1. Phase 2 Kirsty McLauchlan and Vicky Cox The Peer Teaching Society is not liable for false or misleading information…

2. Asthma COPD Pulmonary Fibrosis The Peer Teaching Society is not liable for false or misleading information… Aims

3. The Peer Teaching Society is not liable for false or misleading information… Introduction

4. A chronic relapsing/episodic inflammatory condition of the airways Characterised by 1.Airflow limitation 2.Airway hyper-responsiveness 3.Bronchial inflammation The Peer Teaching Society is not liable for false or misleading information… Asthma

5. 15 % of population 5.2 million people in UK – 1.1million children Prevalence is increasing More in developed counties eg. UK, NZ, Australia The Peer Teaching Society is not liable for false or misleading information… Asthma - Epidemiology

6. Asthma Extrinsic Intrinsic Childhood – atopicMiddle-aged Late onset – occupational - NSAID-intolerance - β-adrenoreceptor blocking agents The Peer Teaching Society is not liable for false or misleading information… Asthma – Aetiology (cause) Not immunologically mediated Type I hypersensitivity reactions

7. The Peer Teaching Society is not liable for false or misleading information… Asthma - triggers ALLERGENS (atopy) Viral infection Cold air Emotion Irritant dusts, vapor, fumes (cigarette smoke) Occupational sensitizers Atmospheric pollution Exercise Drugs – NSAIDs, β-adrenoreceptor blocking agents

8. Type of hypersensitivity – (Type 1) Runs in families Have increased IgE antibodies – allergen specific Can be caused by environmental factors – Early exposure to allergens – Maternal smoking – Hygiene hypothesis The Peer Teaching Society is not liable for false or misleading information… Asthma – what is Atopy?

9. The Peer Teaching Society is not liable for false or misleading information… Occupational Asthma animals latexdyes bleachWood dust Antibiotics Flour paints

10. The Peer Teaching Society is not liable for false or misleading information… Asthma - Pathogenesis Inflammation Mucus and oedema Bronchoconstriction AIRWAY OBSTRUCTION REMODELING Epithelium Smooth muscle Basement membrane

11. The Peer Teaching Society is not liable for false or misleading information… Asthma 1. INFLAMMATION

12. IgE = bronchoconstriction By blocking β-adrenoreceptor in smooth muscle surrounding airways The Peer Teaching Society is not liable for false or misleading information… Asthma – 2. Bronchoconstriction This is why β-adrenoreceptor blockers (e.g propranolol) can trigger asthmatic response!

13. The Peer Teaching Society is not liable for false or misleading information… Asthma 3. oedema + mucus Histamine Smooth muscle contraction Bronchial secretions (mucus plug) Vascular permeability (oedema)

14. Basement membrane Epithelium Smooth muscle The Peer Teaching Society is not liable for false or misleading information… Asthma - remodeling Hypertrophy Contractility Loss of cilia Goblet cells = more infection + more mucus Deposition of collagen = thickened basement membrane

15. Episodes/attack of shortness of breath and wheezing Bilateral, polyphonic, expiratory, widespread Worse at night Cough The Peer Teaching Society is not liable for false or misleading information… Asthma – Clinical Features

16. Spirometry – reduced FEV1 PEF – reduced The Peer Teaching Society is not liable for false or misleading information… Asthma – investigations 15% improvement in either after a bronchodilator indicates asthma Exercise tests Blood count – eosinophils Exhaled nitric oxide - eosinophils

17. Controlling extrinsic factors Long term treatment Treatment of acute attack The Peer Teaching Society is not liable for false or misleading information… Asthma - Treatment

18. The Peer Teaching Society is not liable for false or misleading information… Asthma - Pathogenesis Inflammation Mucus and oedema Bronchoconstriction AIRWAY OBSTRUCTION REMODELING Epithelium Smooth muscle Basement membrane B2-agonist corticosteroid

19. Avoid extrinsic factors Short acting B2agonists– ‘2 puffs as required’ Occasional symptoms PEFR 100% Low dose inhaled corticosteroid Symptoms >3 a week PEFR <80% Add long acting B2-agonist Severe symptoms PEFR 50-80% The Peer Teaching Society is not liable for false or misleading information… Step-wise management High dose corticosteroid Consider leukotriene receptor antagonist Continue severe symptoms PEFR 50-80% Add oral corticosteroids daily Severe deteriorating symptoms PEFR <50% Hospital admission Severe deteriorating symptoms PEFR <30% salbutamol budesonide salmeterol monteleukast prednisolone

