Respiratory Medicine in General Practice Dr Andrew

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DISCLAIMER I wrote all the questions to fit with the topics

They were designed to be similar to AKT questions.

Please ask if anything isn’t clear or looks wrong.

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Question 1 A 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?
Asthma
Bronchiectasis
COPD
Pulmonary Fibrosis
Extrinsic Allergic Alveolitis

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Question 1 A 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?
Asthma
Bronchiectasis
COPD
Pulmonary Fibrosis
Extrinsic Allergic Alveolitis

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Spirometry Available at most practices
Done by practice nurses
Technique dependant – check comments on report
Patient needs to be well – need to see best effort

Useful in patients with:
Chronic Breathlessness
Chronic Cough

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Requesting Spirometry in GP With or Without Reversibility?
If you think it could be asthma – ask for reversibility
Anything else – Post-Bronchodilator Spiro

Is 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

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Interpreting Spirometry Forced Vital Capacity (FVC) – total vol. expired air
Forced Expiratory Volume in 1 second (FEV1)– Vol. Air expired in 1st second of forced expiration
FEV1/FVC ratio – Normal FEV1 should be >70% of FVC

Reversibility = >12% improvement in FEV1

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Interpreting Spirometry Example:
Pre Predicted
FVC 2.67 2.80
FEV1 1.48 2.24
FEV1/FVC 54% 80%

Diagnosis?

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Interpreting Spirometry Example:
Pre Predicted
FVC 2.67 2.80
FEV1 1.48 2.24
FEV1/FVC 54% 80%

Diagnosis?
Obstructive Airways Disease

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Interpreting Spirometry Example:
Pre Predicted Post
FVC 2.67 2.80 2.80
FEV1 1.48 2.24 2.01
FEV1/FVC 54% 80% 71%

Diagnosis?

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Interpreting Spirometry Example:
Pre Predicted Post
FVC 2.67 2.80 2.80
FEV1 1.48 2.24 2.01
FEV1/FVC 54% 80% 71%

Diagnosis?
Obstructive Airways Disease with Reversibility
(i.e. Asthma)

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Question 2 A 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 antibiotics
CRB=2 – Manage in community with oral antibiotics and arrange follow up in 24 hours.
CRB=2 – Arrange admission for IV antibiotics
CRB=3 – Arrange admission for IV antibiotics
CRB-65 score is irrelevant in this case

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Question 2 A 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 antibiotics
CRB=2 – Manage in community with oral antibiotics and arrange follow up in 24 hours.
CRB=2 – Arrange admission for IV antibiotics
CRB=3 – Arrange admission for IV antibiotics
CRB-65 score is irrelevant in this case

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Symptoms of LRTI Cough
- productive or dry
- Generally lasts 7 days – can linger for 3-4 weeks

Sputum
- Green = Dead cells
-Yellow/Brown = Bacteria

Breathlessness
Systemic Features e.g. fever
Chest Pain / Pleurisy / Abdominal Pain

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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.”

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CRB-65 Score for CAP – NICE CKS Scoring: Management:
0 = Low Severity 0-1= Community
1-2 = Intermediate Severity 2= Admission “advised”
>2 = High Severity 3+= Urgent Admission

Cautions:
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

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Question 3 A 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 days
Amoxicillin 500mg TDS + Clarithromycin 500mg BD for 7 days
Amoxicillin 500mg TDS for 5 days
Doxycycline 200mg single dose then 100mg OD for 4 days
C0-Amoxiclav 625mg TDS for 7 days

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Question 3 A 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 days
Amoxicillin 500mg TDS + Clarithromycin 500mg BD for 7 days
Amoxicillin 500mg TDS for 5 days
Doxycycline 200mg single dose then 100mg OD for 4 days
C0-Amoxiclav 625mg TDS for 7 days

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Managing CAP Self Care – rest, fluids, antipyretics

Advise to STOP SMOKING

No 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)

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

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Managing CAP NICE 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.”

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Question 4 Which is the most common cause of Community Acquired Pneumonia?

Mycoplasma Pneumoniae
Streptococcus Pneumoniae
Staphlococcus Aureus
Legionella Pneumophilia
Haemophilus Influenzae
Viral Infections
Pseudomonas Aeuriginosa

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Question 4 Which is the most common cause of Community Acquired Pneumonia?

