CPTP ASTHMA & COPD

Richard Shaw, a 50 year old man who as recently moved into the area goes to register at a
local GP surgery. A routine questionanaire, administered at registration, reveals that Rick has
a history of asthma which began when he was a child. Rick still experiences symptoms
of breathlessness and wheezing, especially early in the morning, and also has a
chronic cough. He has never been hospitalised due to his asthma but has lost days at work
due to chest problems. He has occasional exacerbations of breathlessness,
associated with a cough productive of purulent sputum. These episodes are usually
treated with antibiotics and short courses of prednisolone. His only current asthma treatment
is a salbutamol inhaler which he uses "when he feels he needs it", which is often as
much as eight times a day. He has occasionally had courses of oral and inhaled
steroids in the past but has not continued with inhaled steroids as he does not
notice any effect on his symptoms. Rick had a myocardial infarction 2 years ago and
takes aspirin 75 mg daily and simvastatin 20mg daily. His only other past medical
history is glaucoma for which he uses timolol eye drops.

Q1) List the types of drug treatment available for asthma.

The main aim of treatment is
a) Controller medications
They prevent asthma attack
Airways become less inflamed and less likely to react to triggers
b) Quick-relief medications
Relax the muscles around the airway
Often called the rescue medications

Two basic types of drugs:

1. Bronchodilators
Relieve the symptoms of asthma by relaxing the muscles that can
tighten around the airways
It helps open up the airways

Short- acting bronchodilator:

Often referred to as rescue inhalers and used quickly relieve

cough, wheeze, chest tightness and SOB caused by asthma

They may be also used prior to exercise for people with exercise
induced asthma

They should not be used daily in the daily routine.

IF the usage of short- acting bronchodilator as rescue inhaler is

use more than twice a week, then asthma may not be optimally
controlled.

Long-acting bronchodilator:

Sometimes used in combination with inhaled steroids for control

of asthma symptoms or when someone have ongoing asthma
symptoms despite treatment with daily inhaled steroids.

2. Anti-inflammatory drugs ( inhaled steroids)

These medications prevent asthma attacks and work by reducing

swelling and mucus production in the airways.

Airways therefore become less sensitive and less likely to react to

asthma triggers and cause asthma symptoms

Q2)What would be the most appropriate management plan for this patient?

Continue prn inhaled salbutamol and add prn inhaled fluticasone

Continue prn inhaled salbutamol and add prn inhaled ipratropium
Continue prn inhaled salbutamol and add regular inhaled fluticasone
Stop prn inhaled salbutamol and substitute prn inhaled salmeterol
Stop prn inhaled salbutamol and substitute regular inhaled salmeterol

Rick is
married
and
works as
a van
driver.
He has
smoked
40

cigarettes daily since his teens and drinks about 16 units of alcohol a week.

The general practitioner examines Rick and the only abnormality he discovers is a sparse scattered
polyphonic wheeze on chest auscultation. Rick's temperature is normal, his SpO2 95% and his peak flow is
330 l/min (predicted 560) but increases to 370 after 200 mcg inhaled salbutamol
# The reversibility is only 12% (target in asthma is > 15%)

Q3)How should this patient be managed?

Step up to step 2

Q4)Are steroids appropriate and, if so, how should they be

administered?

Steroids are appropriate as his symptoms / asthma is not purely controlled.

Inhaled corticosteroid

Q5)Comment on his other drug treatment. What changes to this

might be helpful?
Aspirin
10-20% of adults with asthma have sensitivity to aspirin or to NSAIDS
Asthma attacks caused by any of these medications can be severe and
even fatal
Products with acetaminophen is safer alternative for pain reliever for
aspirin-induce asthma patient
Some people with asthma cannot take aspirin or NSAIDS because of
whats know as SAMSTERS TRIAD
Asthma
Aspirin sensitivity
Nasal polys
Beta-blockers
Commonly used to treat numerous condition including heart conditions,
high blood pressure, migraine headache, and eye drop ( glaucoma)
Patient is taking Timolol ( non-selective beta-blocker , treatment for
glaucoma)

