Respiratory Medicine in General Practice - PowerPoint Presentation

1. Respiratory Medicine in General PracticeDr Andrew ThurstonGP

2. Focus on AKT – RCGP Curriculum:Investigations:PEFR, Spirometry, Pulse Oximetry, Sputum CultureIndications for CXR, CT, MRI, BronchoscopyDisease Scoring Tools e.g. CURB65Conditions:URTI, LRTI - Bronchiectasis Ephysema - PneumothoraxPE - Pleural EffusionAsthma - COPDChronic Cough - Respiratory MalignanciesStridor / Hoarseness - Occupational Lung DiseasesFibrosis - Respiratory FailureUse of Oxygen - Connective Tissue Disorders

3. Focus on AKT – RCGP Curriculum:Investigations:PEFR, Spirometry, Pulse Oximetry, Sputum CultureIndications for CXR, CT, MRI, BronchoscopyDisease Scoring Tools e.g. CURB65Conditions:URTI, LRTI - Bronchiectasis Ephysema - PneumothoraxPE - Pleural EffusionAsthma - COPDChronic Cough - Respiratory MalignanciesStridor / Hoarseness - Occupational Lung DiseasesFibrosis - Respiratory FailureUse of Oxygen - Connective Tissue Disorders

4. DISCLAIMERI wrote all the questions to fit with the topicsThey were designed to be similar to AKT questions.Please ask if anything isn’t clear or looks wrong.

5. Question 1A 56 year old woman presents with exertional breathlessness, worsening over 6 months. Spirometry shows:FVC 1.98 (predicted 3.51)FEV1 1.64 (predicted 2.82)FEV1/FVC 83% (predicted 80%)What is the most likely diagnosis?AsthmaBronchiectasisCOPDPulmonary FibrosisExtrinsic Allergic Alveolitis

6. Question 1A 56 year old woman presents with exertional breathlessness, worsening over 6 months. Spirometry shows:FVC 1.98 (predicted 3.51)FEV1 1.64 (predicted 2.82)FEV1/FVC 83% (predicted 80%)What is the most likely diagnosis?AsthmaBronchiectasisCOPDPulmonary FibrosisExtrinsic Allergic Alveolitis

7. SpirometryAvailable at most practicesDone by practice nursesTechnique dependant – check comments on reportPatient needs to be well – need to see best effortUseful in patients with:Chronic BreathlessnessChronic Cough

8. Requesting Spirometry in GPWith or Without Reversibility?If you think it could be asthma – ask for reversibilityAnything else – Post-Bronchodilator SpiroIs the patient capable of performing the test?Need to be able to follow instructions.Is the patient well enough?Wait 4 weeks after any chest infection

9. Interpreting SpirometryObstructiveRestrictiveAsthmaCOPDe.g. FibrosisFVCNormal or ↓Normal or ↓↓↓FEV1↓↓↓↓↓↓FEV1/FVC↓↓NormalReversibility XXForced Vital Capacity (FVC) – total vol. expired airForced Expiratory Volume in 1 second (FEV1)– Vol. Air expired in 1st second of forced expirationFEV1/FVC ratio – Normal FEV1 should be >70% of FVCReversibility = >12% improvement in FEV1

10. Interpreting SpirometryExample: Pre Predicted FVC 2.67 2.80 FEV1 1.48 2.24 FEV1/FVC 54% 80%Diagnosis?

11. Interpreting SpirometryExample: Pre Predicted FVC 2.67 2.80 FEV1 1.48 2.24 FEV1/FVC 54% 80%Diagnosis?Obstructive Airways Disease

12. Interpreting SpirometryExample: Pre Predicted Post FVC 2.67 2.80 2.80FEV1 1.48 2.24 2.01FEV1/FVC 54% 80% 71%Diagnosis?

13. Interpreting SpirometryExample: Pre Predicted Post FVC 2.67 2.80 2.80FEV1 1.48 2.24 2.01FEV1/FVC 54% 80% 71%Diagnosis?Obstructive Airways Disease with Reversibility(i.e. Asthma)

14. Question 2A 66 year old man with no PMH attends with 4 days of productive cough and SOB. O/E there are crackles at the right lower zone. Temp 37.5, Pulse 86 reg, BP 100/54, RR 24, Sats 92%. He does not appear confused. Using CRB-65 score what should you do?CRB=1 - Manage in the community with oral antibioticsCRB=2 – Manage in community with oral antibiotics and arrange follow up in 24 hours.CRB=2 – Arrange admission for IV antibioticsCRB=3 – Arrange admission for IV antibioticsCRB-65 score is irrelevant in this case

15. Question 2A 66 year old man with no PMH attends with a productive cough and SOB. O/E there are crackles at the right lower zone. Temp 37.5, Pulse 86 reg, BP 100/54, RR 24, Sats 92%. He does not appear confused. Using CRB-65 score what should you do?CRB=1 - Manage in the community with oral antibioticsCRB=2 – Manage in community with oral antibiotics and arrange follow up in 24 hours.CRB=2 – Arrange admission for IV antibioticsCRB=3 – Arrange admission for IV antibioticsCRB-65 score is irrelevant in this case

16. Symptoms of LRTICough - productive or dry - Generally lasts 7 days – can linger for 3-4 weeksSputum - Green = Dead cells -Yellow/Brown = BacteriaBreathlessnessSystemic Features e.g. feverChest Pain / Pleurisy / Abdominal Pain

17. CRB-65 Score for CAP – NICE CKS“If a person has clinical symptoms and signs suggestive of CAP, assess the severity of the illness using the CRB-65 score for mortality risk.The score is calculated by giving 1 point for each of the following prognostic features:C = Confusion (new disorientation in person, place, or time).R = Raised respiratory rate (30 breaths per minute or more).B= Low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg).65 = Age 65 years or more.”

18. CRB-65 Score for CAP – NICE CKSScoring: Management:0 = Low Severity 0-1= Community1-2 = Intermediate Severity 2= Admission “advised”>2 = High Severity 3+= Urgent AdmissionCautions:O2 Sats still need to be considered“oxygen saturation below 94% indicates the need for urgent hospital admission.” - NICE“Mortality score doesn’t always accurately predict mortality risk – use clinical judgement” - NICE

19. Question 3A 43 year old smoker with no PMH attends with a 3 day history of a cough productive of yellow sputum. He doesn’t appear confused. There are crackles at the left base, Temp 38.0, Pulse 76 reg, BP 138/78, RR 16, Sats 97%. You decide he requires oral antibiotics, what would you prescribe?Amoxicillin 500mg TDS for 7 daysAmoxicillin 500mg TDS + Clarithromycin 500mg BD for 7 daysAmoxicillin 500mg TDS for 5 daysDoxycycline 200mg single dose then 100mg OD for 4 daysC0-Amoxiclav 625mg TDS for 7 days

20. Question 3A 43 year old smoker with no PMH attends with a 3 day history of a cough productive of yellow sputum. He doesn’t appear confused. There are crackles at the left base, Temp 38.0, Pulse 76 reg, BP 138/78, RR 16, Sats 97%. You decide he requires oral antibiotics, what would you prescribe?Amoxicillin 500mg TDS for 7 daysAmoxicillin 500mg TDS + Clarithromycin 500mg BD for 7 daysAmoxicillin 500mg TDS for 5 daysDoxycycline 200mg single dose then 100mg OD for 4 daysC0-Amoxiclav 625mg TDS for 7 days

21. Managing CAPSelf Care – rest, fluids, antipyreticsAdvise to STOP SMOKINGNo evidence for Cough Medicines“Arrange a CXR for anyone over 60 and smokes” – BTS/NICE - high risk group for Lung Cancer (vague on timings – suggests definitely needed at 6 weeks post onset but ?also at time of acute illness)

22. Managing CAPPrescribe Antibiotics:If CRB-65 = 0Amoxicillin 500mg TDS for 5 daysPenicillin allergy – Doxycycline or Clarithromycin for 5 days“Review at 3 days and increase to 7 day course if response is poor” – NICEIf CRB-65 = 1-2“Consider Dual Therapy for 7-10 days” e.g. Amoxicillin + Clarithromycin

23. Managing CAPNICE guide on prognosis:“Explain to the person that after starting antibiotic treatment, symptoms should improve, although the rate of improvement will vary with the severity of illness. Discuss the natural history of pneumonia symptoms, that by:1 week - fever should have resolved.4 weeks - chest pain and sputum production should have substantially reduced.3 months - most symptoms should have resolved but fatigue might still be present.6 months - symptoms should have fully resolved.”