Mycoplasma Pneumoniae
Streptococcus Pneumoniae
Staphlococcus Aureus
Legionella Pneumophilia
Haemophilus Influenzae
Viral Infections
Pseudomonas Aeuriginosa

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CAP causative organisms BTS Audit No 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%

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Pseudomonas Aeruginosa You 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

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Pseudomonas Aeruginosa Gram Negative Rods
Common in soil and standing water
Opportunistic infection in humans - chest, wounds, nails, otitis externa
Survivor – very hard to eradicate once it has infected
Leads to cycles of recurrent infection and “colonisation” especially in Bronchiectasis and CF
Contributes to deterioration in chronic respiratory diseases e.g. Early infection if CF is a bad prognostic indicator
Chronic infection is associated with worse lung function

Rust coloured sputum (apparently tastes metallic)
Makes nails and wounds green

Only oral antibiotic option is Ciprofloxacin – always speak to micro (or check Respiratory clinic letters) as may need IV
IV treatment = aminoglyosides e.g. Tobramycin, Gentamycin

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Question 4 A 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 Fever
Whooping Cough
Atypical Pneumonia
Tuberculosis
Post Infective Cough

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Question 4 A 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 Fever
Whooping Cough
Atypical Pneumonia
Tuberculosis
Post Infective Cough

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Question 5 A 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 Pneumophilia
Mycoplasma Pneumonia
Chlamydia Psittaci (Psittacosis)
Klebsiella
Coxiella Burnetii

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Question 5 A 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 Pneumophilia
Mycoplasma Pneumonia
Chlamydia Psittaci (Psittacosis)
Klebsiella
Coxiella Burnetii

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Atypical Pneumonia Risk Factors:
Close community settings e.g. university halls, army barracks, cruise ships, schools
Immunosuppression

Key Features:
Persistent Cough (can be productive or dry)
Sore throat / Pharynigitis
Recent community exposure
Age <50
Clinical signs usually mild or absent
Lungs look worse on CXR then they sound on examination
CAP that hasn’t responded to penicillin

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Atypical Pneumonia – BMJ Best Practice Investigations:
CXR – looking for consolidation
Bloods - ↑WCC, ↑CRP, with mycoplasma can sometimes get anaemia + ↑ALT
Sputum culture
I would consider doing all the above in any LRTI not responding to usual treatment
Also consider (depending on history / level of suspicion)
Legionella Urine Antigen
Serology for Mycoplasma / Chlamydia / Coxiella

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Atypical Pneumonia – BMJ Best Practice Managment:
1st line – Macrolide (Azithromycin / Clarithromycin)
Alt 1st line – Doxycycline

2nd line – Fluroquinolone (Levoflocacin / Moxyfloxacin)

I would think about consulting microbiology for advice

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Atypical Pneumonia Mycoplasma:
Community Outbreaks – approx every 4 years
Usually late summer / autumn
Most common in children and young adults
Can have associated headache
Associated with various rahes – usually self limiting maculopapular type – classically...
Erythema Multiforme
Chest usually sounds clear
CXR – patchy consolidation
Micro – Sputum or Throat swabs
Not a notifiable disease

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Atypical Pneumonia Legionella:
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 Diarrhoea
Legionella urine antigen – negative result doesn’t exclude
Sputum culture
Notifiable disease

Psitticosis:
Chlamydia Psittaci carried by birds
Suspect if exposure to commercial (poultry farmers) or pet birds (parrots / budgies)
Chlamydia swab of throat – sputum testing is risk to Lab staff

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Atypical Pneumonia Coxiella Burnetti:
Associated with livestock: Farmers, Vets, Abattoir workers all at risk. Micro lab workers also at risk
Usually 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 test
I would discuss with micro if ever suspecting

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Question 6 A 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 Bacilli
Full blood count and CRP
Thick blood film
QuantiFERON
Chest Radiograph

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Question 6 A 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 Bacilli
Full blood count and CRP
Thick blood film
QuantiFERON
Chest Radiograph

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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,

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Tuberculosis Active Pulmonary TB (majority of cases – 55%)
Persistent Productive Cough +/- Haemoptysis
Weight Loss, Fever, Night sweats
Infectious

Extra-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

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Tuberculosis Investigations (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 clinic

Extra-pulmonary TB:
Chest X-ray
depends on suspected site – e.g. spine plain X-ray

Latent 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”

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Tuberculosis Screening Tests:
Tuberculin Skin Testing
e.g. Heaf Test
Liable to reader bias / error
False positives if previous BCG vaccination

QuantiFERON
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

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Tuberculosis Treatment:
Managed by secondary care – usually Respiratory or Infectious Diseases.
In Bolton – TB clinic run by Respiratory
Notifiable 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

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Question 7 Following 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?

