Respiratory 1 Phase 2 Simon Berry Liz Stedman

Respiratory 1 Phase 2 Simon Berry + Liz Stedman The Peer Teaching Society is not liable for false or misleading information…

Aims • To give a brief overview of the following 3 topics: – COPD – Asthma – Pulmonary Fibrosis (Interstitial Lung Disease) • Apply the knowledge to practice exam questions The Peer Teaching Society is not liable for false or misleading information…

COPD

Introduction Chronic Obstructive Pulmonary Disease made up of Chronic bronchitis vs Emphysema • Chronic Bronchitis (Bronchi) –. Daily productive cough for at least 3 months over 2 years consecutive years. Pathology hyperplasia of mucous glands and infiltration of the airway wall with inflammatory cells. Bronchial wall thickening. • Emphysema (alveoli) – permanent enlargement of airspaces distal to terminal bronchioles. Reduced SA for gas exchange. Reduced recoil, and loss of support = airway narrowing • • • Mainly affects people over 35, more common with increasing age Men >Women Very common reason for hospitalisation (1 in 8 admissions) The Peer Teaching Society is not liable for false or misleading information…

Aetiology • Smoking / occupational exposure / air pollutants irritation and inflammation damage to the airways • 1 in 10 (20/d) and 1 in 4 (40/d) will develop COPD • Genetic alpha-1 -antitryspin deficiency (affects the proteins in the lung, liver and blood disorder). 1 in 100 The Peer Teaching Society is not liable for false or misleading information…

Pathophysiology • Defining feature irreversible airflow limitation during forced expiration. Result of loss of elastic recoil due to lung tissue destruction / increase in resistance of conducting airways (mucus) • May develop HF reduced Ox. in blood and changes in lung tissue leading to increased pressure in pulmonary vasculature. increased strain on H. muscles = HF (worsening Breathlessness and fluid retention) • Respiratory failure level of oxygen in blood too low, CO 2 builds up in blood stream. May need palliative care The Peer Teaching Society is not liable for false or misleading information…

Symptoms • Exertional breathlessness (PC) – MRC breathlessness scale • Chronic productive Cough (PC) : may start of episodic persistent • Wheeze • Frequent winter ‘bronchitis’ / exacerbations – Bacteria 1 in 2/3 in COPD – Vrial 1 in 3 • Symptoms all worsen with time if smoking not stopped!

Signs • Physical examination in detecting mild – moderate COPD is poor. • Severe disease may show – Tachypnea and respiratory distress w/ simple activities – Accessory muscle usage and indrawing of lower IC spaces (Hoover sign – Cyanosis – Elevated JVP – Peripheral Oedema – Hyperinflation • Thoracic signs may show – Hyperinflation (barrel chest) – Wheezing – forced+ unforced expiration – Diffusely decreased breath sounds – Hyperresonance on percussion – Prolonged expiration – Coarse crackles beginning with inspiration in some cases

Bronchitis vs Emphysema • CB (blue bloaters) – alveolar ventilation – Low Pa. O 2 – High Pa. CO 2 – Cyanosed but not Breathless – Rely on hypoxic drive – Oxygen sats: 88 -92% – May progress to cor pulmonale • Emphysema (pink puffers) – alveolar ventilation – near normal Pa. O 2 – Normal / low Pa. CO 2 – Breathless, but NOT cyanosed – May progress to Type 1 RF

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Investigations • Spirometry diagnostic. Check FEV 1 - postbronchodilator – – – FEV 1/FVC < 70% or 0. 7 = COPD (compared to pred. value / matched control) Mild (stage 1) FEV 1 at least 80% predicted value Moderate (stage 2) FEV 1 50%-79% pv Severe (stage 3) FEV 1 30%-49% pv Very Severe (stage 4) FEV 1 <30% pv • ABG – Best clues for acuteness an D. severity / exacerbation • CXR – – check for lung cancer Hyperinflation (> 6 ant. Ribs seen above diaphragm and mid-clavicular line) Flat hemidiaphragms, large central pulmonary arteries in peripheral vasc markings, bullae (emphysema) • High-res CT

Investigations (cont. ) • FBC: anaemia can cause SOB, polycythemia secondary to COPD ( RBC) • Alpha—antitrypsin levels – if early onset, minimal smoking Hx, FHx presence • Steroid trial – see if COPD responsive to steroids • ECG/Echo – Monitor Cor Pulmonale • TLCO – Ix symptoms disproportionate to spirometric impairment

Management • STOP SMOKING • Exercise and weight loss • Influenza and pneumococcal vaccination • Cardiopulmonary rehabilitation • Broncho-pulmonary exercises • Caution with flying (increased risk of pneumothorax with altitude)