24. Question 4Which is the most common cause of Community Acquired Pneumonia?Mycoplasma PneumoniaeStreptococcus PneumoniaeStaphlococcus AureusLegionella PneumophiliaHaemophilus InfluenzaeViral InfectionsPseudomonas Aeuriginosa

25. Question 4Which is the most common cause of Community Acquired Pneumonia?Mycoplasma PneumoniaeStreptococcus PneumoniaeStaphlococcus AureusLegionella PneumophiliaHaemophilus InfluenzaeViral InfectionsPseudomonas Aeuriginosa

26. CAP causative organisms BTS AuditNo Pathogen Identified 45.3%Steptococcus Pneumoniae 36.0%All Viruses 13.1%Haemophilus Influenzae 10.2%Mycoplasma Pneumoniae 1.3%Staphlococcus Aureus 0.8%Legionella Pneumophilia 0.4%

27. Pseudomonas AeruginosaYou are going through your results and a sputum result comes through showing Pseudomonas.What do else do you need to know? Any chronic respiratory conditions? Why was sputum sent? How is the patient now? Any previous Sputum results?What should you do with this result? If they’ve had it before and are well – Nothing Never had it before – Treat - speak to Micro – should aim to eradicate before it colonises. Had it before and unwell – Treat - speak to Micro

28. Pseudomonas AeruginosaGram Negative RodsCommon in soil and standing waterOpportunistic infection in humans - chest, wounds, nails, otitis externaSurvivor – very hard to eradicate once it has infectedLeads to cycles of recurrent infection and “colonisation” especially in Bronchiectasis and CFContributes to deterioration in chronic respiratory diseases e.g. Early infection if CF is a bad prognostic indicatorChronic infection is associated with worse lung functionRust coloured sputum (apparently tastes metallic)Makes nails and wounds greenOnly oral antibiotic option is Ciprofloxacin – always speak to micro (or check Respiratory clinic letters) as may need IVIV treatment = aminoglyosides e.g. Tobramycin, Gentamycin

29. Question 4A 19 year old male student has just returned home for the holidays and now attends with a 5 week history of a persistent dry cough, sore throat, and a rash. He thinks a few other students in his halls have had the same thing. He denies foreign travel and doesn’t smoke. On examination his observations are all normal. His chest and throat are clear. Abdomen is SNT with no organomegaly. There is no lymphadenopathy. The rash is on the trunk and consists of raised target lesions. What is the most likely diagnosis?Glandular FeverWhooping CoughAtypical PneumoniaTuberculosisPost Infective Cough

30. Question 4A 19 year old male student has just returned home for the holidays and now attends with a 5 week history of a persistent dry cough, sore throat, and a rash. He thinks a few other students in his halls have had the same thing. He denies foreign travel and doesn’t smoke. On examination his observations are all normal. His chest and throat are clear. Abdomen is SNT with no organomegaly. There is no lymphadenopathy. The rash is on the trunk and consists of raised target lesions. What is the most likely diagnosis?Glandular FeverWhooping CoughAtypical PneumoniaTuberculosisPost Infective Cough

31. Question 5A 19 year old male student has just returned home for the holidays and now attends with a 5 week history of a persistent dry cough, sore throat, and a rash. He thinks a few other students in his halls have had the same thing. He denies foreign travel and doesn’t smoke. On examination his observations are all normal. His chest and throat are clear. Abdomen is SNT with no organomegaly. There is no lymphadenopathy. The rash is on the trunk and consists of raised target lesions. What is the most likely diagnosis?Legionella PneumophiliaMycoplasma PneumoniaChlamydia Psittaci (Psittacosis)KlebsiellaCoxiella Burnetii

32. Question 5A 19 year old male student has just returned home for the holidays and now attends with a 5 week history of a persistent dry cough, sore throat, and a rash. He thinks a few other students in his halls have had the same thing. He denies foreign travel and doesn’t smoke. On examination his observations are all normal. His chest and throat are clear. Abdomen is SNT with no organomegaly. There is no lymphadenopathy. The rash is on the trunk and consists of raised target lesions. What is the most likely diagnosis?Legionella PneumophiliaMycoplasma PneumoniaChlamydia Psittaci (Psittacosis)KlebsiellaCoxiella Burnetii

33. Atypical PneumoniaRisk Factors:Close community settings e.g. university halls, army barracks, cruise ships, schoolsImmunosuppressionKey Features:Persistent Cough (can be productive or dry)Sore throat / PharynigitisRecent community exposureAge <50Clinical signs usually mild or absent Lungs look worse on CXR then they sound on examinationCAP that hasn’t responded to penicillin

34. Atypical Pneumonia – BMJ Best PracticeInvestigations:CXR – looking for consolidationBloods - ↑WCC, ↑CRP, with mycoplasma can sometimes get anaemia + ↑ALT Sputum cultureI would consider doing all the above in any LRTI not responding to usual treatmentAlso consider (depending on history / level of suspicion)Legionella Urine AntigenSerology for Mycoplasma / Chlamydia / Coxiella

35. Atypical Pneumonia – BMJ Best PracticeManagment:1st line – Macrolide (Azithromycin / Clarithromycin)Alt 1st line – Doxycycline2nd line – Fluroquinolone (Levoflocacin / Moxyfloxacin)I would think about consulting microbiology for advice

36. Atypical PneumoniaMycoplasma:Community Outbreaks – approx every 4 yearsUsually late summer / autumnMost common in children and young adultsCan have associated headacheAssociated with various rahes – usually self limiting maculopapular type – classically...Erythema MultiformeChest usually sounds clearCXR – patchy consolidationMicro – Sputum or Throat swabsNot a notifiable disease

37. Atypical PneumoniaLegionella:Standing water – e.g. Air conditioning, spa pools, showers/taps.Caught from these sources rather then infected individuals. Outbreaks often in hotels, cruise ships, hospitals, nursing homes.Can be associated with DiarrhoeaLegionella urine antigen – negative result doesn’t excludeSputum cultureNotifiable diseasePsitticosis:Chlamydia Psittaci carried by birdsSuspect if exposure to commercial (poultry farmers) or pet birds (parrots / budgies)Chlamydia swab of throat – sputum testing is risk to Lab staff

38. Atypical PneumoniaCoxiella Burnetti:Associated with livestock: Farmers, Vets, Abattoir workers all at risk. Micro lab workers also at riskUsually as outbreaks with other workers affected.Usually self limiting flu-like illness but...Can cause hepatitis – hepatomegaly (less common) and endocarditis (rarely).Recommendation is to treat with antibiotics for 14 days in any symptomatic patient with clinical suspicion.Serology testing is the usual diagnostic testI would discuss with micro if ever suspecting

39. Question 6A 30 year old woman, originally from Somalia, attends with a 3 week history of weight loss and malaise. In last week she has noticed a mild but productive cough. She had been back to Somalia 5 weeks ago to visit a relative in hospital.Which test is most likely to be diagnostic:Sputum Culture for Acid Fast BacilliFull blood count and CRPThick blood filmQuantiFERONChest Radiograph

40. Question 6A 30 year old woman, originally from Somalia, attends with a 3 week history of weight loss and malaise. In last week she has noticed a mild but productive cough. She had been back to Somalia 5 weeks ago to visit a relative in hospital.Which test is most likely to be diagnostic:Sputum Culture for Acid Fast BacilliFull blood count and CRPThick blood filmQuantiFERONChest Radiograph

