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Week 4: Asthma and COPD

Week 4: Asthma and COPD. Dr Felix Woodhead Consultant Physician. Obstructive Lung Disease. Reduced rate of airflow Wheeze Big lungs Asthma COPD Bronchiectasis. Delivery methods. Nebulisers Inhalers Aerosol Dry powder Proprietary types. Drugs. Bronchodilators. β 2 agonists.

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Week 4: Asthma and COPD

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  1. Week 4: Asthma and COPD Dr Felix Woodhead Consultant Physician

  2. Obstructive Lung Disease • Reduced rate of airflow • Wheeze • Big lungs • Asthma • COPD • Bronchiectasis

  3. Delivery methods • Nebulisers • Inhalers • Aerosol • Dry powder • Proprietary types

  4. Drugs Bronchodilators

  5. β2 agonists • Short-acting • Salbutamol • Terbutaline • Long-acting • Salmeterol • Formoterol

  6. Antimuscarinics • Short-acting • ipratropium • Long-acting • tiotropium

  7. Steroids • Beclomethasone (BCZ) • Budesonide • Fluticasone • Small- particle BCZ

  8. Combined agents • Seretide (Purple) • =serevent (salmeterol) + flixotide (fluticasone) • Evohaler (MDI) or accuhaler (DPI) • Symbicort • Oxis (formoterol) + pulmicort (budesonide) • Turbohaler (DPI) • SMART regime

  9. COPD

  10. Definition • 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

  11. GLOBAL INITIATIVE FOR OBSTRUCTIVE LUNG DISEASE • FEV1 ≥ 80% - GOLD stage 1 • FEV1 = 50-79% - GOLD stage 2 • FEV1 = 30-49% - GOLD stage 3 • FEV1 < 30% - GOLD stage 4 • Stage 1 needs symptoms (asymp not COPD) • Relatively poor correlation between FEV1 & symptoms

  12. BODY MASS INDEX OBSTRUCTION DYSPNOEA EXERCISE CAPACITY • BMI : <21 or not • Obstruction: broadly GOLD cutoffs • Dyspnoea: MRC score • Exercise tolerance: 6 minute walk test • Composite score better than GOLD

  13. Treatment of stable disease NICE 2010

  14. Stop smoking! • Assess every time • Not asking is a dereliction of duty • Only intervention that changes natural history of disease • “If you think you’re breathless now, just you wait…” • It is NEVER too late to stop smoking • Do not diagnose asthma if you think they may have COPD

  15. Inhaled treatment • SOB/ex limitation: SABA/SAMA prn • Exacs/SOB • LAMA (tiotropium) regardless of FEV1 • Or • LABA if FEV1 > 50% • Combined LABA/ICS if FEV1 < 50% • Still exacs/SOB • LAMA & Combined LABA/ICS

  16. (Home) Nebulisers • Consider in patients with distressing symptoms despite adequate inhaled Rx • Only continue if beneficial • Side effects can occur • Takes up time • Placebo effect common

  17. Systemic treatment • Corticosteroids – avoid • Theophyllines • Only after inhaled Rx tried, or not tolerated • Particular care in the elderly • Levels increased by macrolide/fluoroquinolone • Mucolytics • Consider in patients with chronic productive cough • Continue only if beneficial

  18. Oxygen therapy • Role is to delay death from cor pulmonale • The breathlessness paradox • SOB often good pO2 • Low sats, often not breathless • LTOT • pO2 < 7.3 kPa when stable • pO2 < 8 kPa and nocturnal hypoxaemia, polycythaemia or cor pulmonale • Needs to be used for at least 15/24 hours • Short burst use (cylinders) – little role

  19. Acute exacerbation of COPD

  20. Definition • Sustained worsening of symptoms from usual state • Beyond daily day-day variation • Acute in onset • Often associated with • ↑ SOB, ↑ cough, ↑ sputum volume, ↑ sputum purulence • May require change in treatment • Occur due to precarious V/Q in bad lungs caused by often minor stimuli

  21. Exclude • Pneumothorax • SVT • Myocardial infarction • Pulmonary oedema • Lung cancer • PE • Pneumonia (NOT ‘infective exacerbation’) • No role for ‘CURB’ score in IECOPD (it is not pneumonia)

  22. Management • ↑ frequency of inhaled treatment (often nebulised) • Steroids for all (30 mg od 7-14/7) • Antibiotics if sputum purulent • O2 given • With care, and control • ALWAYS Venturi acutely • Adjusted by SaO2 not patient/relative/nurse distress • Guided later by ABGs • With NIV if needed

  23. Other issues • Like ‘breathlessness’, fear ‘comfort’ • Keep calm • Do not give opiates/benzos • Get senior help if necessary • Nebulise on air, using nasal specs for sup O2 • NIV - use early • 2.5 mg salbutamol 2° better than 5 mg 4° • IV aminophyline can be useful

  24. Non-invasive ventilation • For ACUTE ventilatory failure • Treats ↓ pH • Allows ↑ FiO2 without ↑ pCO2 • Only suitable if conscious and protecting airway • ↑EPAP (PEEP) useful in pulm oedema and obesity • NOT poor man’s ITU • NO ROLE IN ACUTE ASTHMA/pneumonia

  25. Asthma

  26. Principles • Variable airflow obstruction • Cough and wheeze • Nocturnal features • Specific (allergic) triggers • Non-specific triggers • Eosinophils in airways • Responds to steroids

  27. Acute severe asthma • PEFR 50-33% • RR ≥ 25 • HR ≥ 110 • Unable to complete sentences • But SpO2 >92% • Worse = life-threatening (silent chest, cynanosis, low SpO2) • Better = moderate asthma

  28. Treatment • Steroids • O2 • Nebs driven with O2 • ABG if low sats or drowsy • Normal pCO2 is a sign of bad prognosis • Senior review • Increase inhaled treatment/start it. Educate. Inhaler technique • Consider IV bronchodilators

  29. Stable asthma • Steroids • Inhaled best • Systemic if admission on the cards • 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) • Step 5: help! Montelukast etc, aminophylline • Steroids – psychosocial issues?

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