Goals Recognize common and uncommon presentations of COPD and asthma Make an appropriate assessment of the severity of illness Prescribe appropriate therapy Disposition the patient appropriately ID: 909690
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Slide1
COPD/ASTHMA
Ian Brown, PA-C
Slide2Goals
Recognize common and uncommon presentations of COPD and asthma.
Make an appropriate assessment of the severity of illness.
Prescribe appropriate therapy.
Disposition the patient appropriately.
Give complete discharge instructions that ensure the patient has all the care they need.
Slide3Formulary
Slide4COPD
Slide5COPD Exacerbation
An acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medications. (1)
Cough increases in frequency or severity.
Sputum production increases in volume and/or changes character
Dyspnea increases. (1)
Mild exacerbation: 1/3 Moderate-Severe: 2-3/3
Slide6Case 1
HPI: 64 YOM with 3 day history of increased shortness of breath. Increases cough and sputum production. Symptoms onset after working in his garden earlier this week. PMH of COPD. Has been using Advair and
ProAir
inhalers with no relief of symptoms.
Pt presents with his daughter who informs you that the same thing happened last year at this time. They are here because they do not want it to be as bad as last time.
Vitals: BP: 138/86, HR 92 BPM, Temp 98.4 orally,
Resp
: 22/Min., O2 92% Pain 0
Slide7Physical Exam:
General impression: Pt is well nourished and in no acute distress. He is leaning forward, supporting the weight of his torso on his knees. He sits very erect in his chair.
HEENT: normal *
Heart: normal rate and rhythm. No murmur, rub or gallop.
Lungs: diffuse wheeze bilaterally.
Wheeze
continued
Case 1
Slide8Case 1
Testing?
Assessment: Acute exacerbation of COPD
MDM
PLAN
continued
Slide9Case 1
Plan:
Start neb
X-ray
Labs
Re Assess
continued
Slide10Case 1
Patient instructions:
Continue current therapy. Start the medication prescribed today. Take prednisone in the morning and afternoon with food. Inform your primary care provider of the care you receive here today. If you get worse and not better or any time you feel you need further evaluation follow up with your primary care or follow up with Duke Urgent Care.
Anytime you feel your condition has become acute and you need immediate evaluation and care dial 911 or go to the nearest emergency department.
continued
Slide11Asthma
Slide12Acute Exacerbation of Asthma
Worsening asthma symptoms and lung function.
Can be presenting manifestation of asthma.
Response to a trigger.
Viral URI, allergen or irritant exposure, lack of adherence to controller medication, or unknown stimulus. (2)
*Early recognition is key
Slide13Case 2
HPI: 22 YOM with 2 week history of persistent dry cough. Worse at night. Worse when going outside. Some relief with Benadryl at night. Dayquil and Sudafed provide no relief of symptoms. No fever. No sick contacts. No history of asthma. Pt’s mom and sister have asthma.
Vitals: BP: 138/88, HR 112 BPM, Temp 98.4 orally,
Resp
: 26/Min., O2 95% Pain 0
Slide14Case 2
Physical Exam:
General impression: Pt is well nourished and in no acute distress. Not cyanotic. No stridor.
HEENT: Bilateral TM/EAC normal. No effusion present. Nose:
turbinates
pale and edematous. Cobble stoning present in the posterior oropharynx. Heart: Tachycardia noted. Normal rhythm. No murmur, rub or gallop.
Lungs: diffuse wheeze bilaterally.
Example
continued
Slide15Case 2
Assessment
Working diagnosis
Plan
Initial therapy
Tests / Imaging
continued
Slide16Case 2
continued
X-ray
CBC
Slide17Case 2
Plan continued
Medications
Disposition
Discharge instructions
When to follow up with PCP?What should he tell his PCP?
continued
Slide18Pediatric Asthma
Slide19Pediatric Asthma:
Clinical Decision Making
When is additional therapy necessary?
When is home or office management of an asthma exacerbation appropriate and when should the child be sent to the emergency department?
If the child is sent to the ED, should the child be taken by the parents/caretakers or by ambulance? (3)
How sick is the child?
Which drugs should be used for treatment?
What are the optimal doses and delivery routes?
Slide20Pediatric Asthma Examples
Pediatric respiratory distress.
Slide21In clinic therapy
Albuterol vs.
Duoneb
Dexamethasone vs.
Orapred
Supportive therapy
Slide22Disposition
Home with close follow up
Home with concern about follow up
* Pediatric steroid dosing*
ED
Parents driving
EMS
Slide23QUESTIONS
Slide24Goals
Recognize common and uncommon presentations of COPD and asthma.
Make an appropriate assessment of the severity of illness.
Prescribe appropriate therapy.
Disposition the patient appropriately.
Give complete discharge instructions that ensure the patient has all the care they need.
Slide25REFERENCES
1.
https://www.uptodate.com/contents/copd-exacerbations-management?search=copd%20exacerbations&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
2.
https://www.uptodate.com/contents/acute-exacerbations-of-asthma-in-adults-home-and-office-management?search=acute%20asthma%20exacerbation%20in%20adults&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
3.
https://www.uptodate.com/contents/acute-asthma-exacerbations-in-children-younger-than-12-years-home-office-management-and-severity-assessment?search=acute%20asthma%20exacerbation%20children&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3
4.
https://www.youtube.com/watch?app=desktop&v=C4_eB6Inelo
5.
https://www.youtube.com/watch?app=desktop&v=DBfSPW39N0Q
6. https://www.youtube.com/watch?v=oyqKHcqLnTQ