41. Tuberculosis Mycobacterium Tuberculosis Needs specific culture medium to grow in lab and ZN staining – need to ask for AFB when requesting culture Spread by droplet from people with active pulmonary TB Increasing number of cases in UK Many born outside UK in a high prevalence areas (India, Pakistan, Somalia – most common) 70% of all UK cases come from the 40% most deprived areas – Homeless, overcrowded conditions, prison population Other risk factors : Alcohol / Drug misuse, Comorbidities (diabetes, HIV), Immunosuppression, Previous incomplete TB treatment,

42. TuberculosisActive Pulmonary TB (majority of cases – 55%) Persistent Productive Cough +/- Haemoptysis Weight Loss, Fever, Night sweats InfectiousExtra-pulmonary TB (rare) More likely in children from high risk areas CNS (Meningitis), Bone (Spinal = Pott’s Disease), Pericarditis.Latent TB (10% of cases) No symptoms, non-infectious, Can become active – often when immunocompromised Detected during screening Multi-drug Resistant TB (10% of cases – on the rise) Defined as resistance to 2 first line drugs

43. TuberculosisInvestigations (NICE CKS)Pulmonary TB: Chest X-ray 3 x sputum cultures for AFB (at least 1 early morning) If positive refer all to respiratory TB clinicExtra-pulmonary TB: Chest X-ray depends on suspected site – e.g. spine plain X-rayLatent TB Don’t actively screen in primary care Refer to TB clinic if suspected contact “From 2012, all people resident in a country with high TB prevalence applying for a UK visa for more than 6 months are required to have pre-entry screening”

44. TuberculosisScreening Tests:Tuberculin Skin Testing e.g. Heaf Test Liable to reader bias / error False positives if previous BCG vaccinationQuantiFERON Interferon Gamma Release Assay – detects the immune response to TB Used mainly for Latent TB diagnosis Can’t differentiate between Active and Latent Disease Limitations in sensitivity and specificity mean it’s not currently recommended for non-specialist use

45. TuberculosisTreatment:Managed by secondary care – usually Respiratory or Infectious Diseases.In Bolton – TB clinic run by RespiratoryNotifiable Disease in the UK Contact tracing – close contacts also need treating 6 months multi-drug therapy – usually Isoniazid and Rifampicin. +/- Ethambutol and Pyrazinamide TB nurses keep regular contact to ensure compliance – biggest cause of treatment failure, multi-drug resistance, and risk of spreading TB

46. Question 7Following a positive sputum AFB, you referred the 30 year old Somali woman to Respiratory, who confirmed the diagnosis and started treatment for TB. She has been on treatment for 2 months and returns to see you complaining of reduced vision. Which drug is most likely to be responsible?EthambutolRifampicinIsoniazidPyrazinamideNot likely to be a drug side effect

47. Question 7Following a positive sputum AFB, you referred the 30 year old Somali woman to Respiratory, who confirmed the diagnosis and started treatment for TB. She has been on treatment for 2 months and returns to see you complaining of reduced vision. Which drug is most likely to be responsible?EthambutolRifampicinIsoniazidPyrazinamideNot likely to be a drug side effect

48. TB Drug Side EffectsEthambutol Visual disturbance Peripheral Neuropathy (common) Hyperuricaemia (Gout flares)Isoniazid Peripheral Neuropathy (common) Liver Failure (rare)Pyrazinamide Hyperuricaemia (Gout flares)Rifampicin Turns secretions orange – will stain soft contact lenses and clothing Thrombocytopoenia Nausea / Vomiting

49. TB Drug Side EffectsEssentially:If a patient on TB treatment presents with any of; Peripheral Neuropathy Visual Disturbance Acute Gout Flare Deranged LFTsSuspect the TB drugs as a cause and advise the patient to inform their TB clinic urgently.Don’t stop any TB treatment without consulting the specialist first

50. Asthma – Key FeaturesSymptoms: - Wheeze - Chest Tightness - Cough - Breathlessness Quality of the Symptoms: - Episodic - Diurnal Variation (worse at night or early morning) - Triggered by e.g. exercise, allergens. infection, cold air Other Associations: - Family History - Atopic – Eczema, Allergic Rhinitis - Occupation – Lab work, baking, animals, welding, paint spraying - Drugs e.g. NSAIDs and Beta Blockers

51. Asthma – Why is it so complicated?There is no gold standard diagnostic testAre GP’s over diagnosing asthma?Overlap with other conditions e.g. COPD in adults, Viral Induced Wheeze in childrenIn the UK there are 2 sets of guidelines: - BTS / SIGN Guidelines – updated 2019 - NICE Guidelines – published 2017

52. Question 8A 19 year old woman attends with SOB and wheeze on exertion as well as an early morning cough ongoing for the past year, but getting worse now that it’s winter. She has hayfever, was prone to wheeze as a child, and doesn’t smoke. According to the NICE guidelines what diagnostic test should be done first?Fractional Exhaled Nitric Oxide (FeNO)Peak Flow DiaryPost Bronchodilator SpirometryPre and Post Bronchodilator SpirometryNo further tests needed – trial steroid inhaler

53. Question 8A 19 year old woman attends with SOB and wheeze on exertion as well as an early morning cough ongoing for the past year, but getting worse now that it’s winter. She has hayfever, was prone to wheeze as a child, and doesn’t smoke. According to the NICE guidelines what diagnostic test should be done first?Fractional Exhaled Nitric Oxide (FeNO)Peak Flow DiaryPost Bronchodilator SpirometryPre and Post Bronchodilator SpirometryNo further tests needed – trial steroid inhaler

54. What?!It’s an unfair question because NICE don’t even seem to know the answerNICE published new Asthma Guidelines in November 2017Biggest changes came in diagnosing asthmaEmphasised need for objective evidence rather then clinical diagnosisAdded FeNO to the list of objective tests approved and (seems to) suggests this as the first line investigation - “should be offered to all patients where available”In reality there is still limited access to FeNO in Primary Care so it is rarely requested.Also states that any child over 5 years old should have an objective test e.g. Spirometry

55. FeNOFraction of Exhaled Nitric OxideNO is released by Eosinophils – the primary white blood cells involved in Asthma.↑NO = ↑Eosinophils = AsthmaResults presented as Parts Per Billion (ppb) >40ppb = AsthmaDon’t need to be symptomatic at time of testWay to check steroid compliance Still technique dependantMachine cost: £2000-3000Consumables costs: £5 for 1000 filtersHowever:1 in 5 with a negative test will have asthma1 in 5 with a positive test won’t NICE don’t recommend for routine monitoring

56. Asthma Diagnostic TestsSpirometryPatient has to be symptomatic at the time of test to give a positive resultTechnique dependent – more difficult then FeNOLooking for obstructive picture – FEV1:FVC <70%Ask for reversibility - >12% improvement in FEV1 after bronchodilator PLUS an increase in volume of 200mLPEFR DiaryCaptures the diurnal variationNICE recommends BD readings over 2-4 weeks>20% variability suggests asthmaRelying on patient for good quality evidence

57. Asthma Diagnostic TestsDirect Bronchial ChallengeAims to trigger asthma symptomsHistamine or MethacholineOnly done in secondary care – generally when all other tests have been inconclusive but the clinical picture still suggests asthma.Risks triggering severe symptoms

58. NICE Asthma Diagnosis GuidelineIn symptomatic adults (>17) diagnose asthma if:FeNO >40ppb PLUS either: positive reversibility, positive PEFR diary, or positive bronchial challenge orFeNO 25-39ppb AND positive bronchial challenge orPositive Reversibility AND positive PEFR diary “irrespective of FeNO result”“Suspect Asthma” if Obstructive Spirometry but negative reversibility PLUS either:FeNO >40ppbFeNO 25-39ppb AND positive PEFR DiaryRefer to Respiratory for a second opinion if:Only 1 test comes back positive and others are negative