20. Moderate Able to talk Resp < 25 Pulse <110 Sats > 92 PEF > 50% Short acting B2 agonist + Corticosteroid Severe Not complete sentences Resp > 25 Pulse > 110 Sats >92 PEF 33-50% High flow oxygen + SABA and corticosterois + antimuscarinic Life Threatening Silent chest Cyanosis Hypotension, bradycardia Sats < 92 Oxygen + SABA + corticosteroid + antimuscarinic The Peer Teaching Society is not liable for false or misleading information… Management of Acute Attack IV aminophylline

21. Practice Questions

22. ‘A common progressive disorder characterized by airway obstruction with little or no reversibility’ – Chronic bronchitis – Empyhsema The Peer Teaching Society is not liable for false or misleading information… Chronic Obstructive Pulmonary Disease

23. Obstructive: -  FEV 1 (<80% predicted) -  FEV 1 /FVC(<0.7 predicted) The Peer Teaching Society is not liable for false or misleading information… COPD

24. Prevalence: 10-20% of over-40s 2.5 x 10 6 deaths worldwide The Peer Teaching Society is not liable for false or misleading information… COPD - epidemiology

25. caused by long-term exposure to toxic particles – (cigarette smoking >90% of cases) The Peer Teaching Society is not liable for false or misleading information… COPD - aetiology

26. The Peer Teaching Society is not liable for false or misleading information… COPD - pathophysiology Infiltration of the bronchi/bronchiole walls with inflammatory cells Granulocytes release elasteases and proteases Ulceration, scarring & columnar cell metaplasia Neutrophils & CD8 lymphocytes Inactivation of α1- antitrypsin by cigarette smoke Columnar cells are replaced by squamous cells Widespread narrowing of small ariways

27. The Peer Teaching Society is not liable for false or misleading information… COPD - pathophysiology Early disease, predominantly in the small airways, is reversible.

28. The Peer Teaching Society is not liable for false or misleading information… COPD - pathophysiology Progressive squamous cell metaplasia Fibrosis of bronchial walls Airflow limitation/narrowing With mucous gland hypertrophy

29. The Peer Teaching Society is not liable for false or misleading information… Chronic Bronchitis - pathophysiology. Lumen occlusion by mucus plugging Goblet cell metaplasia Smooth muscle hyperplasia Distortion due to fibrosis Airway narrowing

30. The Peer Teaching Society is not liable for false or misleading information… Emphysema - pathophysiology. permanent enlargement of airspaces loss of alveolar walls  reduced elastic recoil loss of alveolar supporting structure Reduced surface for gas exchange Airflow limitation

31. “cough and sputum production on most days for 3 months of 2 successive years” The Peer Teaching Society is not liable for false or misleading information… Chronic Bronchitis

32. “ enlarged air spaces distal to terminal bronchioles, with destruction of alveolar walls” The Peer Teaching Society is not liable for false or misleading information… Emphysema

33. Productive cough White or clear sputum Wheeze Dyspnoea The Peer Teaching Society is not liable for false or misleading information… Symptoms of COPD

34. COPD: - age of onset > 35 years - smoking (active or passive) - chronic dyspnoea - sputum production - minimal diurnal or day-to-day FEV 1 variation The Peer Teaching Society is not liable for false or misleading information… COPD vs. Asthma

35. Mild disease: no signs or quiet wheeze Severe disease: - tachypnoea - prolonged expiration - use of accessory muscles - intercostal indrawing - lip-pursed expiration - poor chest expansion - hyperinflated lungs The Peer Teaching Society is not liable for false or misleading information… Signs of COPD

36. Mild disease: no signs or quiet wheeze Severe disease: - tachypnoea - prolonged expiration - use of accessory muscles - intercostal indrawing - lip-pursed expiration - poor chest expansion - hyperinflated lungs The Peer Teaching Society is not liable for false or misleading information… Signs of COPD

37. Normally respiratory drive is largely initiated by PaCO 2. The Peer Teaching Society is not liable for false or misleading information… Pink Puffers/Blue Bloaters Pink Puffers ↑ alveolar ventilation Normal PaO 2, normal or low PaCO 2 breathless, not cyanosed may  Type 1 Resp. Failure Blue Bloaters ↓ alveolar ventilation Low PaO 2, high PaCO 2 cyanosed, not breathless May  cor pulmonale HYPOXIC DRIVE

38. -PaO 2 < 8kPa -PaCO 2 > 7kPa The Peer Teaching Society is not liable for false or misleading information… Respiratory Failure Chronic alveolar hypoxia + hypercapnia Constriction of pulmonary arterioles Pulmonary arterial hypertension

39. “heart disease secondary to respiratory disease” Pulmonary hypertension Right ventricular hypertrophy Right heart failure The Peer Teaching Society is not liable for false or misleading information… Cor Pulmonale

