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what are the 5 broad categories for breathlessness? (in systems)
- respiratory
- cardiac
- musculoskeletal
- systemic: acidosis, uraemia, thyroid, anaemia
- psychological: anxiety
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what are the causes of SOB in terms of speed of onset (sudden, rapid, gradual slow)?
- sudden: foreign body obstruction, laryngeal oedema (anaphylaxis), pneumothorax, PE, flash oedema, hyperventilation
- rapid: metabolic acidosis, haemothorax, oedema, PE, asthma/COPD exacerbation, pneumonia, allergic alveolitis
- gradual: pleural effusion, chronic asthma, COPD, fibrosis, carcinoma TB
- slow: COPD, fibrosis, chronic PE, pulmonary hypertension, respiratory muscle weakness, anaemia, hyperthryoidism
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what are the causes of flash pulmonary oedema?
- commonly after AMI, mitral regurgitation
- also AR or HF: essentially anything that increases LV filling pressures
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what is the MRC dyspnoea scale? 5 categories
- 1. strenuous exercise
- 2. hurrying or hill
- 3. walking at own pace
- 4. 100m
- 5. too breathless to leave house or dress/undress
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what are the associated symptoms that need to be asked about when c/o breathlessness?
- cough, sputum
- haemoptysis
- wheeze
- chest pain
- occupation
- smoking
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which investigations need to be done for breathlessness?
- vital obs: pulse, RR, temp, O2 sats, BP
- Bloods: FBC, ABG
- CXR, CTPA
- Lung function: PEFR, spirometry, PFT
- ECG, echo
- sputum check
- bronchoscopy
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what is the difference in wheeze between asthma/copd and fixed large airway obstruction?
- asthma/copd: polyphonic wheeze - musical sound produced by passage of air through narrowed bronchi
- fixed large airway obstruction: stridor, monophonic wheeze (eg carcinoma obstructing trachea)
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describe the type of cough seen in asthma
nocturnal/disturb sleep, precipitated by cold air and exercise
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describe the type of cough seen in infection
transient cough and purulent sputum
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describe the type of cough seen in bulbar palsy and what can this predispose to?
- weak ineffective cough which fails to clear secretions from the airways
- predispose to aspiration pneumonia
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describe the type of cough seen in expiratory muscle weakness and what can this predispose to?
- weak ineffective cough which fails to clear secretions from the airways
- predispose to aspiration pneumonia
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describe the type of cough seen in chronic bronchitis
chronic cough with sputum production, on most days for at least 3 months of 2 consec years
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describe the type of cough seen in bronchiectasis
copious amount of sputum made
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when is a chronic cough seen? give 3 situations
- 1. captopril (ACEi SE)
- 2. GORD with aspiration
- 3. sinusitis with post nasal drip
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what are the 2 consequences of VIOLENT coughing? explain
- cough syncope: impede venous return to heart and impede cerebral perfusion
- cough fracture: rib fracture
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when is bronchorrhoea seen?
alveolar cell carcinoma: make lots of watery sputum
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what is melanoptysis and when is it seen?
coal workers pneumoconiosis cough up black material
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what is the definition of COPD?
- airflow obstruction
- progressive not fully reversible
- abN inflammatory response of the lung to noxious particles or gases
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what is the pathological definition of asthma?
- chronic inflammatory condition of the airways
- variable and reversible airflow obstruction
- airway HYPERRESPONSIVENESS to a variety of stimuli
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what is the clinical definition of asthma?
- paroxysmal wheezing and SOB
- caused by acute reversible narrowing of airways
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give 3 features of asthma that distinguish it from COPD?
- nocturnal symptoms: wake up wheezy
- diurnal variation
- intermittent
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what Q need to be asked in a asthma history?
- younger age
- occupation
- environ
- atopy
- FH
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give 3 features of COPD that distinguish it from asthma
- progressive symptoms
- smoker (>20py)
- recurrent infective exacerbations
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on examination of a pt with asthma what would you expect to find?