Ethambutol
Rifampicin
Isoniazid
Pyrazinamide
Not likely to be a drug side effect

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Question 7 Following 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?

Ethambutol
Rifampicin
Isoniazid
Pyrazinamide
Not likely to be a drug side effect

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TB Drug Side Effects Ethambutol
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

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TB Drug Side Effects Essentially:
If a patient on TB treatment presents with any of;
Peripheral Neuropathy
Visual Disturbance
Acute Gout Flare
Deranged LFTs

Suspect 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

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Asthma – Key Features Symptoms:
- 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

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Asthma – Why is it so complicated? There is no gold standard diagnostic test

Are GP’s over diagnosing asthma?

Overlap with other conditions e.g. COPD in adults, Viral Induced Wheeze in children

In the UK there are 2 sets of guidelines:
- BTS / SIGN Guidelines – updated 2019
- NICE Guidelines – published 2017

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Question 8 A 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 Diary
Post Bronchodilator Spirometry
Pre and Post Bronchodilator Spirometry
No further tests needed – trial steroid inhaler

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Question 8 A 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 Diary
Post Bronchodilator Spirometry
Pre and Post Bronchodilator Spirometry
No further tests needed – trial steroid inhaler

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What?! It’s an unfair question because NICE don’t even seem to know the answer

NICE published new Asthma Guidelines in November 2017
Biggest changes came in diagnosing asthma
Emphasised need for objective evidence rather then clinical diagnosis
Added 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

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FeNO Fraction of Exhaled Nitric Oxide
NO is released by Eosinophils – the primary white blood cells involved in Asthma.
↑NO = ↑Eosinophils = Asthma
Results presented as Parts Per Billion (ppb) >40ppb = Asthma
Don’t need to be symptomatic at time of test
Way to check steroid compliance
Still technique dependant
Machine cost: £2000-3000
Consumables costs: £5 for 1000 filters
However:
1 in 5 with a negative test will have asthma
1 in 5 with a positive test won’t
NICE don’t recommend for routine monitoring

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Asthma Diagnostic Tests Spirometry
Patient has to be symptomatic at the time of test to give a positive result
Technique dependent – more difficult then FeNO
Looking for obstructive picture – FEV1:FVC <70%
Ask for reversibility - >12% improvement in FEV1 after bronchodilator PLUS an increase in volume of 200mL

PEFR Diary
Captures the diurnal variation
NICE recommends BD readings over 2-4 weeks
>20% variability suggests asthma
Relying on patient for good quality evidence

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Asthma Diagnostic Tests Direct Bronchial Challenge
Aims to trigger asthma symptoms
Histamine or Methacholine
Only done in secondary care – generally when all other tests have been inconclusive but the clinical picture still suggests asthma.
Risks triggering severe symptoms

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NICE Asthma Diagnosis Guideline In symptomatic adults (>17) diagnose asthma if:
FeNO >40ppb PLUS either: positive reversibility, positive PEFR diary, or positive bronchial challenge
or
FeNO 25-39ppb AND positive bronchial challenge
or
Positive Reversibility AND positive PEFR diary “irrespective of FeNO result”

“Suspect Asthma” if Obstructive Spirometry but negative reversibility PLUS either:
FeNO >40ppb
FeNO 25-39ppb AND positive PEFR Diary

Refer to Respiratory for a second opinion if:
Only 1 test comes back positive and others are negative

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NICE Asthma Diagnosis Guideline In symptomatic Children (>5) diagnose asthma if:
FeNO >35ppb AND positive PEFR diary
or
Obstructive Spirometry with Reversibility

“Suspect Asthma” if only 1 test is positive

Refer to Respiratory for a second opinion if:
All tests are inconclusive

60

Question 9 According 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 bronchodilator
12% improvement in FEV1 post brochodilator and 22% variability in PEFR diary
FeNO 46ppb, FEV1:FVC 65%, 5% improvement in FEV1 post bronchodilator, and 12% variability in PEFR diary
FeNO 10ppb, 5% variability in PEFR diary, FEV1:FVC 68%, no change post bronchodilator

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Question 9 According 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 bronchodilator
12% improvement in FEV1 post brochodilator and 22% variability in PEFR diary
FeNO 46ppb, FEV1:FVC 65%, 5% improvement in FEV1 post bronchodilator, and 12% variability in PEFR diary
FeNO 10ppb, 5% variability in PEFR diary, FEV1:FVC 68%, no change post bronchodilator

