Asthma, COPD & Anaphylaxis

By Jonny Grek & Chris Mumford

What well cover

Asthma COPD Anaphylaxis Respiratory slideshow questions

Asthma

Characteristic Features

Chronic airway inflammation Increased airway responsiveness causing wheeze, cough and SOB Variable airways obstruction, reversible with treatment

Diagnostic Features of Asthma

SOB Nocturnal cough/waking Wheeze/chest tightness Symptoms are variable, worse at night Associated with triggers Environmental allergens Stress/Exercise Cigarette smoke Peak Flow Diurnal variation of >20% on >3 days per week for 2 weeks Spirometry Obstructive defecit >15% improvement in FEV1 following 2-agonist

Assessment of Severity

Moderate

PEF: 50-75%

Assessment of Severity

Moderate

PEF: 50-75% Inability to complete full sentences RR: >25, HR: >110 PEF: 33-50%

Severe

Assessment of Severity

Moderate

PEF: 50-75% Inability to complete full sentences RR: >25, HR: >110 PEF: 33-50% Cyanosis, silent chest Bradycardia & exhaustion PEF: <33%

Severe

Life-threatening

Emergency Management: ABC

Emergency Management: ABC

A: Ensure patent Sit patient up Anaesthetist input?

Emergency Management: ABC

A: Ensure patent Sit patient up Anaesthetist input? B: Peak Flow 15L/min O2 Percuss/listen to chest 5mg Salbutamol nebs 0.5mg Ipratropium bromide nebs 40mg Prednisolone PO

Emergency Management: ABC

C: ?IV access Bloods: If infection suspected 100mg Hydrocortisone IV if cant swallow ECG

Emergency Management: Extras

CXR Maintain sats >94%

ABG: PaCO2 if normal/raised GET HELP!!!!

Salbutamol nebs every 15 mins Ipratropium nebs every 4-6 hours Document in notes GET HELP!!!

Features of life-threatening asthma Patient tiring PaCO2 level

Discharge Criteria Following Admission

Off nebs and on normal inhalers for >24 hours PEFR > 75% Minimal PEFR diurnal variation Appropriate education in inhaler technique and selfmanagement GP follow up: 1 week Respiratory follow up: 4 weeks

Long-term Management
Always ensure adequate inhaler technique and compliance before proceeding to next step!

Long-term Management
Always ensure adequate inhaler technique and compliance before proceeding to next step! Inhaled short-acting 2-agonist PRN

Salbutamol

Long-term Management
Always ensure adequate inhaler technique and compliance before proceeding to next step! Inhaled short-acting 2-agonist PRN

Salbutamol Becalametasone Budesonide Side effects: Candidasis & Hoarseness

Add inhaled steroid 200-800 ug/day

Long-term Management

Long-term Management

Add inhaled long-acting 2-agonist

Usually combined inhaler Symbicort Seretide

Long-term Management

Add inhaled long-acting 2-agonist

Usually combined inhaler Symbicort: Formeterol & Budesenide 800ug/day Seretide: Salmeterol & Fluticasone 800ug/day

Long-term Management

Add inhaled long-acting 2-agonist

Usually combined inhaler Symbicort: Formeterol & Budesenide 800ug/day Seretide: Salmeterol & Fluticasone 800ug/day

Add leukotriene receptor agonist

Theophylline

Prednisolone PO

Long-term Management
1.

Add inhaled long-acting 2-agonist

Usually combined inhaler Symbicort Seretide

2. 3.

Add leukotriene receptor agonist Daily oral steroids

Good Asthma Control

No daytime symptoms No night-time waking due to symptoms No rescue medication Ability to function with normal ADLs and exercise No exacerbations PEF: >80% predicted

COPD

OSCE Station

You are an FY1 in MAU. A patient is wheeled past you on a trolley, who looks short of breath and unwell. You have been asked by your registrar to clerk this patient, and begin basic management. You will be assessed on your ability to take a focussed history from this patient, and offer an appropriate management plan.

What questions will you ask?

Demographics PC HPC PMH SH

78 year old female

PC: 2/7 history worsening SOB, cough with green sputum PMH:

COPD No previous ICU admissions No previous NIV

78 year old female presents to MAU

PC: 2/7 history worsening SOB, cough with green sputum

PMH:

COPD

No previous ICU admissions No previous NIV Home inhalers only (no home NEBs / LTOT)

HPC:

Normal exercise tolerance = 10 yards Current ET = none Still smoking 40 / day, 70 pack year history

On examination

Obs:

BP 85 / 45 P 110 RR 32 O2 sats 70% on RA T 38.1 C

Cachectic Using accessory muscles Bilateral expiratory wheeze ? Crackles @ right base
Bilateral pitting oedema ankles

How will you manage this patient?

How will you manage this patient?

Unable to complete sentences, has patent airway

How will you manage this patient?

Unable to complete sentences, has patent airway

How will you manage this patient?