- polyphonic diffuse expiratory wheeze
- (may be normal)
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On examination of a pt with COPD, what would you expect to find?
hyperinflation: as reduced recoil of lungs, breath at higher RV
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what are the clinical features of emphysema that differ from chronic bronchitis?
- emphysema:
- dyspnoea: early and severe
- cough: minimal with scanty sputum
- infections: rare
- bronchitis:
- dyspnoea: mild
- cough: chronic and productive
- infections: common
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what are the difference in O2 and CO2 levels in emphysema and bronchitis?
- emphysema: O2 and CO2 maintained at muscular cost
- bronchitis: low O2 and high CO2 tolerated (via renal regen and reten of bicarb)
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what type of respiratory failure do you get with emphysema and bronchitis and what are the consequences of this?
- emphysema: type 1 RF - cor pulmonale terminal events
- bronchitis: type 2 FR - cor pulmonale
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if you could only choose ONE investigation for asthma, what would it be and how is it diagnosed?
- PEF chart
- clinical diagnosis at GP/community
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which one investigation is paramount for diagnosing COPD?
spirometry: has to show signs of obstruction
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which other tests need to be done to confirm asthma?
- spirometry
- reversibility
- eosinophilia
- skin prick tests
- challenge tests
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which other tests need to be done in COPD?
- reversibility testing
- CXR
- oximetry
- FBC: Hb level and PCV as polycythaemia
- ECG: or pulmonale (RVH, RAD, prominent R wave in lead 1)
- alpha1 antitrypsin level (Pizz)
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in ACUTE asthma, how do you differentiate between severe and life threatening in terms of the pt's SPEECH?
- severe: cannot complete sentences
- life threatening: silent/limited
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in ACUTE asthma, how do you differentiate between severe and life threatening in terms of the pt's RESP RATE
- severe: > 25
- life threatening: feeble effort
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in ACUTE asthma, how do you differentiate between severe and life threatening in terms of the pt's PULSE
- severe: >110
- life threatening: bradycardia
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in ACUTE asthma, how do you differentiate between severe and life threatening in terms of the pt's BP
- severe: pulsus paradoxes (reduction in BP by >10mmHg on inspiration)
- life threatening: hypotension
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what are the normal variations in pulse and BP when you breathe IN?
- BP: down cos more bld flows to R heart (intrathoracis pressure becomes more neg. which increases VR)
- Pulse: up as baroreceptor reflex stimulating sympathetic outflow to heart
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in ACUTE asthma, how do you differentiate between severe and life threatening in terms of the pt's general appearance
- severe: anxious
- life threatening: confused and exhausted
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in ACUTE asthma, how do you differentiate between severe and life threatening in terms of the pt's blood gases
- severe: low O2 and normal or reduced CO2 (as may be hyperventilating)
- life threatening: low O2, high CO2, acidotic
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in ACUTE asthma, how do you differentiate between severe and life threatening in terms of the pt's PEF?
- severe: 33-50%
- life threatening: <33%
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why do patients with COPD get nocturnal hypoxia? give the main reason and 3 subreasons!?
- alveolar hypoventilation due to
- 1. inhibition of intercostal and access muscles in REM sleep
- 2. shallow breathing in REM sleep so reduced ventilation (more dead space vent)
- 3. reduced muscle tone in REM sleep so increased upper airway resistance
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what tablets should not be given to pt with COPD which keep waking up at night due to hypoxia and desaturation?
sleeping tablets as it will further depress their resp drive!
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what treatment should be given to COPD pt with nocturnal hypoxia?
CPAP
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how can you assess the severity of acute asthma in terms of speech, RR, PR, BP, general appearance, ABG, PEF?