40. Dyspnoea Fatigue Syncope Cyanosis Tachycardia Raised JVP RV Heave Loud P 2 Pansystolic Murmur – tricuspic regurgitation The Peer Teaching Society is not liable for false or misleading information… Cor Pulmonale – clinical features

41. Lung Function tests (↓FEV 1 :FVC, ↓ PEFR) Chest X-ray (often normal) High-resolution CT (to show bullae in empyhsema) Blood gases (often normal) The Peer Teaching Society is not liable for false or misleading information… COPD - Investigations

42. British Thoracic Society/NICE COPD guidelines – Mild: FEV 1 50-80% of predicted – Moderate: FEV 1 30-49% of predicted – Severe: FEV 1 <30% of predicted The Peer Teaching Society is not liable for false or misleading information… COPD – Assessing Severity

43. General Treatments – stop smoking – encourage exercise – treat poor nutrition or obesity – influenza and pneumococcal vaccinations The Peer Teaching Society is not liable for false or misleading information… COPD – Treatment

44. Initial Treatment Antimuscarinic (e.g. Ipratropium) or β2 agonist (e.g. Salbutamol) inhaled PRN The Peer Teaching Society is not liable for false or misleading information… COPD - Treatment

45. The Peer Teaching Society is not liable for false or misleading information… COPD - Treatment Persistent breathlessness or exacerbations FEV1 > 50% LABA (Long-acting Beta2 Agonist) LAMA (Long-acting Muscarinic Antagonist) FEV1 < 50% LABA + ICS (combined inhaler) LAMA

46. Severe Disease LABA + Inhaled Steroid + Anticholinergic + Refer to specialist + Consider steroid trial The Peer Teaching Society is not liable for false or misleading information… COPD - Treatment

47. Long Term Oxygen Therapy Consider LTOT if PaO2 <7.3kPa The Peer Teaching Society is not liable for false or misleading information… COPD - Treatment

48. Controlled Oxygen Therapy Start at 24-28% Aim for PaO 2 > 8.0kPa Nebulised Bronchodilators Salbutamol 5mg/4h + Ipratropium 500ug/6h Steroids IV Hydrocortisone 200mg + Oral Prednisalone 30-40mg (continue for 10-14 days) The Peer Teaching Society is not liable for false or misleading information… COPD – Acute Management

49. Antibiotics Use if evidence of infection e.g. Amoxicillin 500mg/8h PO Physiotherapy To aid sputum expectoration If not response, consider Repeat Nebs, consider IV aminophylline, NIPPV etc. The Peer Teaching Society is not liable for false or misleading information… COPD – Acute Management

50. Also known as diffuse parenchymal lung disorders Collection of disorders affecting – Alveoli – Alveolar epithelium – Capillary endothelium – And the spaces in-between The Peer Teaching Society is not liable for false or misleading information… Pulmonary Fibrosis – (interstitial lung disease)

51. Interstitial Lung Disease Acute Adult respiratory distress syndrome Drug/toxin reaction Radiation pneumonitis Trauma Infection Asbestos Chronic Hypersensitivity pneumonitis Interstitial pneumonia = idiopathic pulmonary fibrosis Sarcoidosis Pneumoconiosis (occupational) Rheumatoid / SLE Diffuse malignancy The Peer Teaching Society is not liable for false or misleading information… Acute and Chronic

52. The Peer Teaching Society is not liable for false or misleading information… ACEPT A - Ankylosing spondylitis C – Cancer E – Extrinsic allergic alveolitis P – Pneumoconiosis T - TB

53. The Peer Teaching Society is not liable for false or misleading information… SARCOIDOSIS Multisystem granulomatous disorder Affects age 30-40 Pulmonary infiltration Often no symptoms If persists over 6 months treat with prednisolone

54. The Peer Teaching Society is not liable for false or misleading information… 123123 1 – primary pulmonary fibrosis 2 – secondary pulmonary fibrosis 3 - asbestosis

55. The Peer Teaching Society is not liable for false or misleading information… Diffuse Chemotherapy Drugs Radiation And progression of disease

56. Scarred lungs Breathlessness Dry cough Fatigue Clubbing RESTRICTIVE The Peer Teaching Society is not liable for false or misleading information… Clinical Picture

57. Obstructive Hard to exhale  FEV1  TLC Asthma, COPD, bronchiectasis, cystic fibrosis Restrictive Difficult to expand lungs  FVC Pulmonary fibrosis, obesity, neuromuscular, sarcoidosis The Peer Teaching Society is not liable for false or misleading information…

58. Remove offending agent Suppress inflammation (glucocorticosteroids) Manage hypoxemia The Peer Teaching Society is not liable for false or misleading information… Treatment depends on cause

59. Practice Questions