need for a DPI?
Fast and deep | Inhaler should make a whistling sound
63
What age are DPIs not licensed?
< 5 years
64
What antibiotic is used in a rescue pack and what would you do if the rescue pack does not work?
Amoxicillin TDS or doxycycline if penicillin allergic Test sputum for appropriate ABX
65
How do you measure FEV1/FVC ratio?
Spirometry test
66
What investigations do you need to do in a COPD patient?
- Spirometry - Sputum test - Oxygen sats - FBC including CRP- for infections - MRC score - Any exacerbations in last year? How many times have they been in hospital? Is there a risk of exacerbation?
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