59. NICE Asthma Diagnosis GuidelineIn symptomatic Children (>5) diagnose asthma if:FeNO >35ppb AND positive PEFR diary orObstructive Spirometry with Reversibility“Suspect Asthma” if only 1 test is positiveRefer to Respiratory for a second opinion if:All tests are inconclusive

60. Question 9According to NICE, which of the following would confirm a diagnosis of asthma in a 19 year old with night time cough and exertional wheeze? More then one may be correct:FeNO 34ppb, normal spirometry and a 25% variability in PEFR diary FeNO 56ppb , normal PEFR diary, 15% improvement in FEV1 post bronchodilator12% improvement in FEV1 post brochodilator and 22% variability in PEFR diaryFeNO 46ppb, FEV1:FVC 65%, 5% improvement in FEV1 post bronchodilator, and 12% variability in PEFR diaryFeNO 10ppb, 5% variability in PEFR diary, FEV1:FVC 68%, no change post bronchodilator

61. Question 9According to NICE, which of the following would confirm a diagnosis of asthma in a 19 year old with night time cough and exertional wheeze? More then one may be correct:FeNO 34ppb, normal spirometry and a 25% variability in PEFR diary FeNO 56ppb , normal PEFR diary, 15% improvement in FEV1 post bronchodilator12% improvement in FEV1 post brochodilator and 22% variability in PEFR diaryFeNO 46ppb, FEV1:FVC 65%, 5% improvement in FEV1 post bronchodilator, and 12% variability in PEFR diaryFeNO 10ppb, 5% variability in PEFR diary, FEV1:FVC 68%, no change post bronchodilator

62. Question 9According to NICE, which of the following would confirm a diagnosis of asthma in a 19 year old with night time cough and exertional wheeze? More then one may be correct:FeNO 34ppb, normal spirometry and a 25% variability in PEFR diary FeNO 56ppb , normal PEFR diary, 15% improvement in FEV1 post bronchodilator12% improvement in FEV1 post brochodilator and 22% variability in PEFR diaryFeNO 46ppb, FEV1:FVC 65%, 5% improvement in FEV1 post bronchodilator, and 12% variability in PEFR diaryFeNO 10ppb, 5% variability in PEFR diary, FEV1:FVC 68%, no change post bronchodilator

63. BTS/SIGN Asthma Diagnosis GuidelinePublished 2019Response to treatment is key to confirming diagnosisBased on clinical judgement does the patient have a High, Intermediate, or Low probability of their symptoms being Asthma:High probability of AsthmaCode as “Suspected Asthma”Start Treatment – if responds then Asthma diagnosis confirmedPoor response – move to IntermediateIntermediate probability of AsthmaTest for airway obstruction (e.g. PEFR diary, Spirometry) or eosinophil activity (i.e. FeNO)If positive code as “Suspected Asthma” and start treatmentIf responds then Asthma diagnosis confirmedPoor Response – move to low probabilityLow Probability of AsthmaConsider alternative diagnosis, or Specialist referral

64. SIGN / BTS Asthma Diagnosis Guideline2019

65. Question 10You have (finally!) diagnosed the 19 year old with asthma. You assess her symptoms and find that she is being woken at night by her cough and is getting exertional wheeze at least 3 times a week. According to NICE guidelines what drug treatment should you start? Short Acting Beta Agonist (SABA) e.g. salbutamolInhaled Corticosteroid (ICS) e.g. beclomethasoneLeukotrine Receptor Antagonist (LTRA) e.g. montelukastSABA + ICSICS + LTRA

66. Question 10You have (finally!) diagnosed the 19 year old with asthma. You assess her symptoms and find that she is being woken at night by her cough and is getting exertional wheeze at least 3 times a week. According to NICE guidelines what drug treatment should you start? Short Acting Beta Agonist (SABA) e.g. salbutamolInhaled Corticosteroid (ICS) e.g. beclomethasoneLeukotrine Receptor Antagonist (LTRA) e.g. montelukastSABA + ICSICS + LTRA

67. NICE Asthma Treatment Guideline1. Offer all patients a SABA (salbutamol)2. Assess symptoms at diagnosis: - If night time waking or asthma symptoms >3 times a week then offer ICS - Otherwise treat with SABA alone (step up to ICS if uncontrolled)3. Remain uncontrolled on ICS? - Add LTRA (montelukast)4. Still uncontrolled on ICS and LTRA? - Either add LABA (e.g. salmeterol) or swap LTRA for LABA - NICE advises “discuss with patient about whether to continue LTRA”5. Still uncontrolled on ICS, LABA +/- LTRA? - Consider MART (Maintenance and Reliever Therapy) regimen. - stop SABA and use low dose ICS + LABA combination for both maintenance and reliever6. Still uncontrolled on MART regimen +/- LTRA? - Increase steroid dose (either as MART or fixed doses + SABA reliever)7. Still uncontrolled? - Consider specialist referral – may need oral steroidsConsider decreasing therapy once symptoms have been stable for 3 months

68. BTS/SIGN Asthma Treatment Guideline1. SABA + “Consider” ICS – when “suspected asthma”If good response to either SABA alone or SABA + ICS = Asthma confirmed:2. Maintenance low dose ICS + SABA ↕3. Add LABA to low dose ICS (combination e.g. Sirdupla) ↕4. Increase ICS or add any of LTRA, oral Theophylline, or LAMA (e.g. Tiotropium) ↕5. Add 4th agent / Consider Specialist referral ↕6. Specialist Referral - Oral Steroids

69. NICE vs BTS/SIGN on TreatmentNICE gives more options BUT is difficult to follow compared to the simple structure set by BTS/SIGNNICE suggests LTRA at earlier stage for adults – critics suggest this will encourage patients to underuse their inhalersBTS/SIGN is easy to follow step up / step down system - hence much easier to implement in primary care

70. Guide to Asthma DrugsSABA LABA - Salbutamol (Ventolin) - Formeterol - Terbutaline (Bricanyl) - Salmeterol (Serevent)ICS- Beclometasone (Clenil 200-1000mcg BD, Qvar 50-400mcg BD)- Budesonide (Pulmicort 100-800mcg BD)- Fluticasone (Flixotide 100-500mcg BD)- Ciclesonide (Alvesco 80-320mcg BD)Combinations- Fluticasone + Salmeterol (Seretide, Sirdupla, Seriflo, AirFluSal)- Beclometasone + Formeterol (Fostair)- Budesonide + Formeterol (Symbicort)

71. Guide to Asthma DrugsLeukotrine Receptor Antagonists- Montelukast (Singulair) 10mg at night (4-10mg depending on age for kids)- Side effects = Diarrhoea, Headache, NauseaTheophylline- Usually initiated in secondary care- Potent bronchodilator- Usually modified release (Slo-Phyllin, Uniphyllin, Nuelin)- Need to monitor blood levels – 3 days after any dose increase – effective range 10-20mg/L, SE’s common >20mg/L- Enzyme Inhibitors raise levels (Macrolides, allopurinol)- Side effects = Nausea, Tachycardia, Arrhythmia, Tremor, Hyperuricaemia, Seizures- In combination with Beta Agonists can lead to severe Hypokalaemia

72. Secondary Care TreatmentsOmalizumab (Xolair) Anti IgE monoclonal antibodyMonthly subcutaneous injectionNeed high levels of IgE to qualify for treamentMepolizumab (Nucala) + Reslizumab (Cinqaero)Anti-Interleukin 5 (anti-IL-5) monoclonal antibodyMonthly subcutaneous injection (Nucala) or IV infusion (Cinqaero)Only for severe eosinophilic asthmaBronchial ThermoplastyAims to shrink bronchial wall smooth muscleBronchoscopy under sedation or GASmall catheter then administers short pulses of radiofrequency energy Treat approx 1/3 of airways over 3 sessions (3-4 weeks between sessions)