- severe attack: cant complete full sentences, RR>25, PR>110, BP pulsus paradoxes, anxious, ABG: hypoxic but N CO2 or low as hypervent, PEF: 33-50%
- life threatening attack: silent chest, low RR as feeble resp effort, bradycadia, lowBP, exhausted/confused, ABG: high CO2 acidotic as cant blow out, PEF<33%
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what is the management of acute asthma attack?
- warn ITU, Rx before Ix!
- sit patient up
- high flow O2 (non rebreather)
- salbutamol 5mg
- ipratropium bromide 0.5mg
- both nebulised with O2
- hydrocortisone 100mg iv
- or prednisolone 40mg PO (both if v.ill)
- CXR to exclude pneumothorax
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what extra management needs to be done if life threatening asthma attack features?
- inform ITU, sisters
- add MgSO4
- salbutamol nebs every 15mins
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if patient is not improving from initial treatment for acute asthma attack after 15-30mins what should be done?
- continue 100% 02
- hydrocortisone 100mg iv
- prednisolone 30mg if not already given
- salbutamol nebs every 15mins
- ipratropium 0.5mg every 4-6h
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if after all treatment tried for acute severe asthma attack, nothing works what needs to be done?
- ITU
- repeat salbutamol nebs every 15mins
- MgS04
- aminophylline - must check if already on one cos SE
- may need to intubate
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how is the effects of treatment for acute asthma attack monitored?
- repeat PEF 15mins after initiating treatment
- O2 sats > 92%
- ABG
- record pre and post Bagonist PEF in hospital at least 4 times
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what needs to be done before discharge of a patient that has just recovered from severe acute asthma attack?
- been on discharge medication for 24h
- had inhaler technique checked
- PEF > 75% predicted
- steroid and bronchodilator therapy
- own a PEF and have a management plan
- GP appt within 1wk
- reps clinic appt within 4 weeks
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what is the 5 step treatment for asthma?
- 1. short acting B2 agonist PRN e.g. salbutamol for SYMPTOM relief. if used more than once daily or night time symptoms, go to step 2
- 2. ADD regular inhaled steroid eg beclometasone 200ug/12h or fluticasone
- 3. ADD long acting B2 agonist e.g. salmeterol NB may or may not benefit so continue/stop accordingly. can also increase dose of beclometasone to 400ug/12h
- 4. ADD different trials: beclometasone inc dose, theophylline, LK antagonist eg montelukast
- 5. ADD oral steroids OD, PO, prednisolone. lowest possible dose and refer to asthma clinic
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what is the MOA of B2 agonist and give 2 e.g. of short acting and one of long
- SABA: salubtamol, terbutaline
- LABA: salmeterol
- B2 receptor in smooth muscle
- activate adenylate cyclase
- to increase cAMP in smooth muscle
- this relaxes SM and quick onset bronchodilation
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what are the SE of B2 agonists?
- dose related so unlikely at low doses and inhaled
- 1. fine tremor
- 2. tachycardia
- 3. low K+
- 4. arrhythmia long QT
- 5. headaches
- 6. palpitations
- 7. muscle cramps
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what are the cautions for using B2 agonists? which diseases?
- hyperthyroidism
- arrhythmia
- CVD
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what is a potential SE of long acting B2 agonist? and give e.g.
- salmeterol
- paradoxical bronchospasm
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how many hours are short acting BA active for?
up to 4 hours
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how is salbutamol prescribed for stage 1 asthma treatment? give dose, route, max dose
- 1-2 puffs PRN
- dose inhalation 100-200ug
- max QDS
- can use for exercise induced bronchospasm
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how many hours are long acting BA active for?
up to 12 hours
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which type of asthma is LABA useful for?
nocturnal asthma
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when should you not use LABA?
for relief of an acute asthma attack as slower onset of action than SABA
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what is the mechanism of action of corticosteroid and why used in asthma?
- reduce airway inflammation
- less oedema, mucus secretion
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when are inhaled steroids indicated in asthma?
- 1. as regular prophylaxis when pts need SABA >2x/week
- 2. if symptoms disturb sleep
- 3. reduce acute exacerbations
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what is the speed of onset of effect of steroids?