Management (cont. ) • Pulmonary Rehab programme (physiotherapy and broncho-pulmonary exercises Stage 1 • SABA or antimuscarinic (Beta agonist or anticholinergic) as needed • +LABA Stage 2 • Cardiopulmonary rehab Stage 3 Stage 4 Stage 5 • Inhale glucocorticoid (if repeated exacerbations) • Anticholinergic + LABA + inhaled steroid • + LTOT +? Lung Surgery

Asthma

Introduction • Paroxysmal and reversible airways obstruction – Airway hyperresponsiveness – Inflammation of the bronchi – Airway remodelling The Peer Teaching Society is not liable for false or misleading information…

Aetiology • Extrinsic – Atopic individuals – Often accompanied by eczema – Can be Ig. E related or non-Ig. E related • Intrinsic – Middle age (‘late onset’) The Peer Teaching Society is not liable for false or misleading information…

Precipitants • • • Occupational sensitizers Cold symptoms – upper respiratory tract infection (URTI) Cold air Exercise (during or after) Pollution eg cigarette smoke, car fumes Infection Drugs eg beta blockers, NSAIDs Allergens – pollen exposure, exposure to animals, dust mites Time of day: natural dip in peak flow overnight The Peer Teaching Society is not liable for false or misleading information…

Symptoms • • • Intermittent dyspnoea Wheeze Cough (often nocturnal) Sputum Ask about: – Triggers: at home, at work – Diurnal variation – Other atopic disease – Da The Peer Teaching Society is not liable for false or misleading information…

Severity • RCP 3 – Recent nocturnal waking? – Usual asthma symptoms in day? – Interference with ADLs? • Asthma control test (out of 25) The Peer Teaching Society is not liable for false or misleading information…

Signs • • • Tachypnoea Hyperinflated chest Hyperresonant percussion note Diminished air entry Widespread, polyphonic wheeze The Peer Teaching Society is not liable for false or misleading information…

Investigations • Respiratory Function Tests – Peak Expiratory Flow (PEF) • diurnal variation of >20% on 3 d a wk for 2 wks – Spirometry • obstructive defect (↓FEV 1/FVC, ↑RV), >15% increase improvement in FEV 1 following beta 2 agonists • Other tests – Corticosteroid trial – Skin prick tests – CXR – exclude pneumothorax/ aspergillosis The Peer Teaching Society is not liable for false or misleading information…

Management of Acute Attack • • • 100% O 2 via non-rebreathing bag Nebulized salbutamol + ipratropium bromide Hydrocortisone IV or prednisolone PO CXR to exclude pneumothorax Magnesium sulphate if life-threatening The Peer Teaching Society is not liable for false or misleading information…

Long-term Management • Conservative Management – DON’T FORGET – Smoking cessation – Avoid Precipitants – Education: Inhaler technique, PEF monitoring, self -management by altering medications in light symptoms, advise about oral prednisolone for rescue therapy – Asthma action plan The Peer Teaching Society is not liable for false or misleading information…

Long-term Management Medical Management Step 1 Step 2 • Inhaled short-acting β 2 agonist PRN • Add inhaled steroid 200 -800 mcg/day • Add inhaled long-acting β 2 agonist (LABA) Step 3 • If LABA fails, increase steroid dose Step 4 Step 5 • Addition of fourth drug eg leukotriene receptor antagonist, theophylline, cromoglicate, omalizumab • Increase inhaled steroid up to 2000 mcg/day • Prednisolone PO

Asthma vs COPD • COPD – permanent damage and constriction to airways • Asthma – reversible constriction of the smooth muscle in the airways • COPD more likely to cause productive cough than asthma • Waking at night with SOB and wheeze asthma > COPD • COPD rare <35, asthma common <35 • Asthma, allergies, eczema (atopic conditions)

Pulmonary Fibrosis

Introduction • Three main types: – Replacement fibrosis 2 ry to lung damage • Eg infarction, TB and pneumonia – Focal fibrosis in response to irritants • Eg coal dust and silica – Diffuse parenchymal lung disease • Occurs in idiopathic pulmonary fibrosis (IPF) and extrinsic allergic alveolitis The Peer Teaching Society is not liable for false or misleading information…

Epidemiology + Aetiology • Peak age 50 -70 yrs. M=F • Common causes: – Idiopathic pulmonary fibrosis – – – – Replacement fibrosis Pneumoconioses eg silicosis, asbestosis, CWP etc Extrinsic allergic alveolitis Granulomatous diseases eg sarcoidosis Exposure to drugs eg amiodarone Radiation exposure Connective tissue diseases eg rheumatoid arthritis, SLE etc The Peer Teaching Society is not liable for false or misleading information…