 BNF: Beta blockers should not be used in patients with:

a) Asthma
b) COPD
BNF on timolol: systemic absorption can follow topical application to the
eyes, therefore eye drops containing a beta-blockers are contra-indicated
in patient with bradycardia, heart block and uncontrolled heart failure and
asthma
Change to other option:
1. Prostaglandin analogue
2. Sympathomimetics
o Is a selective
alpha 2
adrenoreceptor agonist
o Is licensed for the
reduction of
intra-ocular pressure in patients for whom beta-blockers
are not suitable
3. Carbonic anhydrase
inhibitors
o Dorzolamide &
brinzolamide are topical carvonic anhydrase inhibitors
o Are licensed for use in patients resistant to betablockers or those who are contraindicated with beta
blockers.
ACE-Inhibitor
Generally, it is safe in asthmatic patient.
But, it can cause coughs in about 10% of the patients who use them.
This may not be asthma but, it can be confused with asthma.
If the cough is caused by ACEI, it will usually go away a week or so
after the ACEI is stopped.
When cough, then it may lead to case of unstable airways, may trigger
asthma symptoms.
The GP adjusts Rick's medication in line with BTS guidelines. Six weeks later Rick
returns to the practice for review of his treatment. He is feeling better. His peak
flow is 390 l/min first thing in the morning and 435 l/min in the evening (his
best figure). He is still breathless on exertion and occasionally wakes in the
early morning with coughing and a chest that feels tight.
The GP considers further modifying Rick's treatment.

Q6) What further management would you recommend?

Check compliance
Check dosage
Check inhaler technique
Check & eliminate trigger factors ( smoking smoking cessation)
Change / step up to step 3 ( LABA)

Six months later Rick is (rightly or wrongly) being prescribed inhaled salbutamol as
required (he usually takes usually 200 mcg 2-3 times daily), regular inhaled
beclometasone (800 mcg/day) inhaled salmeterol (50 mcg twice daily) and oral
theophylline 450 mg daily. He has been well, without morning waking due to
breathlessness. He occasionally coughs, sometimes producing mucoid sputum. He
still smokes. A chest X-ray shows hyper-expanded lungs but no fibrosis or other
abnormalities. His best peak flow is 500 L/min.
One evening he comes to the evening surgery with an exacerbation of his breathlessness
associated with a cough productive of purulent sputum. He is seen by a locum GP who
on examining Rick hears wheezes throughout both lung fields. When measured, Rick's
peak flow is 275 l/min. ( 49% severe attack)

Q7)What management is required now?

Admit patient

High flow oxygen

Nebulised SABA

Oral Prednisolone
Monitor patient

Following 3 days treatment the GP is called to review Rick at home. Rick's symptoms have not
improved, indeed his peak flow has fallen to 200 l/min and he feels very breathless at rest. His
respiratory rate is 35 /min and pulse is 134 /min. When talking he is unable to complete a full
sentence.
The GP calls an ambulance to take Rick to hospital and refers him to the Medical Admissions
Unit where he is admitted under the care of Dr Jackson, the general physician on call. A chest
X-ray taken on admission shows left basal consolidation and blood tests show:

Haemoglobin

14.2 g/dL (1318)

White Cell Count

17.8 x 109/L (411) (high)

Platelet Count

195 x 109/L (150400)

Serum sodium

139 mmol/L (137144)

Serum potassium

4.2 mmol/L (3.54.9)

Serum urea

6.1 mmol/L (2.57.0)

Serum creatinine

107 mol/L (60110)

Serum glucose

7.3 mmol/L (4.4-7.7)

CRP

37 mg/L (<5) (high)

Arterial Blood Gases show:

pH 7.34
PaO2 7.9 kPa (less than 8 is life threatening)
PaCO2 5.5 kPa
HCO3-

(remain mystery) but we think it should be increase

How would Rick's asthma best be described at this stage?

0

Acute Severe
Life Threatening
Mild
Moderate
Near Fatal

Discussion Point
How should this exacerbation be managed?

Same as management severe attack

Add inhaled ipratropium
Consider Add antibiotic

What are the likely infecting organisms?

Strep. Pneumonia
Haemophilus Influenza

Should Rick be given antibiotics? If so which antibiotics would be appropriate?

Consider!!!!
Amoxicillin ( oxford textbook)
Macrolides antibiotic (interfere with theophylline metabolism (clinical pharmacology
textbook)

Ricks symptoms do not respond adequately to the initial treatment with salbutamol,
ipratropium and hydrocortisone and the admitting doctor decides to add a magnesium
infusion.