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Question 9 According 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 bronchodilator
12% improvement in FEV1 post brochodilator and 22% variability in PEFR diary
FeNO 46ppb, FEV1:FVC 65%, 5% improvement in FEV1 post bronchodilator, and 12% variability in PEFR diary
FeNO 10ppb, 5% variability in PEFR diary, FEV1:FVC 68%, no change post bronchodilator

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BTS/SIGN Asthma Diagnosis Guideline Published 2019
Response to treatment is key to confirming diagnosis
Based on clinical judgement does the patient have a High, Intermediate, or Low probability of their symptoms being Asthma:

High probability of Asthma
Code as “Suspected Asthma”
Start Treatment – if responds then Asthma diagnosis confirmed
Poor response – move to Intermediate

Intermediate probability of Asthma
Test for airway obstruction (e.g. PEFR diary, Spirometry) or eosinophil activity (i.e. FeNO)
If positive code as “Suspected Asthma” and start treatment
If responds then Asthma diagnosis confirmed
Poor Response – move to low probability

Low Probability of Asthma
Consider alternative diagnosis, or Specialist referral

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SIGN / BTS Asthma Diagnosis Guideline2019

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Question 10 You 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. salbutamol
Inhaled Corticosteroid (ICS) e.g. beclomethasone
Leukotrine Receptor Antagonist (LTRA) e.g. montelukast
SABA + ICS
ICS + LTRA

66

Question 10 You 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. salbutamol
Inhaled Corticosteroid (ICS) e.g. beclomethasone
Leukotrine Receptor Antagonist (LTRA) e.g. montelukast
SABA + ICS
ICS + LTRA

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NICE Asthma Treatment Guideline 1. 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 reliever
6. 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 steroids

Consider decreasing therapy once symptoms have been stable for 3 months

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BTS/SIGN Asthma Treatment Guideline 1. 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

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NICE vs BTS/SIGN on Treatment NICE gives more options BUT is difficult to follow compared to the simple structure set by BTS/SIGN

NICE suggests LTRA at earlier stage for adults – critics suggest this will encourage patients to underuse their inhalers

BTS/SIGN is easy to follow step up / step down system - hence much easier to implement in primary care

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Guide to Asthma Drugs SABA 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 Drugs Leukotrine Receptor Antagonists
- Montelukast (Singulair) 10mg at night (4-10mg depending on age for kids)
- Side effects = Diarrhoea, Headache, Nausea

Theophylline
- 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 Treatments Omalizumab (Xolair)
Anti IgE monoclonal antibody
Monthly subcutaneous injection
Need high levels of IgE to qualify for treament

Mepolizumab (Nucala) + Reslizumab (Cinqaero)
Anti-Interleukin 5 (anti-IL-5) monoclonal antibody
Monthly subcutaneous injection (Nucala) or IV infusion (Cinqaero)
Only for severe eosinophilic asthma

Bronchial Thermoplasty
Aims to shrink bronchial wall smooth muscle
Bronchoscopy under sedation or GA
Small 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 Diagnosis Which 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 Diagnosis Which 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 All of these!

75

Asthma – Patient Education Key to effective long term control

Better 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 seminars

Good 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 / deaths Asthma 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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Question 11 A 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 case
Give 4 puffs of Salbutamol via spacer and repeat PEFR
Give 5mg Salbutamol via nebuliser and repeat PEFR
Admit to Medics but will need ambulance transfer

78

Question 11 A 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 case
Give 4 puffs of Salbutamol via spacer and repeat PEFR
Give 5mg Salbutamol via nebuliser and repeat PEFR
Admit to Medics but will need ambulance transfer

79

Question 12 After 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 attack
Give more bronchodilator
Admit to Medics with ambulance transfer
Refer to community respiratory nurses and prescribe prednisolone

80

Question 12 After 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 attack
Give more bronchodilator
Admit to Medics with ambulance transfer
Refer to community respiratory nurses and prescribe prednisolone

81

Acute Asthma Exacerbations Signs of severe asthma attack:
Drowsiness / Agitation
Signs of exhaustion: can’t complete sentences, cyanosis, accessory muscle use

For all patients:
Examine chest – wheeze, ?crackles, air entry,
Record RR, pulse, BP, and O2 Sats
Measure PEFR – best of 3, compare to usual best
Find out about previous admissions, ever been on ICU?