73. New Asthma DiagnosisWhich of these should you (or the practice nurse) arrange / offer your patient?- Personalised Asthma Action Plan- Teach Inhaler Technique and advise when to use- Ensure they have a PEFR meter- Provide advice on weight loss- Provide advice on stopping smoking- Advise they avoid known triggers- Advise they avoid potential triggers e.g. NSAIDs- Refer to Respiratory if Occupational Asthma is suspected- Ensure childhood vaccinations were completed- Yearly influenza vaccine- Pneumococcal vaccination- Assess for Anxiety / Depression- Provide sources of information and support e.g. Asthma UK- Annual Asthma review

74. New Asthma DiagnosisWhich of these should you (or the practice nurse) arrange / offer your patient?- Personalised Asthma Action Plan- Teach Inhaler Technique and advise when to use- Ensure they have a PEFR meter- Provide advice on weight loss- Provide advice on stopping smoking- Advise they avoid known triggers- Advise they avoid potential triggers e.g. NSAIDs- Refer to Respiratory if Occupational Asthma is suspected- Ensure childhood vaccinations were completed- Yearly influenza vaccine- Pneumococcal vaccination- Assess for Anxiety / Depression- Provide sources of information and support e.g. Asthma UK- Annual Asthma reviewAll of these!

75. Asthma – Patient EducationKey to effective long term controlBetter patient understanding = less exacerbations and less hospitalisations.However, often left to practices nurses to fit in during annual asthma reviews.More efficient ways? – e.g. group patient education seminarsGood resources:- Asthma UK website- www.bolton.orcha.co.uk – rates health apps

76. Asthma Deaths 1,400 asthma deaths in 2018 (↑8% on 2017) 3 people die every day as a result of an asthma attack Between 2008-18 – 12,700 deaths (33% increase)National Review of Asthma Deaths published 2014 46% of deaths preventable Made 19 recommendations – only 1 had been implemented up to 2017 Some claim the controversial new NICE guidelines have distracted from targeting preventable asthma admissions / deathsAsthma Action Plans With a robust action plan patients are 4 times less likely to end up in hospital Only 42% of asthmatics have one as of 2017 Can be found on Asthma UK website

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78. Question 11A 27 year old asthmatic man attends with 1 day history of wheeze and chest tightness. This was preceded by 4 days of a mild coryzal illness. He takes montelukast and Qvar 100mcg BD. Today he has used 8 puffs of salbutamol every 4 hours. There is bilateral wheeze but no crackles. His PEFR reading is 180 (usual best 410). Other then a RR 18, his other obs are normal.What should you do? Prescribe prednisolone 40mg, advise 4 puffs salbutamol 4 hourly until he improves Call 999 and bring the emergency oxygen to the room just in caseGive 4 puffs of Salbutamol via spacer and repeat PEFRGive 5mg Salbutamol via nebuliser and repeat PEFRAdmit to Medics but will need ambulance transfer

79. Question 11A 27 year old asthmatic man attends with 1 day history of wheeze and chest tightness. This was preceded by 4 days of a mild coryzal illness. He takes montelukast and Qvar 100mcg BD. Today he has used 8 puffs of salbutamol every 4 hours. There is bilateral wheeze but no crackles. His PEFR reading is 180 (usual best 410). Other then a RR 18, his other obs are normal.What should you do? Prescribe prednisolone 40mg, advise 4 puffs salbutamol 4 hourly until he improves Call 999 and bring the emergency oxygen to the room just in caseGive 4 puffs of Salbutamol via spacer and repeat PEFRGive 5mg Salbutamol via nebuliser and repeat PEFRAdmit to Medics but will need ambulance transfer

80. Question 12After an appropriate bronchodilator has been given and the PEFR is now up to 200 (usual best 410) and RR is now 16. What should you do? Prescribe prednisolone 40mg, advise 4 puffs salbutamol 4 hourly until he improves Call 999 – this is a life threatening asthma attackGive more bronchodilatorAdmit to Medics with ambulance transferRefer to community respiratory nurses and prescribe prednisolone

81. Question 12After an appropriate bronchodilator has been given and the PEFR is now up to 200 (usual best 410) and RR is now 16What should you do? Prescribe prednisolone 40mg, advise 4 puffs salbutamol 4 hourly until he improves Call 999 – this is a life threatening asthma attackGive more bronchodilatorAdmit to Medics with ambulance transferRefer to community respiratory nurses and prescribe prednisolone

82. Acute Asthma ExacerbationsSigns of severe asthma attack:Drowsiness / AgitationSigns of exhaustion: can’t complete sentences, cyanosis, accessory muscle useFor all patients:Examine chest – wheeze, ?crackles, air entry, Record RR, pulse, BP, and O2 SatsMeasure PEFR – best of 3, compare to usual bestFind out about previous admissions, ever been on ICU?

83. Acute Asthma ExacerbationsClassify severity based on PEFR:Moderate = PEFR >50-75%Severe = PEFR 33-50%or any of: RR >25 in adults, Pulse >110 in adultsLife Threatening = PEFR <33%or any of: Sats <92%, signs of exhaustion, hypotension, poor respiratory effort, cardiac arrhythmia, altered consiousness

84. Acute Asthma ExacerbationsManaging Moderate Exacerbations (PEFR >50-75%)Short course of Salbutamol: 4 puffs followed by 2 puffs every 2 minutes up to max 10 puffs to achieve relief of symptoms. Initially can repeat after 10-20 minutesIn first 1-2 days can repeat every 4 hours and reduce to PRN when able – if needing <4 hourly then needs further reviewShort course of oral steroids:e.g. Prednisolone 40mg for 5 days. Don’t adjust ICS doseAre Antibiotics needed? E.g. AmoxicillinAdvise they monitor PEFR + Safety netConsider offering follow up to check response to treatment

85. Acute Asthma ExacerbationsManaging Severe Exacerbations (PEFR 33-50%)Give appropriate bronchodilator immediately and reassess - 5mg Salbutamol Neb is better optionIf PEFR now >50% and no other concerning features can treat as a moderate exacerbation in the community.If no improvement – need to admit to hospital

86. Acute Asthma ExacerbationsManaging Life Threatening Exacerbations (PEFR <33%)Get help – emergency alarm, call 999Give Oxygen – aim sats >94%Give Salbutamol 5mg Neb (2.5mg if <5)– oxygen driven preferable. Repeat every 20-30 mins if neededIf no improvement give Ipratropium 500mcg Neb (if available, 250mcg if <12) – can only use every 4 hoursMonitor Obs and PEFR until ambulance arrives

87. Question 13Annual seasonal Influenza vaccination is recommended to all over the age of 65, children aged 2-10 years and anyone aged 6 months to 65 years who fall into a “Clinical Risk Group”.Which of the following diagnoses do not fit into a “Clinical Risk Group” and would not qualify for an NHS flu vaccination?More then one answer may applyBronchiectasisStrokeImmunosuppressionDiabetes MellitusEpilepsyCKD stage 3Obesity (BMI>30)Pregnant Women

88. Question 13Annual seasonal Influenza vaccination is recommended to all over the age of 65, children aged 2-9 years and anyone aged 6 months to 65 years who fall into a “Clinical Risk Group”.Which of the following diagnoses do not fit into a “Clinical Risk Group and would not qualify for an NHS flu vaccination?More then one answer may applyBronchiectasisStrokeImmunosuppressionDiabetes MellitusEpilepsyCKD stage 3Obesity (BMI>30)Pregnant Women