Unable to complete sentences, has patent airway

Already listened to chest Oxygen? ABG NEBs CXR

ABG on 28% FiO2

pH PCO2 PO2 HCO3 BE

7.20 18 6 40 +7

? Impression

ABG on 28% FiO2

pH PCO2 PO2 HCO3 BE

7.20 18 6 40 +7

Impression = Type 2 Respiratory Failure / respiratory acidosis

Probably best get your senior now...

How will you manage this patient?

Unable to complete sentences, has patent airway

Already listened to chest Oxygen? ABG NEBs Salbutamol 5mg Ipratropium Bromide (atrovent) 500g CXR

Bloods FBC, U&E, CRP, blood cultures Cannula If dehydrated IVT ECG

How else will you manage this patient?

Need for NIV? (persistent hypercapnia)

Repeat ABG Discuss with senior (& decision about escalation) Start on prednisolone 30mg 7/7 Need for Abx? Prophylactic LMWH (dalteparin in LTHT) Write up drug chart

Bloods are back....

WCC 16.72 Hb 12.1 Platelets 270 CRP 320 Urea 12.1 Creatinine 160 (baseline on results server = 75) Na 130 K 4.0 ? Impression

Bloods are back....

WCC 16.72 Hb 12.1 Platelets 270 CRP 320 Urea 12.1 Creatinine 160 (baseline on results server = 75) Na 130 K 4.0 ? Impression = AKI 2 dehydration; inflammatory markers up

CXR

? Impression

CXR

? Impression = RML consolidation

Working diagnosis

Infective exacerbation of COPD CAP

Scoring tool?

Working diagnosis

Infective exacerbation of COPD CAP

Scoring tool CURB 65 Cx U R B 65 Confusion (AMTS <8) ; urea > 7; RR > 30; BP <90/60

? Abx

Working diagnosis

Infective exacerbation of COPD CAP

Scoring tool CURB 65 Cx U R B 65

? Abx CONSULT LOCAL GUIDELINES

(IV co-amoxiclav 1.2g tds & IV clarithromycin 500mg bd) Consider penicillin allergy

What happens to the patient?

Transferred to Respiratory Care Unit ABGs improve on NIV Inflammatory markers improve on IV Abx Renal function improves

Patient

lives

eDAN with 6/52 follow-up

The patients due to leave today...

Develop sudden-onset left-sided pleuritic chest pain Dropped O2 sats Increasing SOB.... And collapses!

? Impression =

The patients due to leave today...

Develop sudden-onset left-sided pleuritic chest pain Dropped O2 sats Increasing SOB.... And collapses!

? Impression = PE
The patient hasnt been receiving their LMWH for a week! ? Management

The patients due to leave today...

Develop sudden-onset left-sided pleuritic chest pain Dropped O2 sats Increasing SOB.... And collapses! ? Impression = PE The patient hasnt been receiving their LMWH for a week!

? Management =

ABC Treatment dose Analgesia

tinzaparin (175mg / kg)

CTPA
Warfarin from day 3 INR 2-3

Respiratory Failure Type 1

pCO2 pO2 Causes

Type 2

Respiratory Failure Type 1 Normal / low Low ( < 8 ish) Pneumonia, PE, acute asthma Type 2 High ( > 6 ish) Low ( < 8 ish) COPD, severe asthma (fatigue), OSA, post-op pain, opiates,

pCO2 pO2 Causes

Other potential OSCE questions about COPD:

Explain diagnosis of COPD to patient Explain chronic management to patient Smoking cessation advice Examination of patient

Anaphylaxis

Some Food for Thought

You are called to see Mr X who has become very wheezy. His lips and tongue appear very swollen. He had his evening meds including a tablet called Septrin for a newly diagnosed chest infection 30 mins ago

Definition

Rapidly progressing, life-threatening allergic reaction Type I IgE-mediated hypersensitivity reaction Release of histamine and other agents from mast cells Vasodilatation and leakage of fluid from capillaries CV collapse

Hypersensitivity
1.

2.

Immediate: AKA anaphylactic or atopic. Mediated by IgE antibodies Cytotoxic: Caused by IgG/IgM reacting with antigen present on a cell membrane

Haemolytic anaemia & Thrombocytopenia

3.

Immune Complex: Caused by IgG/IgM reacting with soluble antigen

Vasculitis & Farmers lung

4.

Delayed: CD4+ T cells that produce IFN-

Contact dermatitis & Coeliac disease

Mechanism of Anaphylaxis

Allergen at epithelial surfaces interacts with IgE on mast cells, releases

Histamine (vasodilatation, smooth muscle contraction, vascular permeability) Heparin & Tryptase

Systemic introduction of allergen causes RAPID CV collapse Absorption of allergen through skin/mucosa is slower, causing urticaria, angioedema & bronchospasm

Precipitants

Medical

Non-medical

Drugs (Penicillin) Blood products Contrast media Latex Colloids

Nuts Insect stings Eggs Strawberries

Presentation of Anaphylaxis

Within 5 mins 2 hours of exposure to allergen depending upon route of exposure Signs & Symptoms

Oedema of lips and tongue Bronchospasm: wheeze, stridor & SOB Flushing & urticaria Vomiting & diarrhoea Anaphylactic shock!!!