82

Acute Asthma Exacerbations Classify severity based on PEFR:

Moderate = PEFR >50-75%

Severe = PEFR 33-50%
or any of: RR >25 in adults, Pulse >110 in adults

Life Threatening = PEFR <33%
or any of: Sats <92%, signs of exhaustion, hypotension, poor respiratory effort, cardiac arrhythmia, altered consiousness

83

Acute Asthma Exacerbations Managing 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 minutes
In first 1-2 days can repeat every 4 hours and reduce to PRN when able – if needing <4 hourly then needs further review

Short course of oral steroids:
e.g. Prednisolone 40mg for 5 days. Don’t adjust ICS dose

Are Antibiotics needed? E.g. Amoxicillin

Advise they monitor PEFR + Safety net

Consider offering follow up to check response to treatment

84

Acute Asthma Exacerbations Managing Severe Exacerbations (PEFR 33-50%)

Give appropriate bronchodilator immediately and reassess - 5mg Salbutamol Neb is better option

If 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

85

Acute Asthma Exacerbations Managing Life Threatening Exacerbations (PEFR <33%)

Get help – emergency alarm, call 999

Give Oxygen – aim sats >94%

Give Salbutamol 5mg Neb (2.5mg if <5)– oxygen driven preferable. Repeat every 20-30 mins if needed

If no improvement give Ipratropium 500mcg Neb (if available, 250mcg if <12) – can only use every 4 hours

Monitor Obs and PEFR until ambulance arrives

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Question 13 Annual 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 apply

Bronchiectasis
Stroke
Immunosuppression
Diabetes Mellitus
Epilepsy
CKD stage 3
Obesity (BMI>30)
Pregnant Women

87

Question 13 Annual 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 apply

Bronchiectasis
Stroke
Immunosuppression
Diabetes Mellitus
Epilepsy
CKD stage 3
Obesity (BMI>30)
Pregnant Women

88

Seasonal Influenza Vaccination Clinical Risk Groups:
Chronic Respiratory Disease
Chronic Heart Disease
Chronic Kidney Disease
Chronic Liver Disease
Chronic Neurological Disease – includes TIA but not Epilepsy
Diabetes Mellitus
Immunosuppression
Splenectomy
Pregnant Women – at any stage
Morbid Obesity BMI > 40 – “use clinical judgement”

Certain Healthy Individuals also qualify
Over 65 years of age
Children aged 2-3 (done via GP) and 4-9 (done via school)
People in long stay care facilities e.g. Residential Homes
Carer’s
Household contacts of immuno-compromised individuals
Healthcare and Social Workers involved in patient care – includes students
Hajj and Umrah Pilgrims – advised by Saudi Ministry of Health - ?on NHS

89

Seasonal Influenza Vaccination Influenza types A and B
sub-strains of each alternate in prevalence every winter
Type A causes more severe infections and epidemics
Type B – smaller outbreaks, more common in children

Vaccines
All (but 1) are Inactivated Vaccines via IM injection
Trivalent – covers 2 strains of A, 1 strain of B
Quadrivalent – covers 2 strains of A, 2 strains of B
Fluenz Tetra – Quadrivalent Attenuated Live Vaccine – Nasal administration

90

Seasonal Influenza Vaccination Contraindications:
Previous Anaphylactic Reaction or Angioedema to the flu vaccine
Egg 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 days
Severely Immunocompromised
Heavy Nasal Congestion

91

Seasonal Influenza Vaccination Advise of common side effects:
All usually disappear within 1-2 days without treatment
Pain, redness, or swelling at injection site
Low grade fever, malaise, shivering, or fatigue
Headache, myalgia, or arthralgia
Nasal congestion and rhinorrhoa – with nasal vaccine
Basically; mild symptoms of the body’s usual reaction to any infection

Rare side effects:
Neuralgia, paraesthesia, convulsions
Transient thrombocytopoenia
Vasculitis with renal involvement (very rare)
Encephalomyelitis (very rare)

Impossible side effects:
Getting the flu from the vaccine!