3-7 days after initiation as they act on NUCLEAR receptors and cause transcription of antiinflamm mediators
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what are the SE of inhaled corticosteroids?
- oral candida (so should rinse and spit after use)
- hoarse voice
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how should inhaled steroids be prescribed?
- low dose bd.
- e.g. beclomethasone 100mcg(brown) to 400mcg (purple) BD
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which inhaler is the mainstay of asthma therapy?
inhaled corticosteroids
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in severe asthma, what time of day should oral prednisolone be taken? and why?
morning to reduce disturbance to circadian cortisol secretion
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give 2 examples of methylxanthines
- theophylline
- aminophylline
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what is the MOA of methylxanthines?
- 1. inhibit phosphodiesterase which break down cAMP
- so get more cAMP to relax smooth muscle - bronchodilation
- 2. block adenosine receptor (competitive antag) so reduce SMC contraction
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what is the caution to be taken with methylxanthines?
narrow TI
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what are the SE of methylxanthines?
- GI: gastric irritation so N&V
- heart: arrhythmia (as inc cAMP), palps, tacky
- CNS: convulsions (as inc cAMP), headache, insomnia
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which methylxanthine is better absorbed?
aminophylline is better absorbed than theophylline
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what is the most toxic type of bronchodilator?
methylxanthines
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give an example of Leukotriene antagonists?
montelukast
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what is the MOA of LT antag?
- block LT receptors on inflam cells and SM
- anti inflammatory AND bronchodilation
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what is the route of admin of LT antag?
oral
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when are LT antag used in asthma?
- not alone
- has additive effect with B2 agonist and steroids
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what are the SE of LT antagonists? (HHAT)
- 1. abdo pain
- 2. thirst
- 3. hyperkinesia esp chldren
- 4. headache
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give 2 examples of cromolyns
- sodium cromoglycate
- nedrocromil sodium
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what is the MOA of cromolyns?
- unsure
- prevent mast cell degran in vitro
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what is the route of admin of cromolyns?
inhalation
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what are the SE of cromolyns?
- few as it is a weak drug (treatment failure common!)
- cough
- transient bronchospasm
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when is cromolyns given? and why?
- worth trying in children
- as no risk of growth suppression (cf to steroids)
- prevent exercise induced asthma
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give 2 eg of anti-cholinergic drugs used in COPD and the difference between them
- ipratropium bromide inhaled/neb: short term relief
- tiotropium: long acting anti musc bronchodilator
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in COPD, who would you give salbutamol to and who anticholinergics?
- younger: salbutamol
- elderly: anticholinergic
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what is the MOA of anticholinergic in COPD?
reduce SMC contraction
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what is the stepwise treatment of COPD?
- stop smoking & pneumo and flu vaccines
- 1. bronchodilator: either short acting B2 agonist OR short acting anticholinergic
- 2. combined therapy: SABA (salbutamol) and anticholinergic (ipratropium bromide)
- 3. long acting bronchodilator: either B2agonist (salmeterol) or antichol (tiotropium)
- 4. mod/severe: combo of LABA and inhaled corticosteroid (beclomethasone). stop LABA if no good in 4 weeks
- 5. add theophylline
- 6. if functionally disabled then need pulmonary rehab
- 7. surgery - bullectomy, lung volume reduction surgery, transplant
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what is a bull?
air sacks with trapped air in lungs which compress underlying lung
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what is the treatment for acute COPD exacerbation?
- 1. look for cause: infection or pneumothorax
- 2. salbutamol 5mg/4h and ipatropium
- 3. steroids iv hydrocortisone and oral prednisolone
- 4. if pyrexial or evidence of infection then abx: amox 500mg/8h/PO
- 5. physic to help sputum out
- if no response: repeat nebs, theophylline, NIPPV
- still no response: NIPPC, intubate and ventilate, doxapram (resp stimulant)
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