Management: Scenario

You are called to see Mr X who has become very wheezy. His lips and tongue appear very swollen. He had his evening meds including a tablet called Septrin for a newly diagnosed chest infection 30 mins ago Obs: BP: 98/62 HR: 98 RR: 32 Sats: 86% Temp: 37.2

Management: ABC

Management: ABC

A: Ensure patent 0.5mg (0.5ml 1:1000) Adrenaline IM 5mg Salbutamol nebs if bronchospasm Use of manoeuvres/adjuncts

Management: ABC

A: Ensure patent 0.5mg (0.5ml 1:1000) Adrenaline IM 5mg Salbutamol nebs if bronchospasm Use of manoeuvres/adjuncts B: 15L/min O2

Management: ABC

A: Ensure patent 0.5mg (0.5ml 1:1000) Adrenaline IM 5mg Salbutamol nebs if bronchospasm Use of manoeuvres/adjuncts B: 15L/min O2 C: Large bore IV access Bloods inc. mast cell tryptase 0.9% Saline Stat 10mg Chlorphenamine slow IV 200my Hydrocortisone slow IV

Further Management

IM Adrenaline repeated every 5 mins

Guided by obs
Any recent changes in pts management? Documented allergies Has anything like this happened before? Possible triggering events? Admit to HDU/ICU?

Check notes and drug chart

Brief History and Examination

Senior help

Document in notes Incident reporting

Think before Prescribing

Check allergy status before prescribing/ administering

Is it a true allergy or intolerance?

Septrin:

Think before Prescribing

Check allergy status before prescribing/ administering

Is it a true allergy or intolerance?

Septrin:

AKA Co-trimoxazole

Trimethoprim & Sulfamethoxazole

Augmentin:

Think before Prescribing

Check allergy status before prescribing/ administering

Is it a true allergy or intolerance?

Septrin:

AKA Co-trimoxazole

Trimethoprim & Sulfamethoxazole

Augmentin:

AKA Co-amoxiclav Amoxicillin & Clavulanate

Tazocin:

Think before Prescribing

Check allergy status before prescribing/ administering

Is it a true allergy or intolerance?

Septrin:

AKA Co-trimoxazole

Trimethoprim & Sulfamethoxazole

Augmentin:

Tazocin:

AKA Co-amoxiclav Amoxicillin & Clavulanate Pipercillin & Tazobactam

Think before Prescribing

Check allergy status before prescribing/ administering

Is it a true allergy or intolerance?

Septrin:

AKA Co-trimoxazole

Trimethoprim & Sulfamethoxazole

Augmentin:

AKA Co-amoxiclav Amoxicillin & Clavulanate Tazocin: Pipercillin & Tazobactam 10% patients with penicillin anaphylaxis have reaction to cephlasporins Check Trust guidelines or ask Microbiologist

Slideshow Quiz

Slideshow questions

Should be 1 minute per question...

1.

What do these spirometry results show? (1 mark) Name 1 cause of this result (1 mark)

FEV1 / FVC = 64% FEV1 = 45%

2.

Name the following oxygen devices (5 marks)

3
4

3.

What is this treatment (1 mark)? What are the indications for this treatment? (1 mark)

4.

Give 3 possible causes for this CXR appearance (3 marks)

5.

What is your diagnosis of this CXR? (1 mark) How will you treat this condition? (2 marks)

6.

What is the diagnosis and treatment shown here? (1 mark) What tests would you send off the sample for? (2 marks) What are potential causes of this condition? (2 marks)

7.

What does this CXR show? (1 mark)

Slideshow answers

1.

What do these spirometry results show? (1 mark) Name 1 cause of this result (1 mark)

FEV1 / FVC = 64% FEV1 = 45% Obstructive spirometry Severe COPD / asthma

2.

Name the following oxygen devices (5 marks)

3
4

3.

What is this treatment (1 mark)? What are the indications for this treatment? (1 mark)

Long Term Oxygen Therapy

Pa02 <7.3kpa with optimum therapy on 2 occasions over 3 weeks apart

Pa02 7.3-8kpa with pulmonary htn, cor pulmonale, polycythaemia

4.

Give 3 possible causes for this CXR appearance (3 marks)

1. Pneumonectom y 2. Left massive pleural effusion 3. Total lung collapse

5.

What is your diagnosis of this CXR? (1 mark) How will you treat this condition? (2 marks)
1. ABC 2. Large cannula into 2nd IC space, MCL (directly above 3rd rib) 3. Call senior

6.

Diagnosis (1 mark)

Right pleural effusion with ICD-in-situ

Tests (2 marks)

MC&S , LDH & protein, cytology, pH

Causes (2 marks)

Transudative (protein <30g/L) the failures (pulmonary oedema, cirrhosis, nephrotic syndrome) Exudative (protein >30g/L) malignancy, infection, haemothorax Empyema

7.

What does this CXR show? (1 mark)

Hiatus Hernia

Thanks for listening!!!