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COPD – Key Features Symptoms:
- 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

93

Question 14 Which of the following is not a recognised risk factor for developing COPD?
More then one answer may apply

Occupational Exposure (e.g. Welder) in non-smokers
Occupational Exposure (e.g. Welder) in smokers
Homozygous alpha-1 antitrypsin deficiency
Heterozygous alpha-1 antitrypsin deficiency
Passive smoking
E-cigarettes
Obesity (BMI>30)
Air pollution

94

Question 14 Which of the following is not a recognised risk factor for developing COPD?
More then one answer may apply

Occupational Exposure (e.g. Welder) in non-smokers
Occupational Exposure (e.g. Welder) in smokers
Homozygous alpha-1 antitrypsin deficiency
Heterozygous alpha-1 antitrypsin deficiency
Passive smoking
E-cigarettes (not yet anyway)
Obesity (BMI>30)
Air pollution

95

Risk Factors for COPD SMOKING
But non-smokers can get COPD too:

Occupation exposures
Dust, noxious chemicals, welding fumes, particles of grains or silica, coal
20% COPD cases linked to occupational causes

Air Pollution
Particularly in developing countries that use wood or coal for household heating
Less of a factor in UK
However – vehicle pollution is linked to ↓lung function

96

Risk Factors for COPD Alpha-1 Antitrypsin Deficiency
Only confirmed genetic cause of COPD
WBC’s produce Trypsin enzyme to move between other cells and to break down bacteria or react to toxins e.g. Tobacco smoke
Antitrypsin stops trypsin damaging healthy lung tissue.

Genetics:
Autosomal Co-dominent – severity of disease depends on combination of genes inherited as both will be expressed

Simplified verion- Three forms of the A1A gene:
M = normal levels, Z = deficiency, S = mild deficiency

Homozygous A1AD (ZZ genotype)
Develop COPD under age of 45
Liver 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 COPD
Won’t necessarily develop COPD or any lung disease

97

E-cigarettes Big gaps in evidence
Big opportunity for misinformation to thrive
Big opportunity to make money in the confusion

Key points:
They are safe: In that they meet the minimum requirements of safety in order to be sold. But so does tobacco

Produce 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

98

E-cigarettes – Deaths in USA Centre for Disease Control and Prevention (CDC) update:
As of Oct 2019 – 1,479 case of “lung injury” reported
79% of patients were under 35 years old
33 deaths confirmed related to e-cigarettes
Most 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 known

Flavoured 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

99

Question 15 You 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 correct

Post Bronchodilator Spirometry
Chest X-ray
FeNO
PEFR
Pre and Post Bronchodilator Spirometry
ECG
Full Blood Count
Pulse Oximetry

100

Question 15 You 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 correct

Post Bronchodilator Spirometry
Chest X-ray
FeNO
PEFR
Pre and Post Bronchodilator Spirometry
ECG
Full Blood Count
Pulse Oximetry

101

Diagnosing COPD – NICE Guidelines Arrange the following for all people with suspected COPD:
Post Bronchodilator Spirometry
- FEV1:FVC <70% (<0.7) confirms diagnosis
- Reversibility testing not recommended
Chest X-ray
- Exclude differential diagnoses
Full Blood Count
- Pick up anaemia or secondary polycythaemia

Arrange the following additional investigations where appropriate:
Pulse Oximetry – What’s normal?
ECG + Echocardiogram – if signs of cor pulmonale
Sputum Culture – if purulent sputum is persistent feature

102

COPD Severity Graded using the FEV1

Stage 1 – Mild FEV1 >80% predicted

Stage 2 – Moderate FEV1 50-79% predicted

Stage 3 – Severe FEV1 30-49% predicted

Stage 4 – Very Severe FEV1 <30% predicted

103

COPD Severity MRC Dyspnoea Scale is also helpful (recommended by NICE)

104

Question 16 You 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)

105

Question 16 You 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)

106

Managing COPD – NICE Guidelines

107

Managing COPD – NICE Guidelines

108

Managing COPD – NICE Guidelines 2018 What about LABA or LAMA alone?
Combination inhalers more effective
Should not be prescribing LABA or LAMA alone

When to step up treatment?
>2 exacerbations in last year
1 hospitalisation as a result of COPD exacerbation
Still symptomatic (use MRC scale to judge)

What to check before stepping up?
Smoking?
Inhaler technique - ?need different device

109

Managing COPD Lifestyle Advice
Stop Smoking
Promote Exercise
Dietary Advice

Preventation + Screening
Immunisation – Seasonal Flu + Pneumococcal (single dose)
Screen for Depression + Anxiety
Screen for Heart Failure
Social, Physio, Occupational Therapy needs?

