Respiratory Medicine in General Practice Dr Andrew Thurston

Respiratory Medicine in General Practice Dr Andrew Thurston GP Focus on AKT RCGP Curriculum: Investigations: PEFR, Spirometry, Pulse Oximetry, Sputum Culture Indications for CXR, CT, MRI, Bronchoscopy Disease Scoring Tools e.g. CURB65 Conditions: URTI, LRTI - Bronchiectasis Ephysema - Pneumothorax PE - Pleural Effusion Asthma - COPD Chronic Cough - Respiratory Malignancies Stridor / Hoarseness - Occupational Lung Diseases

Fibrosis- Respiratory Failure Use of Oxygen - Connective Tissue Disorders Focus on AKT RCGP Curriculum: Investigations: PEFR, Spirometry, Pulse Oximetry, Sputum Culture Indications for CXR, CT, MRI, Bronchoscopy Disease Scoring Tools e.g. CURB65 Conditions: URTI, LRTI - Bronchiectasis Ephysema - Pneumothorax PE - Pleural Effusion Asthma - COPD Chronic Cough - Respiratory Malignancies Stridor / Hoarseness - Occupational Lung Diseases Fibrosis- Respiratory Failure Use of Oxygen - Connective Tissue Disorders

DISCLAIMER I wrote all the questions to fit with the topics They were designed to be similar to AKT questions. Please ask if anything isnt clear or looks wrong. Question 1 A 56 year old woman presents with exertional breathlessness, worsening over 6 months. Spirometry shows: FVC1.98 (predicted 3.51) FEV1 1.64 (predicted 2.82) FEV1/FVC 83% (predicted 80%)

What is the most likely diagnosis? A) Asthma B) Bronchiectasis C) COPD D) Pulmonary Fibrosis E) Extrinsic Allergic Alveolitis Question 1 A 56 year old woman presents with exertional breathlessness, worsening over 6 months. Spirometry shows: FVC1.98 (predicted 3.51) FEV1 1.64 (predicted 2.82) FEV1/FVC 83% (predicted 80%) What is the most likely diagnosis? A) Asthma B) Bronchiectasis

C) COPD D) Pulmonary Fibrosis E) Extrinsic Allergic Alveolitis 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 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 Interpreting Spirometry Obstructive Restrictive Asthma

COPD e.g. Fibrosis FVC Normal or Normal or FEV1

FEV1/FVC Normal Reversibility X

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

80% Diagnosis? Interpreting Spirometry Example: Pre Predicted FVC 2.67 2.80 FEV1 1.48 2.24 FEV1/FVC 54% 80% Diagnosis? Obstructive Airways Disease 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? 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)

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? A) CRB=1 - Manage in the community with oral B) C) D) E) 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 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? A) CRB=1 - Manage in the community with oral B) C) D) E) 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 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 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. 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 doesnt always accurately predict mortality risk use clinical judgement - NICE Question 3 A 43 year old smoker with no PMH attends with a 3 day

history of a cough productive of yellow sputum. He doesnt 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? A) Amoxicillin 500mg TDS for 7 days B) Amoxicillin 500mg TDS + Clarithromycin 500mg BD for 7 days C) Amoxicillin 500mg TDS for 5 days D) Doxycycline 200mg single dose then 100mg OD for 4 days E) C0-Amoxiclav 625mg TDS for 7 days Question 3 A 43 year old smoker with no PMH attends with a 3 day history of a cough productive of yellow sputum. He

doesnt 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? A) Amoxicillin 500mg TDS for 7 days B) Amoxicillin 500mg TDS + Clarithromycin 500mg BD for 7 days C) Amoxicillin 500mg TDS for 5 days D) Doxycycline 200mg single dose then 100mg OD for 4 days E) C0-Amoxiclav 625mg TDS for 7 days 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) 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 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.

