1. + Asthma & COPD Finals Teaching 2013 Alison Portes FY1

2. + 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…

3. + Asthma

4. + Definition Pathophysiology History Examination Investigations Management Acute Chronic Medications Paediatric Asthma

5. + Definition Obstructive airways disease Chronic Inflammatory Variable Reversible Hyperresponsiveness

6. + 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

7. + 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

8. + Examination Standard respiratory exam ?Start at the back Tachypnoea Widespread polyphonic wheeze Hyperresonant percussion note Diminished breath sounds Hyperinflated chest

9. + Investigations Bedside PEF Bloods Blood gas – when and why? Imaging CXR – when and why? Special tests PEF monitoring Spirometry - Bronchodilator challenge

10. + 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…

11. Asthma Medications Salbutamol Salmeterol Mechanism? Beclomethasone Salmeterol plus flixotide

12. + 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

13. + 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!

14. + 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

15. + 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…

16. + 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

17. + COPD

18. + Definition Pathophysiology History Examination Investigations Management Chronic Acute Exacerbation

19. + 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

20. + 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

21. + History Full respiratory history plus… Smoking, smoking, smoking!! Consider your differentials – ILD, bronchiectasis, malignancy, heart failure – and rule them out Red flag symptoms

22. + Examination Look and comment! Tar stains Accessory muscles Barrel chest Crepitations Wheeze

23. + Investigations Bedside Sputum, ECG Bloods FBC, U&E, CRP, blood cultures, ABG Imaging CXR Echo Special tests Spirometry α 1-antitrypsin levels

24. + 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

25. Antimuscarinics Ipratropium Short-acting Tiotropium Long-acting Mechanism?

26. + 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!

27. + 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

28. + 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%

29. + 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 2 nd step in the BTS asthma ladder? And the 4 th ? What level SpO2 should you aim for in COPD patients? What is Spiriva?

30. + 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?

31. + Extras

32. + Typical graphs

33. Reading Chest X-Rays RIP...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