89. Seasonal Influenza VaccinationClinical Risk Groups:Chronic Respiratory DiseaseChronic Heart DiseaseChronic Kidney DiseaseChronic Liver DiseaseChronic Neurological Disease – includes TIA but not EpilepsyDiabetes MellitusImmunosuppressionSplenectomyPregnant Women – at any stageMorbid Obesity BMI > 40 – “use clinical judgement”Certain Healthy Individuals also qualifyOver 65 years of ageChildren aged 2-3 (done via GP) and 4-9 (done via school)People in long stay care facilities e.g. Residential HomesCarer’sHousehold contacts of immuno-compromised individualsHealthcare and Social Workers involved in patient care – includes studentsHajj and Umrah Pilgrims – advised by Saudi Ministry of Health - ?on NHS

90. Seasonal Influenza VaccinationInfluenza types A and B sub-strains of each alternate in prevalence every winterType A causes more severe infections and epidemicsType B – smaller outbreaks, more common in childrenVaccinesAll (but 1) are Inactivated Vaccines via IM injectionTrivalent – covers 2 strains of A, 1 strain of BQuadrivalent – covers 2 strains of A, 2 strains of BFluenz Tetra – Quadrivalent Attenuated Live Vaccine – Nasal administration

91. Seasonal Influenza VaccinationContraindications:Previous Anaphylactic Reaction or Angioedema to the flu vaccineEgg protein (Ovalbumin) Allergy – tiny amounts in all flu vaccines, but varies between brands, safe to give unless known to have severe allergic reaction.Postpone if person acutely unwell – However, “minor illnesses without fever or systemic upset are not valid reasons to postpone immunisation”CI’s Specific to Fluenz Tetra Nasal Vaccine:Severe Asthma or Acute Wheeze (within last 72 hrs)Taking or taken oral steroids in last 14 daysSeverely Immunocompromised Heavy Nasal Congestion

92. Seasonal Influenza VaccinationAdvise of common side effects:All usually disappear within 1-2 days without treatmentPain, redness, or swelling at injection siteLow grade fever, malaise, shivering, or fatigueHeadache, myalgia, or arthralgiaNasal congestion and rhinorrhoa – with nasal vaccineBasically; mild symptoms of the body’s usual reaction to any infectionRare side effects:Neuralgia, paraesthesia, convulsionsTransient thrombocytopoeniaVasculitis with renal involvement (very rare)Encephalomyelitis (very rare)Impossible side effects:Getting the flu from the vaccine!

93. COPD – Key FeaturesSymptoms: - Wheeze - Chest Tightness - Cough - Breathlessness - Sputum - Recurrent chest infections Quality of the Symptoms: - Progressive – inevitable and incurable - >35 years old - No clear pattern of Variation (but can be worse at night) - Poor response to bronchodilators - Exacerbations triggered by e.g. Exercise, infection, cold air Complications: - Disability - Impaired Quality of Life - Depression - Anxiety - Cor Pulmonale - Secondary Polycythaemia - Lung Cancer - Type 2 Respiratory Failure

94. Question 14Which of the following is not a recognised risk factor for developing COPD?More then one answer may applyOccupational Exposure (e.g. Welder) in non-smokersOccupational Exposure (e.g. Welder) in smokersHomozygous alpha-1 antitrypsin deficiencyHeterozygous alpha-1 antitrypsin deficiencyPassive smokingE-cigarettesObesity (BMI>30)Air pollution

95. Question 14Which of the following is not a recognised risk factor for developing COPD?More then one answer may applyOccupational Exposure (e.g. Welder) in non-smokersOccupational Exposure (e.g. Welder) in smokersHomozygous alpha-1 antitrypsin deficiencyHeterozygous alpha-1 antitrypsin deficiencyPassive smokingE-cigarettes (not yet anyway)Obesity (BMI>30)Air pollution

96. Risk Factors for COPDSMOKINGBut non-smokers can get COPD too:Occupation exposuresDust, noxious chemicals, welding fumes, particles of grains or silica, coal20% COPD cases linked to occupational causesAir PollutionParticularly in developing countries that use wood or coal for household heatingLess of a factor in UKHowever – vehicle pollution is linked to ↓lung function

97. Risk Factors for COPDAlpha-1 Antitrypsin DeficiencyOnly confirmed genetic cause of COPDWBC’s produce Trypsin enzyme to move between other cells and to break down bacteria or react to toxins e.g. Tobacco smokeAntitrypsin stops trypsin damaging healthy lung tissue.Genetics: Autosomal Co-dominent – severity of disease depends on combination of genes inherited as both will be expressedSimplified verion- Three forms of the A1A gene:M = normal levels, Z = deficiency, S = mild deficiencyHomozygous A1AD (ZZ genotype)Develop COPD under age of 45Liver disease – (tends to be in most severe form and presents in childhood) Heterozygous or mild homozygous A1AD (MZ, SZ, MS, SS genotypes) rarely diagnosed but may explain why some people are more prone to COPDWon’t necessarily develop COPD or any lung disease

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99. E-cigarettesBig gaps in evidenceBig opportunity for misinformation to thriveBig opportunity to make money in the confusionKey points:They are safe: In that they meet the minimum requirements of safety in order to be sold. But so does tobaccoProduce less carcinogenic substances then tobacco –therefore the RCP and NICE support their use in smoking cessation (but not as a “safe” alternative to smoking)Liquid cartridge usually contain nicotine, propylene glycol, glycerol, water, and “flavourings” – No evidence on the long term effects of these (alone or in combination)Battery powered heater produces the vapour – no evidence on environmental impact

100. E-cigarettes – Deaths in USACentre for Disease Control and Prevention (CDC) update:As of Oct 2019 – 1,479 case of “lung injury” reported79% of patients were under 35 years old33 deaths confirmed related to e-cigarettesMost of these patients reported use of THC containing products (either shop bought or off the street)Advise against use of all e-cigarettes as exact cause not yet knownFlavoured liquids / devices are suspected to be a cause – lawmakers planning to temporarily remove from sale (possibly a move to encourage tighter regulation - FDA pretty relaxed so far)UK / EU have tighter regulation – hence RCP/PHE still advise that e-cigarettes are safe and advocate their use in tobacco smoking cessation

101. Question 15You are suspecting COPD in a 60 year old smoker with progressive exertional breathlessness over 6 months.What tests should be performed in all cases according to NICE? More than one answer may be correctPost Bronchodilator SpirometryChest X-rayFeNOPEFRPre and Post Bronchodilator SpirometryECGFull Blood CountPulse Oximetry

102. Question 15You are suspecting COPD in a 60 year old smoker with progressive exertional breathlessness over 6 months.What tests should be performed in all cases according to NICE? More than one answer may be correctPost Bronchodilator SpirometryChest X-rayFeNOPEFRPre and Post Bronchodilator SpirometryECGFull Blood CountPulse Oximetry

103. Diagnosing COPD – NICE GuidelinesArrange the following for all people with suspected COPD:Post Bronchodilator Spirometry - FEV1:FVC <70% (<0.7) confirms diagnosis - Reversibility testing not recommendedChest X-ray - Exclude differential diagnosesFull Blood Count - Pick up anaemia or secondary polycythaemiaArrange the following additional investigations where appropriate:Pulse Oximetry – What’s normal?ECG + Echocardiogram – if signs of cor pulmonaleSputum Culture – if purulent sputum is persistent feature

104. COPD SeverityGraded using the FEV1Stage 1 – Mild FEV1 >80% predictedStage 2 – Moderate FEV1 50-79% predictedStage 3 – Severe FEV1 30-49% predictedStage 4 – Very Severe FEV1 <30% predicted

105. COPD SeverityMRC Dyspnoea Scale is also helpful (recommended by NICE)GradeLevel of Activity1Not troubled by breathlessness except during strenuous exercise2Short of breath when hurrying or walking up a slight hill3Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace4Stops for breath after walking about 100 m or after a few minutes on the level5Too breathless to leave the house, or breathless when dressing or undressing

