Asthma, COPD & Anaphylaxis

Dr Edwin Chau & Dr Saarth Shiralkar Calderdale & Huddersfield NHS Trust

Objectives
Epidemiology Investigations Management Acute severe asthma Acute exacerbation of COPD

Asthma
Chronic disease characterised by recurrent attacks of SOB and wheeze Varying severity and frequency Bronchial muscle contraction airway narrowing Mucosal swelling and inflammation release of inflammatory mediators airway wall thickening

Asthma Clinical Features

Intermittent dyspnoea, wheeze, cough, sputum Precipitants: cold air, exercise, emotions, allergens, infection, smoking, NSAIDs, blocker Diurnal variation symptoms often worse at night; peak flow worse in morning

Asthma - Investigations
Peak flow Spirometry Chest x-ray Skin prick test Aspergillus antibodies Histamine/methacholine challenge

Asthma Management

Asthma Management (Adults)

Asthma Management (Kids)

Acute Asthma Moderate

Tachypnoea Hyperinflated chest Hyper-resonant percussion Bilateral expiratory polyphonic wheeze Decreased air entry Peak flow >50% of normal

Acute Asthma Severe

Unable to complete sentences HR >110 bpm RR >25/min Peak flow 33-50% of normal Sats <92% (on air) Use of accessory muscles

Acute Asthma Life Threatening

Silent chest Cyanosis Bradycardia Confusion Peak flow <33% of normal Exhaustion

Acute Asthma Investigations

Peak flow Sputum culture FBC U&Es CRP Blood culture ABG (if Sats <95% on air)

Acute Asthma Management

Oxygen 15L via non-rebreathe mask Salbutamol 5mg nebs Hydrocortisone 100mg IV or prednisolone 40mg PO Ipratropium bromide 500mcg nebs Magnesium sulphate 2g IV

COPD
Persistent blockage of airflow from the lungs Umbrella term for emphysema and chronic bronchitis FEV1 <80% of predicted FEV1:FVC ratio <70% of predicted

COPD Blue Bloaters

Type 2 respiratory failure Cyanosis; not breathless Rely on hypoxic drive Predominantly chronic bronchitis

COPD Pink Puffers

alveolar ventilation, normal PaO2 & PaCO2 Breathless; not cyanosed May progress to type 1 respiratory failure Predominantly emphysema

COPD Clinical Features

Productive cough Dyspnoea at rest Wheeze Use of accessory muscles Hyperinflation Quiet breath sounds Hyper-resonant to percussion

COPD Investigations
FBC CXR ABG ECG Lung functions

COPD Management

Acute Exacerbation of COPD

Increased SOB, wheeze, purulent sputum Oxygen 24-28% via Venturi mask Salbutamol 5mg nebs Ipratropium bromide 500mcg nebs Antibiotics Hydrocortisone 200mg IV stat Prednisolone 30-40mg OD for 7/7 NIPPV

COPD vs. Asthma

COPD Smoker/Ex-smoker Symptoms aged <35 Most Rare Asthma Possibly Common

Chronic productive cough

Breathlessness Orthpnoea Normal FEV1 with drug therapy

Common
Persistent, progressive Uncommon Not with significant disease

Uncommon
Variable Common Probably

Anaphylaxis
Severe, life threatening Type 1 IgE mediated hypersensitivity reaction Caused by foreign substance

Anaphylaxis Clinical Features

Erythema Urticaria Oedema Tachycardia Hypotension Laryngeal obstruction

Anaphylaxis Management
ABCDE approach Adrenaline 0.5mg 1:1000 IM Remove/treat underlying cause Chlorphenamine 10mg IV Hydrocortisone 200mg IV Salbutamol 5mg nebs May need ICU admission

Scenario 1
A 7 year old girl has had poor control of asthma for the past 6 months. She has been using 2 agonist inhaler (with spacer) alone. How would you modify her treatment? a) Add a steroid inhaler b) Add a ipratropium bromide inhaler c) Add a salbutamol turboinhaler d) Add an oral steroid

Scenario 1
A 7 year old girl has had poor control of asthma for the past 6 months. She has been using 2 agonist inhaler (with spacer) alone. How would you modify her treatment? a) Add a steroid inhaler b) Add a ipratropium bromide inhaler c) Add a salbutamol turboinhaler d) Add an oral steroid

Scenario 2
A 25 year old asthmatic male is visiting your town for the weekend. His asthma in the past week has been poor and he has had to use his salbutamol inhaler 3 times daily. On examination his peak flow is 70%. As a GP what do you do? a) Tell him to wait to see his own GP b) Prescribe more salbutamol inhalers c) Prescribe steroid and salbutamol inhalers d) Prescribe oral steroids

Scenario 2
A 25 year old asthmatic male is visiting your town for the weekend. His asthma in the past week has been poor and he has had to use his salbutamol inhaler 3 times daily. On examination his peak flow is 70%. As a GP what do you do? a) Tell him to wait to see his own GP b) Prescribe more salbutamol inhalers c) Prescribe steroid and salbutamol inhalers d) Prescribe oral steroids

Scenario 3
A patient with respiratory problems presents to A&E. You suspect COPD. The nurse has put in an IV cannula and taken bloods. What is the next investigation? a) Chest x-ray b) Skin prick test c) ABG d) Sputum culture

Scenario 3
A patient with respiratory problems presents to A&E. You suspect COPD. The nurse has put in an IV cannula and taken bloods. What is the next investigation? a) Chest x-ray b) Skin prick test c) ABG d) Sputum culture

Scenario 4
A patient with COPD presents to A&E. His blood gases show SpO2 = 6 and SpCO2 = 7. He is started on 60% FiO2. His next blood gas shows SpO2 = 14 and SpO2 = 8. What would be the next appropriate action? a) Mechanical ventilation b) Give combined O2 and CO2 c) Decrease FiO2 d) Request a nurse to monitor him

Scenario 4
A patient with COPD presents to A&E. His blood gases show SpO2 = 6 and SpCO2 = 7. He is started on 60% FiO2. His next blood gas shows SpO2 = 14 and SpCO2 = 8. What would be the next appropriate action? a) Mechanical ventilation b) Give combined O2 and CO2 c) Decrease FiO2 d) Request a nurse to monitor him

Scenario 5
A 50 year old male presents to A&E with a severe adverse reaction to a wasp sting. What would be your initial management? a) Pour vinegar on the sting b) Give chlorphenamine 10mg IV c) Secure the airway d) Transfer the patient to ICU

Scenario 5
A 50 year old male presents to A&E with a severe adverse reaction to a wasp sting. What would be your initial management? a) Pour vinegar on the sting b) Give chlorphenamine 10mg IV c) Secure the airway d) Transfer the patient to ICU

Summary
Asthma tends to be a disease of the young COPD tends to be a disease of middle age Learn NICE & BTS guidelines for long term management Always use ABCDE approach for acute illness Memorise doses for acute drugs

Any Questions?