Pulmonary Rehabilitation
Consider for anyone suffering with breathlessness
https://www.youtube.com/watch?v=8x6Er-ifaXM

110

Managing COPD – Other Therapies Mucolytics
Consider if chronic productive cough with difficulty expectorating

Carbocisteine
- 750mg TDS for 4 weeks
- if “successful” then continue but reduce to 750mg BD
- if no response – STOP

Macrolides e.g. Azithromycin
- Only initiated by Secondary Care

Nebulised Saline
- Only initiated by Secondary Care
- Minimal impact with normal (0.9%) saline
- Need Hypertonic for significant effect

111

Managing COPD – Other Therapies Theophylline
Consider when persistent bronchospasm (wheeze) despite max inhaled therapy.

E.g. Uniphyllin MR – starting dose 200mg BD

Need to monitor levels (target 10-20mg/L)

Toxicity can cause: Nausea, Tachycardia, Arrhytmia, Hypokalaemia, Irritability, Seizures

112

Managing COPD – Other Therapies Phosphodiesterase type-4 inhibitors
E.g. Roflumilast (only PDE4i licensed for severe COPD)

PDE4 breaks down anti-inflammatory enzymes and therefore promotes inflammation

In severe COPD – reduces exacerbations and improves FEV1

Only started by secondary care

Roflumilast 500mcg OD – 30 tablets cost £37

Side effects: Weight loss, insomnia, headache, GI upset

Interacts with Theophylline – don’t co-prescribe

113

COPD – When to Refer (Bolton CCG) Diagnostic Uncertainty
Severe/Worsening COPD
Haemoptysis
Frequent respiratory infections
Suspected Cor Pulmonale
Symptoms don’t match Spirometry results
Age <40 or FH of A1AD
Assessment for Nebuliser / Home Oxygen Therapy

114

Question 17 Which of the following is a benefit of Long Term Oxygen Therapy in COPD?
More then one answer may be correct

Improved sleep
Reduced anxiety
Reduced breathlessness
Improved mood
Improved life expectancy
Reduced cough
Reduced hospital admissions

115

Question 17 Which of the following is a benefit of Long Term Oxygen Therapy in COPD?
More then one answer may be correct

Improved sleep
Reduced anxiety
Reduced breathlessness
Improved mood
Improved life expectancy
Reduced cough
Reduced hospital admissions

116

COPD – Oxygen Therapy (BTS) Treatment for Chronic Hypoxaemia (PaO2 <7.3kPa)
Does not relieve breathlessness

Different 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/anxiety

Ambulatory Oxygen
- Portable, improves quality of life
- Rarely used if patient doesn’t qualify for LTOT

117

COPD – Oxygen Therapy (BTS) When to refer for LTOT:
Baseline oxygen saturations <92% on air

Very Severe airflow obstruction – FEV1 <30%

Peripheral Oedema or Raised JVP (Cor Pulmonale)

Secondary Polycythaemia

Cyanosis

Refer to Respiratory Nurses – BART
When not to refer – if they still smoke!

118

Oxygen Therapy (BTS) – other uses Short 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 Headache

Palliative Oxygen
- Considered for breathlessness in terminal disease
- Only of benefit in hypoxaemic breathless patients
- Even then studies show little benefit on reducing symptoms
Other 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

119

Question 18 The 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 spacer
Call 999
Give oxygen – target sats >94%
Give oxygen – target sats 88-92%
Give Salbutamol 5mg Neb

120

Question 18 The 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 spacer
Call 999
Give oxygen – target sats >94%
Give oxygen – target sats 88-92%
Give Salbutamol 5mg Neb

121

Acute Exacerbations of COPD Signs of Severe Exacerbation
- O2 sats <90% - use of accessory muscles
- RR >25 - pursed lip breathing - Confusion
- Cyanosis - Peripheral oedema - ↓ ↓ET

Emergency 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?

122

Acute Exacerbations of COPD Managing in Primary Care
Increase dose/freqency of SABA
e.g. 4 puffs 4 hourly – best via spacer

Oral Corticosteroids
Prednisolone 30mg OD for 7-14 days

Oral 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

123

Rescue Packs Don’t prescribe without educating:
How to recognise an exacerbation
- SOB, wheeze, cough, ↓ET, ↑sputum
Infective vs Non-infective?
- Purulent sputum (yellow/brown) - change in sputum
What to do before starting the rescue pack?
- increase SABA - Breathing exercises
When to start steroids?
- if the above measures aren’t helping
When to start antibiotics?
- only if purulent sputum