Question 4 Which is the most common cause of Community Acquired Pneumonia? A) B) C) D) E) F) G) Mycoplasma Pneumoniae Streptococcus Pneumoniae Staphlococcus Aureus Legionella Pneumophilia Haemophilus Influenzae

Viral Infections Pseudomonas Aeuriginosa Question 4 Which is the most common cause of Community Acquired Pneumonia? A) B) C) D) E) F) G) Mycoplasma Pneumoniae Streptococcus Pneumoniae Staphlococcus Aureus

Legionella Pneumophilia Haemophilus Influenzae Viral Infections Pseudomonas Aeuriginosa CAP causative organisms BTS Audit No Pathogen Identified Steptococcus Pneumoniae All Viruses 13.1% Haemophilus Influenzae Mycoplasma Pneumoniae Staphlococcus Aureus Legionella Pneumophilia 45.3% 36.0%

10.2% 1.3% 0.8% 0.4% 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 theyve 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 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 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 doesnt 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? A) B) C)

D) E) Glandular Fever Whooping Cough Atypical Pneumonia Tuberculosis Post Infective Cough 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 doesnt 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? A) B) C) D) E) Glandular Fever Whooping Cough Atypical Pneumonia Tuberculosis Post Infective Cough 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 doesnt 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? A) B) C) D) E) Legionella Pneumophilia Mycoplasma Pneumonia

Chlamydia Psittaci (Psittacosis) Klebsiella Coxiella Burnetii 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 doesnt 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? A) B)

C) D) E) Legionella Pneumophilia Mycoplasma Pneumonia Chlamydia Psittaci (Psittacosis) Klebsiella Coxiella Burnetii 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 hasnt responded to penicillin 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 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 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 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 doesnt 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 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 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: A) B) C) D) E) Sputum Culture for Acid Fast Bacilli Full blood count and CRP

Thick blood film QuantiFERON Chest Radiograph 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: A) B) C) D) E)

Sputum Culture for Acid Fast Bacilli Full blood count and CRP Thick blood film QuantiFERON Chest Radiograph 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, 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 = Potts 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 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 Dont 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 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 Cant differentiate between Active and Latent Disease Limitations in sensitivity and specificity mean its not currently recommended for non-specialist use

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 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? A) B) C) D) E) Ethambutol Rifampicin Isoniazid Pyrazinamide Not likely to be a drug side effect

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? A) B) C) D) E) Ethambutol Rifampicin Isoniazid Pyrazinamide

Not likely to be a drug side effect 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

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. Dont stop any TB treatment without consulting the specialist first 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 Asthma Why is it so complicated? There is no gold standard diagnostic test Are GPs 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 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 its winter. She has hayfever, was prone to wheeze as a child, and doesnt smoke. According to the NICE guidelines what diagnostic test should be done first? A) B) C) D)

E) Fractional Exhaled Nitric Oxide (FeNO) Peak Flow Diary Post Bronchodilator Spirometry Pre and Post Bronchodilator Spirometry No further tests needed trial steroid inhaler 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 its winter. She has hayfever, was prone to wheeze as a child, and doesnt smoke. According to the NICE guidelines what diagnostic test should be done first? A)

B) C) D) E) Fractional Exhaled Nitric Oxide (FeNO) Peak Flow Diary Post Bronchodilator Spirometry Pre and Post Bronchodilator Spirometry No further tests needed trial steroid inhaler What?! Its an unfair question because NICE dont 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 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 Dont 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 wont NICE dont recommend for routine monitoring 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 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 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 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 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: A) FeNO 34ppb, normal spirometry and a 25% variability in B) C) D) E) 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 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: A) FeNO 34ppb, normal spirometry and a 25% variability in B) C) D) E)

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 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: A) FeNO 34ppb, normal spirometry and a 25% variability in B)

C) D) E) 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 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 SIGN / BTS Asthma Diagnosis

Guideline 2019 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? A) Short Acting Beta Agonist (SABA) e.g. salbutamol B) Inhaled Corticosteroid (ICS) e.g. beclomethasone C) Leukotrine Receptor Antagonist (LTRA) e.g. montelukast D) SABA + ICS E) ICS + LTRA

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? A) Short Acting Beta Agonist (SABA) e.g. salbutamol B) Inhaled Corticosteroid (ICS) e.g. beclomethasone C) Leukotrine Receptor Antagonist (LTRA) e.g. montelukast D) SABA + ICS E) ICS + LTRA 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

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 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 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) 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, SEs 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 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) 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 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! 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

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 / Asthma Action Plans deaths 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 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? A) Prescribe prednisolone 40mg, advise 4 puffs salbutamol 4 B) C) D)

E) 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 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? A) Prescribe prednisolone 40mg, advise 4 puffs salbutamol 4 B) C) D) E) 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 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? A) Prescribe prednisolone 40mg, advise 4 puffs B) C) D) E) 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 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? A) Prescribe prednisolone 40mg, advise 4 puffs salbutamol 4 hourly until he improves B) Call 999 this is a life threatening asthma attack C) Give more bronchodilator D) Admit to Medics with ambulance transfer E) Refer to community respiratory nurses and prescribe prednisolone Acute Asthma Exacerbations Signs of severe asthma attack: Drowsiness / Agitation

