By Laura Parker
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To be able to define Asthma and COPD
To have an understanding of the pathogenesis
of each disease and the common causes / risk
factors associated
To be able to recognise the presentation of
patient with Asthma or COPD
To be able to manage an acute exacerbation of
Asthma / COPD
To understand the long term management
options available for clinicians for Asthma /
COPD
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Asthma: chronic inflammatory disease of the lungs
characterised by airway obstruction that is reversible
Extrinsic
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Immune
Onset childhood
Eosiniphilia blood & sputum
Intrinsic
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Abnormal autonomic reulation of airways
Onset Adulthood
Eosinophilia sputum
Assoc w/ chronic bronchitis
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5.4 million receive treatment UK (~5%)
Most common chronic medical condition in
children
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Risk Factors
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Personal history of atopy
Family history of asthma or atopy
SYMTPOMS
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Wheeze
Cough
Difficulty breathing
Chest tightness
?diurnal variation
?triggers
?atopy
SIGNS
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Normal between attacks
Prolonged expiration
Wheeze
Respiratory distress
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Idiopathic or Iatrogenic
Genetic:
Vascular:
Infective:
Trauma:
Autoimmune:
Metabollic:
Inflammatory:
Neoplastic:
Degenerative:
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Anaphylaxis eg penicillin allergic patient given
penicillin
alpha 1 Antitrypsin disease
PE, Anaemia
Pneumonia, Bronchiectasis
Tension pneumothorax
Autoimmune:
Metabollic:
COPD, Asthma
Lung Ca
Fibrosis
Inpatient
• Peak flow
• Sputum
• Urine
• Bloods
• ABG
• ECG
• CXR
• Pulmonary Function Tests
• +/- further imaging ( CT, HRCT)
A,B,C,D,E…
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OXYGEN
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NEBS
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Sats 94-98%
BETA AGONIST
IPRATROPIUM
STERIODS
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oral / IV
IV MgSO4
ABX if suspicious infective exacerbation
Aims:
 No symptoms during the day
 No waking at night due to symptoms
 No exacerbations
 No need for rescue medication
 No exercise limitation
 Normal lung function
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Yearly Asthma Review
Smoking status
Triggers and avoidance
Concordance
Inhaler technique
Stepwise approach….
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Chronic Obstructive Pulmonary Disease
(COPD): collective term for an inflammatory
lung disease in which airway obstruction is
progressive and only partially reversible by
bronchodilators
Chronic Bronchitis: persistent cough with
sputum production for > 3months/year for 2
years
Emphysema: permanent enlargement of air
spaces distal to the terminal bronchiole due to
alveolar septal destruction
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Est 3 million people UK
Prevalence 1.5% population
Risk factors
SMOKING (effects approx 15% smokers)
Increases with age
More common in men
More common deprived communities
SYMPTOMS
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Wheeze
Chronic cough
SOBOE
Regular sputum
production
Frequent winter
'bronchitis”
? >35yrs old
?hx of smoking
SIGNS
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Pink puffers / blue
bloaters
Respiratory distress
Hyper-expansion
Hyper-resonant
Prolonged expiration
Wheeze
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Anaphylaxis eg penicillin allergic patient given
penicillin
alpha-1 Antitrypsin
PE, Anaemia
Pneumonia, Bronchiectasis
Tension pneumothorax
Autoimmune:
Metabollic:
COPD, Asthma
Lung Ca
Fibrosis
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Inpatient
Peak flow
Sputum
Urine
Bloods
ABG
ECG
CXR
Pulmonary Function Tests
+/- further imaging ( CT, HRCT)
A,B,C,D,E
 Controlled oxygen therapy
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Aim Saturations 88-92%
Nebulised bronchodilators
Oral corticosteroids
+/ABX
NIV
Multi-Disciplinary
 Smoking Cessation
Vaccination
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Mucolytics
Oral bronchodilators eg theophylline (nb narrow
therapeutic window)
therapeutic range of theophylline is 10-20 mg/litre
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Oxygen
LTOT / SBOT
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NIV
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Surgery: bullectomy, lung volume reduction surgery
and lung transplantation
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To be able to define Asthma and COPD
To have an understanding of the pathogenesis
of each disease and the common causes / risk
factors associated
To be able to recognise the presentation of
patient with Asthma or COPD
To be able to manage an acute exacerbation of
Asthma / COPD
To understand the long term management
options available for clinicians for Asthma /
COPD
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11.
Remove cap
Shake the device
If you have not used the inhaler for a week or more, or it is the
first time you have used the inhaler, spray it into the air before
using to check that it works
Hold the inhaler upright with you forefinger on the top
Big breath out
Place the mouthpiece in your mouth between your teeth, and
close your lips around it
Start to breathe in slowly and deeply, at the same time, press
down on the canister releasing a “mist”
Hold your breath for as long as is comfortable, then breathe out
as normal.
If you need 2 puffs, wait 30 seconds then repeat
Do not release two puffs at the same time
Replace cap
Accurate History
Pack year =
no. cigarettes smoked per day
20
X no. years smoked
Assess “readiness to change”
Cessation
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Nicotine Replacement Therapy
• Patches
Bupropion (nb reduces seizure threshold)
• Varenicline (champix) (nb use in caution in a Pt w/ psych
hx)
• E-cigarettes: evidence controversial, recent BMJ article
suggest they encourage and glamourize smoking, not
available by prescription at present
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A 64 year old gentleman presents to A&E with
increasing SOB over the last 3 days. This is
associated with a cough productive of thick,
green sputum. He has a past medical history of
“asthma”, but he has smoked 50 cigarettes a day
for the past 40 years. Obs: RR 30 O2 sats 85%
on 21% HR 120 BP 138/82. O/E he is using his
accessory muscles to breathe, bilateral diffuse
coarse crepitations and widespread wheeze
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Differential diagnoses?
Initial management?
Investigations?
Treatment?
Patient is successfully treated for infective
exacerbation of COPD and discharged from hospital.
You see him in your GP surgery a few weeks later for a
medication review. How may you optimise the
management of this patient?
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http://emedicine.medscape.com/article/296301-overview
http://www.patient.co.uk/doctor/bronchial-asthma
British Guideline on the Management of Asthma. British Thoracic
Society and the Scottish Intercollegiate Guidelines Network.
(Revised January 2012). Available online at http://www.britthoracic.org.uk
Regulation in chronic obstructive pulmonary disease: the role of
regulatory T-cells and Th17 cells: Nina Lane*, R. Adrian Robins*,
Jonathan Corne† and Lucy Fairclough* Clinical Science
(2010) 119, (75–86)
Chronic Obstructive Pulmonary Disease (2010). Clinical Gudeline
101. National Institute for Health and Care Excellence. Available
online athttp://www.nice.org.uk/CG101
How to use inhaled devices:
http://www.medicines.org.uk/guides/pages/how-to-use-yourinhaler-videos
BNF
Are There Any Questions?