106. Question 16You review a 65 year old COPD sufferer who is having persistent breathlessness despite using Terbutaline (SABA) PRN. According to NICE guidance, which of the following could be added next?LABA (e.g. Salmeterol)ICS (e.g. Budesonide)SAMA (e.g. Ipratropium)LABA + ICS (e.g. Sirdupla)LAMA (e.g. Tiotropium – Spiriva)LAMA + LABA (e.g. Spiolto Respimat)LTRA (e.g. Montelukast)LABA + LAMA + ICS (e.g. Trelegy)

107. Question 16You review a 65 year old COPD sufferer who is having persistent breathlessness despite using Terbutaline (SABA) PRN. According to NICE guidance, which of the following could be added next?LABA (e.g. Salmeterol)ICS (e.g. Budesonide)SAMA (e.g. Ipratropium)LABA + ICS (e.g. Sirdupla)LAMA (e.g. Tiotropium – Spiriva)LAMA + LABA (e.g. Spiolto Respimat)LTRA (e.g. Montelukast)LABA + LAMA + ICS (e.g. Trelegy)

108. Managing COPD – NICE Guidelines

109. Managing COPD – NICE Guidelines

110. Managing COPD – NICE Guidelines 2018What about LABA or LAMA alone?Combination inhalers more effectiveShould not be prescribing LABA or LAMA alone When to step up treatment?>2 exacerbations in last year1 hospitalisation as a result of COPD exacerbationStill symptomatic (use MRC scale to judge)What to check before stepping up?Smoking? Inhaler technique - ?need different device

111. Managing COPD Lifestyle AdviceStop SmokingPromote ExerciseDietary AdvicePreventation + ScreeningImmunisation – Seasonal Flu + Pneumococcal (single dose)Screen for Depression + AnxietyScreen for Heart FailureSocial, Physio, Occupational Therapy needs?Pulmonary RehabilitationConsider for anyone suffering with breathlessnesshttps://www.youtube.com/watch?v=8x6Er-ifaXM

112. Managing COPD – Other TherapiesMucolyticsConsider if chronic productive cough with difficulty expectoratingCarbocisteine - 750mg TDS for 4 weeks - if “successful” then continue but reduce to 750mg BD - if no response – STOPMacrolides e.g. Azithromycin - Only initiated by Secondary CareNebulised Saline - Only initiated by Secondary Care - Minimal impact with normal (0.9%) saline - Need Hypertonic for significant effect

113. Managing COPD – Other TherapiesTheophyllineConsider when persistent bronchospasm (wheeze) despite max inhaled therapy.E.g. Uniphyllin MR – starting dose 200mg BDNeed to monitor levels (target 10-20mg/L)Toxicity can cause: Nausea, Tachycardia, Arrhytmia, Hypokalaemia, Irritability, Seizures

114. Managing COPD – Other TherapiesPhosphodiesterase type-4 inhibitorsE.g. Roflumilast (only PDE4i licensed for severe COPD)PDE4 breaks down anti-inflammatory enzymes and therefore promotes inflammationIn severe COPD – reduces exacerbations and improves FEV1Only started by secondary careRoflumilast 500mcg OD – 30 tablets cost £37Side effects: Weight loss, insomnia, headache, GI upsetInteracts with Theophylline – don’t co-prescribe

115. COPD – When to Refer (Bolton CCG)Diagnostic UncertaintySevere/Worsening COPDHaemoptysisFrequent respiratory infectionsSuspected Cor PulmonaleSymptoms don’t match Spirometry resultsAge <40 or FH of A1ADAssessment for Nebuliser / Home Oxygen Therapy

116. Question 17Which of the following is a benefit of Long Term Oxygen Therapy in COPD?More then one answer may be correctImproved sleepReduced anxietyReduced breathlessnessImproved moodImproved life expectancyReduced coughReduced hospital admissions

117. Question 17Which of the following is a benefit of Long Term Oxygen Therapy in COPD?More then one answer may be correctImproved sleepReduced anxietyReduced breathlessnessImproved moodImproved life expectancyReduced coughReduced hospital admissions

118. COPD – Oxygen Therapy (BTS)Treatment for Chronic Hypoxaemia (PaO2 <7.3kPa)Does not relieve breathlessnessDifferent types:LTOT – Long Term Oxygen Therapy - at least 15 hours a day. 0.5-2L flow rate - increases life expectancy and improves sleep - improves outcomes in Cor Pulmonale, Polcythaemia, and Pulmonary Hypertension - Use in Hypercapnic patients does not increase mortality - No impact on hospitalizations or mood/anxietyAmbulatory Oxygen - Portable, improves quality of life - Rarely used if patient doesn’t qualify for LTOT

119. COPD – Oxygen Therapy (BTS)When to refer for LTOT:Baseline oxygen saturations <92% on airVery Severe airflow obstruction – FEV1 <30%Peripheral Oedema or Raised JVP (Cor Pulmonale)Secondary PolycythaemiaCyanosisRefer to Respiratory Nurses – BARTWhen not to refer – if they still smoke!

120. Oxygen Therapy (BTS) – other usesShort Burst Oxygen - 10-20 minute bursts of high flow oxygen e.g. 12L - Not recommended for use in exertional breathlessness by BTS - But NICE say “consider for people not eligible for LTOT who have episodes of severe breathlessness not relieved by other treatments” - used for symptomatic relief in Cluster HeadachePalliative Oxygen - Considered for breathlessness in terminal disease - Only of benefit in hypoxaemic breathless patients - Even then studies show little benefit on reducing symptomsOther options for Dyspnoea in Palliative Care: - Opiates e.g. Low doses of morphine PRN - Clonazepam drops - Fan therapy and CBT are other options - Refer to palliative care

121. Question 18The receptionist asks you to urgently see a COPD patient with 2 days of breathlessness, who has become more SOB in the waiting room. They take Trelegy and are getting no relief from salbutamol. Their observations are: T 36.7, pulse 86 reg, BP 109/62, RR 28, O2 sats 86%. They look tired, are pursed lip breathing, and using accessory muscles. On auscultation there is wide spread wheeze and prolonged expiration.What should you do first?Give 10 puffs Salbutamol via spacerCall 999Give oxygen – target sats >94%Give oxygen – target sats 88-92%Give Salbutamol 5mg Neb

122. Question 18The receptionist asks you to urgently see a COPD patient with 2 days of breathlessness, who has become more SOB in the waiting room. They take Trelegy and are getting no relief from salbutamol. Their observations are: T 36.7, pulse 86 reg, BP 109/62, RR 28, O2 sats 86%. They look tired, are pursed lip breathing, and using accessory muscles. On auscultation there is wide spread wheeze and prolonged expiration.What should you do first?Give 10 puffs Salbutamol via spacerCall 999Give oxygen – target sats >94%Give oxygen – target sats 88-92%Give Salbutamol 5mg Neb

123. Acute Exacerbations of COPDSigns of Severe Exacerbation - O2 sats <90% - use of accessory muscles - RR >25 - pursed lip breathing - Confusion - Cyanosis - Peripheral oedema - ↓ ↓ETEmergency Management - Nebulised Salbutamol 5mg - Oxygen – aim sats 88-92% (NICE) - Most will need admission - If stabilising can consider community management e.g. Admissions Avoidance Team - Should there be a bigger push towards community management?