Signs of exhaustion: cant 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? 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 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. Dont adjust ICS dose Are Antibiotics needed? E.g. Amoxicillin Advise they monitor PEFR + Safety net Consider offering follow up to check response to treatment

Acute Asthma Exacerbations Managing Severe Exacerbations (PEFR 3350%) 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 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 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 A) B)

C) D) E) F) G) H) Bronchiectasis Stroke Immunosuppression Diabetes Mellitus Epilepsy CKD stage 3 Obesity (BMI>30) Pregnant Women 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 A) B) C) D) E) F) G) H) Bronchiectasis Stroke

Immunosuppression Diabetes Mellitus Epilepsy CKD stage 3 Obesity (BMI>30) Pregnant Women 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 Carers 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 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 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 CIs 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 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 bodys 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! 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 Question 14 Which of the following is not a recognised risk factor for developing COPD? More then one answer may apply A) Occupational Exposure (e.g. Welder) in nonB) C) D) E)

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

A) Occupational Exposure (e.g. Welder) in nonB) C) D) E) F) G) H) 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

Risk Factors for COPD 1.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 Risk Factors for COPD Alpha-1 Antitrypsin Deficiency Only confirmed genetic cause of COPD

WBCs 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 Wont necessarily develop COPD or any lung disease 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

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 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 A) B) C) D) E) F) G) H)

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

D) E) F) G) H) Post Bronchodilator Spirometry Chest X-ray FeNO PEFR Pre and Post Bronchodilator Spirometry ECG Full Blood Count Pulse Oximetry 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 Whats normal? ECG + Echocardiogram if signs of cor pulmonale Sputum Culture if purulent sputum is persistent feature COPD Severity Graded using the FEV1 Stage 1 Mild FEV1 >80% predicted

Stage 2 Moderate FEV1 50-79% predicted Stage 3 SevereFEV1 30-49% predicted Stage 4 Very Severe FEV1 <30% predicted COPD Severity MRC Dyspnoea Scale is also helpful (recommended by NICE) Grade Level of Activity 1

Not troubled by breathlessness except during strenuous exercise 2 Short of breath when hurrying or walking up a slight hill 3 Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace 4 Stops for breath after walking about 100 m or after a few minutes on the level

5 Too breathless to leave the house, or breathless when dressing or undressing 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? A) B) C) D) E)

F) G) H) 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) 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? A) B) C) D) E) F) G) H) 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) Managing COPD NICE Guidelines Managing COPD NICE Guidelines 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 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

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

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 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 dont co-prescribe COPD When to Refer (Bolton CCG) Diagnostic Uncertainty Severe/Worsening COPD Haemoptysis Frequent respiratory infections Suspected Cor Pulmonale Symptoms dont match Spirometry results Age <40 or FH of A1AD Assessment for Nebuliser / Home Oxygen

Therapy Question 17 Which of the following is a benefit of Long Term Oxygen Therapy in COPD? More then one answer may be correct A) B) C) D) E) F) G) Improved sleep Reduced anxiety Reduced breathlessness

Improved mood Improved life expectancy Reduced cough Reduced hospital admissions Question 17 Which of the following is a benefit of Long Term Oxygen Therapy in COPD? More then one answer may be correct A) B) C) D) E) F) G)

Improved sleep Reduced anxiety Reduced breathlessness Improved mood Improved life expectancy Reduced cough Reduced hospital admissions 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 doesnt qualify for LTOT 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!

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

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? A) B) C) D) E)

Give 10 puffs Salbutamol via spacer Call 999 Give oxygen target sats >94% Give oxygen target sats 88-92% Give Salbutamol 5mg Neb 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? A)

B) C) D) E) Give 10 puffs Salbutamol via spacer Call 999 Give oxygen target sats >94% Give oxygen target sats 88-92% Give Salbutamol 5mg Neb 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? 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 Rescue Packs Dont 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 arent 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 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 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 wont 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 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 E) Watch and wait (with safety netting advice) A) B) C) D) 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 E) Watch and wait (with safety netting advice) A) B) C) D) 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 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 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? A)

B) C) D) E) 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 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? A) B) C) D) E) 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

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

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 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

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 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 dont prescribe Codeine - All opiates suppress cough but not particularly well - Lot of SEs 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

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