Important points:
Never put on repeat prescription
If had >3 courses of steroids in 12 months and >65 – will need bone protection

124

Bronchiectasis What is it?
Chronic - Dilated, thick walled bronchi
Excess sputum and cilliary dysfunction

What causes it?
Any prolonged condition that damages the lungs
Affects up to 30% of COPD sufferers
Commonest cause is severe LRTI
Other causes: CF, aspiration, ABPA, Asthma, RA, Immune deficiency

When to suspect it?
Chronic excess sputum production – persistent cough
Unusual sputum results e.g. Pseudamonas
Prolonged LRTIs – requiring extended courses of antibiotics

125

Bronchiectasis Diagnosis
Can only be confirmed by High Resolution CT
But 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 first

But 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 antibiotics

Worth remembering that up to 30% COPD sufferers may need 10-14 day courses of antibiotics and better to send sputum before treating

126

Question 19 A 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 PE
Arrange an urgent chest x-ray
2 week wait referral to respiratory
Treat as suspected LRTI and arrange follow up in 1 week
Watch and wait (with safety netting advice)

127

Question 19 A 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 PE
Arrange an urgent chest x-ray
2 week wait referral to respiratory
Treat as suspected LRTI and arrange follow up in 1 week
Watch and wait (with safety netting advice)

128

Suspected Lung Cancer - NICE Refer 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 or

Are aged 40 and over with unexplained haemoptysis

129

Suspected Lung Cancer - NICE Offer 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 lymphadenopathy

Anyone >40 with 2 of, or any smoking history with 1 of;
Unexplained:
- Cough - Fatigue
- Weight Loss - SOB
- Chest Pain - Appetite loss

130

Question 20 A 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 weeks
Trial regular inhaled corticosteroid
2 week wait referral to respiratory
5 day course of Amoxicillin 500mg TDS
Start Omeprazole 20mg OD regularly and reassess in 1 month

131

Question 20 A 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 weeks
Trial regular inhaled corticosteroid
2 week wait referral to respiratory
5 day course of Amoxicillin 500mg TDS
Start Omeprazole 20mg OD regularly and reassess in 1 month

132

Cough NICE divides into: I tend to simplify to:
Acute = 0-3 weeks - Acute = 0-4 weeks
Subacute = 3-8 weeks - Persistant = >4 weeks
Chronic = >8 weeks

There is no effective treatment for cough – but can treat the causes

There 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

133

Cough NICE divides into: I tend to simplify to:
Acute = 0-3 weeks - Acute = 0-4 weeks
Subacute = 3-8 weeks - Persistant = >4 weeks
Chronic = >8 weeks

There is no effective treatment for cough – but can treat the causes

There 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

134

Persistent Cough - Assessment Good history is key:
Smoker? - think Lung Cancer or Smoking related
Dry 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 Failure
Timing
- Diurnal variation? – think Asthma
- Seasonal? – think Allergic (asthma or rhinitis)

135

Persistent Cough - Assessment Good 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 Asthma
Foreign Travel
- Cruise/Hotel – anyone else unwell? – think Legionella
- TB exposure?
Drugs
- ACEi – short or long term us
- Long term Nitrofurantoin – cause of Pulmonary Fibrosis
Red Flags:
- Haemoptysis -Weight loss

136

Persistent Cough - Assessment Investigations – my approach:

Chest X-ray
- Consider for any cough lasting >4 weeks
- Rule out Lung Ca, Pneumonia, ILD

Spirometry
- If any features of asthma
- If any exertional breathlessness suggestive of COPD/ILD

Sputum Culture
- If any sputum production

137

Persistent Cough - Assessment Normal CXR +/- Normal Spirometry:
Features of Reflux?
- Trial PPI for 1-2 months
- e.g. Omeprazole 20mg OD

Features 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

138

“Treatments” for Cough Dextromethorphan
- Active ingredient in most cough mixtures
- Minimal evidence of efficacy – therefore NOT recommended by NICE

Sedating Antihistamines
- Another ingredient in OTC cough mixtures
- Effects probably due to sedation rather then any antitussive effect

Expectorants – claim to help clear secretions – no evidence they do this
Demulcent preparation – “soothing” properties – may sooth but still cough

Simple Linctus
- Main ingredient is Citric Acid – no evidence of efficacy – don’t prescribe

Codeine
- 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

Respiratory Medicine in General Practice Dr Andrew

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Respiratory Medicine in General Practice Dr Andrew

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