Presentation • Dependent on disease process • May be: – Acute, with a fulminant, progressive, remitting or resolving course – Subacute, with a resolving, remitting, relapsing or progressive course – Chronic, insidious and slowly progressive • May be incidental findings on CXR, spirometry, occupational risk assessment The Peer Teaching Society is not liable for false or misleading information…

Symptoms • • • Dyspnoea Chronic cough Wheezing Haemoptysis Chest pain The Peer Teaching Society is not liable for false or misleading information…

Signs • Central cyanosis, fine end-inspiratory pulmonary crackles • Nonspecific features eg low grade fever and myalgia • Finger clubbing, esp with idiopathic pulmonary fibrosis and asbestosis • Signs of pulmonary hypertension and cor pulmonale The Peer Teaching Society is not liable for false or misleading information…

Investigations • FBC - ? mild anaemia, ESR / CRP may ↑ • Autoantibodies (antinuclear antibodies, rheumatoid factor) • ABGs: O 2 desaturation is common • Lung function tests – Restrictive pattern (but obstruction of airways may also be present). – Reduced total lung capacity. – Reduced residual volume. – Reduced gas transfer. The Peer Teaching Society is not liable for false or misleading information…

Imaging • CXR – May show no abnormality – Reticular and/or nodular opacities – Honeycombing is a late finding = severe disease • High resolution chest CT scanning – characteristic findings, extent and progression The Peer Teaching Society is not liable for false or misleading information…

Management • Supportive measures – Smoking cessation, avoidance of cause, influenza and pneumococcal vaccine, pulmonary rehabilitation • Drug treatment – Immunosuppressive therapy • Corticosteroids • Cytotoxic drugs (azathioprine) • Lung transplantation The Peer Teaching Society is not liable for false or misleading information…

Complications • Pulmonary hypertension • Coronary artery disease • Lung cancer The Peer Teaching Society is not liable for false or misleading information…

ABGs

Respiratory Failure • Type 1 Respiratory Failure – Pa. O 2 LOW < 8 k. Pa – *Pa. CO 2 LOW/ NORMAL < 6. 5 k. Pa* • Type 2 Respiratory Failure – Pa. O 2 LOW < 8 k. Pa – *Pa. CO 2 HIGH > 6. 5 k. Pa* The Peer Teaching Society is not liable for false or misleading information…

Respiratory Failure • Type 1 Respiratory Failure – Ventilation-perfusion mismatch • Under-ventilated alveoli eg pulmonary oedema, pneumonia, pneumothorax, pulmonary fibrosis • Venous blood bypasses (eg R-L cardiac shunts, PE) • Type 2 Respiratory Failure – Inadequate alveolar ventilation eg asthma, COPD The Peer Teaching Society is not liable for false or misleading information…

Practice Questions

Practice Question • What is the key pathological feature of asthma? a) b) c) d) e) Collapse of small airways on exhalation Increased connective tissue deposition Intermittent, inappropriate bronchoconstriction Loss of alveolar surface area Smooth muscle hyperplasia and increased mucus The Peer Teaching Society is not liable for false or misleading information…

Practice Question 1. A young patient with a history of asthma arrives at the accident and emergency department with acute severe breathlessness, and is obviously wheezy and distressed. The doctors immediately give him a treatment which will rapidly improve his arterial oxygenation Answer: C The Peer Teaching Society is not liable for false or misleading information…

Practice Question 2. The doctors then examine and investigate the same patient described in question 1 (above) and make a diagnosis of acute severe asthma. They decide to prescribe the bronchodilator treatment for initial therapy Answer: I The Peer Teaching Society is not liable for false or misleading information…

Practice Question 3. Shortly after this the doctors then decide to administer antiinflammatory treatment to the same patient. Which is the most appropriate treatment? Answer: G The Peer Teaching Society is not liable for false or misleading information…

Practice Question 1. A 67 year old man is seen in outpatients with a 4 year history of progressive shortness of breath. He has worked for 12 years in a power station and was regularly exposed to all types of dust. Answer: C The Peer Teaching Society is not liable for false or misleading information…

Practice Question 2. An 18 -year-old hairdresser apprentice was seen by her GP with a 12 hour history of wheeze and shortness of breath. She was wheezy on examination with a pulse rate of 120 bpm, and had a recorded peak flow at 30% of her predicted value just prior to a nebuliser of salbutamol. Answer: B The Peer Teaching Society is not liable for false or misleading information…

Hints and Tips • For phase list: – Patient. co. uk/patientplus • For OSCE – Geeky medics youtube channel The Peer Teaching Society is not liable for false or misleading information…

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Appendix

Appendix The Peer Teaching Society is not liable for false or misleading information…

Asthma Control Test