124. Acute Exacerbations of COPDManaging in Primary CareIncrease dose/freqency of SABA e.g. 4 puffs 4 hourly – best via spacerOral Corticosteroids Prednisolone 30mg OD for 7-14 daysOral Antibiotics Only if purulent sputum 1st line – Amoxicillin 500mg TDS for 5 days Pen Allergy – Clarithromycin 2nd line – Doxycycline 200mg then 100mg OD 5 day course

125. Rescue PacksDon’t prescribe without educating:How to recognise an exacerbation - SOB, wheeze, cough, ↓ET, ↑sputumInfective vs Non-infective? - Purulent sputum (yellow/brown) - change in sputumWhat to do before starting the rescue pack? - increase SABA - Breathing exercisesWhen to start steroids? - if the above measures aren’t helpingWhen to start antibiotics? - only if purulent sputumImportant points:Never put on repeat prescriptionIf had >3 courses of steroids in 12 months and >65 – will need bone protection

126. BronchiectasisWhat is it?Chronic - Dilated, thick walled bronchiExcess sputum and cilliary dysfunctionWhat causes it?Any prolonged condition that damages the lungsAffects up to 30% of COPD sufferersCommonest cause is severe LRTIOther causes: CF, aspiration, ABPA, Asthma, RA, Immune deficiencyWhen to suspect it?Chronic excess sputum production – persistent coughUnusual sputum results e.g. PseudamonasProlonged LRTIs – requiring extended courses of antibiotics

127. BronchiectasisDiagnosisCan only be confirmed by High Resolution CTBut do we need to refer everyone to respiratory? - NICE says yes, especially if young - All will need: CXR, Spirometry, and sputum cultures to exclude alternative causes firstBut e.g. - COPD patient with prolonged exacerbations – confirming the diagnosis won’t change much – can suspect bronchiectasis and manage by checking sputum and Rx longer courses of antibioticsWorth remembering that up to 30% COPD sufferers may need 10-14 day courses of antibiotics and better to send sputum before treating

128. Question 19A 59 year old male smoker attends with a 3 week history of cough. He is frequently coughing up small amounts of blood. He denies breathlessness, chest pain, or sputum production. He has not had any fever or coryzal symptoms. He has not travelled abroad in the last 12 months and has never been exposed to TB. He has no PMH and is not on any medications. Chest examination and all observations are normal.What should you do? Admit to medics as suspected PEArrange an urgent chest x-ray2 week wait referral to respiratoryTreat as suspected LRTI and arrange follow up in 1 weekWatch and wait (with safety netting advice)

129. Question 19A 59 year old male smoker attends with a 3 week history of cough. He is frequently coughing up small amounts of blood. He denies breathlessness, chest pain, or sputum production. He has not had any fever or coryzal symptoms. He has not travelled abroad in the last 12 months and has never been exposed to TB. He has no PMH and is not on any medications. Chest examination and all observations are normal.What should you do? Admit to medics as suspected PEArrange an urgent chest x-ray2 week wait referral to respiratoryTreat as suspected LRTI and arrange follow up in 1 weekWatch and wait (with safety netting advice)

130. Suspected Lung Cancer - NICERefer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if they:Have chest X-ray findings that suggest lung cancer orAre aged 40 and over with unexplained haemoptysis

131. Suspected Lung Cancer - NICEOffer urgent Chest X-ray to the following:Anyone >40 with: - Finger Clubbing - Persistent chest infection - Chest signs suggestive of Lung Ca (bronchial BS, unilat ?effusion) - Thrombocytosis - Supraclavicular lymphadenopathyAnyone >40 with 2 of, or any smoking history with 1 of;Unexplained: - Cough - Fatigue - Weight Loss - SOB - Chest Pain - Appetite loss

132. Question 20A 53 year old woman attends with a persistent irritating dry cough for the last 5 weeks. It tends to be worse at night and she reports constantly having a dry throat. She has well controlled hypertension on 5mg Ramipril and has intermittent heart burn for which she occasionally takes OTC Ranitidine. She denies haemoptysis and has never smoked. What would be the best initial management plan? Stop the Ramipril and reassess in 2 weeksTrial regular inhaled corticosteroid2 week wait referral to respiratory5 day course of Amoxicillin 500mg TDSStart Omeprazole 20mg OD regularly and reassess in 1 month

133. Question 20A 53 year old woman attends with a persistent irritating dry cough for the last 5 weeks. It tends to be worse at night and she reports constantly having a dry throat. She has well controlled hypertension on 5mg Ramipril and has intermittent heart burn for which she occasionally takes OTC Ranitidine. She denies haemoptysis and has never smoked. What would be the best initial management plan? Stop the Ramipril and reassess in 2 weeksTrial regular inhaled corticosteroid2 week wait referral to respiratory5 day course of Amoxicillin 500mg TDSStart Omeprazole 20mg OD regularly and reassess in 1 month

134. CoughNICE divides into: I tend to simplify to:Acute = 0-3 weeks - Acute = 0-4 weeksSubacute = 3-8 weeks - Persistant = >4 weeksChronic = >8 weeksThere is no effective treatment for cough – but can treat the causesThere are lots of potential causes of a persistent cough: - Asthma - COPD - Post Infective - Bronchiectasis - Lung Ca - Tuberculosis - Pertussis - Pneumonia - Bronchitis - GORD (silent) - ACEi - Post Nasal Drip - Smoking related - ILD - Heart Failure - Foreign Body Aspiration - Atypical Pneumonia

135. CoughNICE divides into: I tend to simplify to:Acute = 0-3 weeks - Acute = 0-4 weeksSubacute = 3-8 weeks - Persistant = >4 weeksChronic = >8 weeksThere is no effective treatment for cough – but can treat the causesThere are lots of potential causes of a persistent cough: - Asthma - COPD - Post Infective - Bronchiectasis - Lung Ca - Tuberculosis - Pertussis - Pneumonia - Bronchitis - GORD (silent) - ACEi - Post Nasal Drip - Smoking related - ILD - Heart Failure - Foreign Body Aspiration - Atypical Pneumonia

136. Persistent Cough - AssessmentGood history is key:Smoker? - think Lung Cancer or Smoking relatedDry or Productive?Improving, worsening or stable?Coughing bouts? - think Pertussis (+/- inspiratory “whoop” or vomiting)Any illness at onset - think Infective (prolonged or post)Associated symptoms - Acid brash, heartburn? – think Reflux - Blocked nose / rhinorrhoea? – think Post nasal drip - Swallowing difficulty? – think Aspiration - Cardiac History? – think Heart Failure - Breathlessness? – think COPD / ILD / Heart FailureTiming - Diurnal variation? – think Asthma - Seasonal? – think Allergic (asthma or rhinitis)

137. Persistent Cough - AssessmentGood history is key:Triggers - Laying on back / bending forward? – think Reflux - Allergens – pets? dust? temperature?Occupation - Asbestos exposure? – think ILD / Mesothelioma - Coal Miner? – think Pneumoconiosis - Baker? – Occupational AsthmaForeign Travel - Cruise/Hotel – anyone else unwell? – think Legionella - TB exposure?Drugs - ACEi – short or long term us - Long term Nitrofurantoin – cause of Pulmonary FibrosisRed Flags: - Haemoptysis -Weight loss

138. Persistent Cough - AssessmentInvestigations – my approach:Chest X-ray - Consider for any cough lasting >4 weeks - Rule out Lung Ca, Pneumonia, ILDSpirometry - If any features of asthma - If any exertional breathlessness suggestive of COPD/ILDSputum Culture - If any sputum production

139. Persistent Cough - AssessmentNormal CXR +/- Normal Spirometry:Features of Reflux? - Trial PPI for 1-2 months - e.g. Omeprazole 20mg ODFeatures of Post Nasal Drip / Allergic Rhinitis - Trial steroid nasal spray for 3 months - e.g. Mometasone 50mcg OD - Other options – Ipratropium Nasal Spray (Rinatec)On ACEi with no features of any other cause? - Stop ACEi and review in 4 weeks

140. “Treatments” for CoughDextromethorphan - Active ingredient in most cough mixtures - Minimal evidence of efficacy – therefore NOT recommended by NICESedating Antihistamines - Another ingredient in OTC cough mixtures - Effects probably due to sedation rather then any antitussive effectExpectorants – claim to help clear secretions – no evidence they do thisDemulcent preparation – “soothing” properties – may sooth but still coughSimple Linctus - Main ingredient is Citric Acid – no evidence of efficacy – don’t prescribeCodeine - All opiates suppress cough – but not particularly well - Lot of SE’s and risk of dependence - Rarely prescribed but can try if e.g. Poor sleep due to coughing (short term)Palliative Care - Morphine can be useful in terminal Lung Cancer