WriSkE Task
Write a prescription for an appropriate initial infusion of magnesium.
Rick makes a good recovery and is discharged from hospital. While he is admitted he is reviewed by the
respiratory medicine team who revise his chronic treatment.

Five years later, Rick goes to see his GP. He has had worsening breathlessness and wheezing
over the preceding 2 months, both of which are worse on on exertion. He also has a daily
cough productive of off-white sputum. He has also noticed and increasing leg oedema
(pulmonary Hypertension secondary to COPD). He has continued to smoke 40 cigarettes a
day.
Rick is apyrexial. On respiratory auscultation the GP hears a few polyphonic wheezes. Physical
examination is otherwise unremarkable. Rick's peak flow is 280 l/min (predicted 560) and his
oxygen saturation on room air is 93%.
Although the GP does not think that Rick has an acute infection he sends blood for full blood
count and urea and electrolytes. The results, when available 2 days later, are normal. He also
sends Rick to the local hospital for spirometry which shows Rick to have an FEV1 40% of
predicted and FEV1/FVC ratio post-bronchodilator of 0.46.

Is Rick's primary problem now still asthma?

COPD (? Pulmonary hypertension, heart failure, electrolyte imbalance)

diagnosis of COPD if FEV1/FVC < 0.7
Ratio post-bronchodilator of 0.46 ( less than 0.7)
> 35 years old likely to be COPD
Heavy smoker
Chronic cough with white sputum
NICE:
A diagnosis of COPD should be considered in patients over the age of 35
who have risk factor( smoking) and who present with one or more of the
following symptoms:
1.
2.
3.
4.

Exertional breathlessness
Chronic cough
Regular sputum production
Frequent winter bronchitis

5. Wheeze

How
should this
patient be managed?

Smoking cessation
Consider vaccination (pneumococcal and influenza)

Are inhaled bronchodilators and steroids appropriate?

Yes NICE guideline

Add ipratropium
Mucolytic
Stop theophylline

What are the risks of inhaled steroids in this patient?

Side effect of steroids (STEROIDS)

Oral candida & hoarseness
Stomach ulcer
Thin skin

Edema
Right and left heart failure
Osteoporosis
Infection (lower respiratory tract)
Diabetes
Syndrome of Cushing

Six weeks after seeing his GP, Rick is admitted to hospital having presented to the emergency
department with a 3 day history of left-sided pleuritic chest pain and a cough productive of
green sputum. On arrival in the ED he was breathless but not cyanosed, able to speak in full
sentences oxygen saturation on room air was 90%, respiratory rate 30/minute and chest
auscultation reveals widespread expiratory wheeze. Rick's JVP was noted to be elevated and
he had pitting oedema to the knees. Once again he was admitted to the medical ward under
Dr Jackson's care.

The presence of which clinical finding gives the strongest indication of the need for hospital
admission?
0

Green sputum
Pitting oedema to the knee
Pleuritic chest pain
Respiratory Rate 30 /min
SpO2 90%

Discussion Point
What is your differential diagnosis of the acute problem?

Cor pulmonale
Pneumonia
Heart Failure

How would you manage this acute presentation?

Take ABG
Chest X-ray
Blood culture
Full Blood count
Sputum Culture
ECG
Theophylline level
U&E kidney function

How would you treat the hypoxia?

Give slowly oxygen (88-92 % is the target of Spo2) & monitor

Rick's admission chest X-ray is shown below:

X-ray finding:

Plain Chest Radiograph

Not sure about AP/ PA
Trachea is centrally located
Hilum dilated pulmonary vessels
Lung zones clear
Pleura normal
Costophrenic angle normal
Diaphragm Flattened Diaphragm ( Left side hemidiaphragm
Heart tubular which indicating heart might be compressed
Mediastinum not shifted
Bone and soft tissue normal
Hyper inflated lung ( 8 anterior ribs)

Arterial blood gases on 24% oxygen show:

pH 7.31
Po2 6.8 kPa
Pco2 7.4 kPa
HCO3- 34 mmol/L
Discussion Point
What do the blood gases indicate?

1. Type 2 respiratory failure

2. Compensated Respiratory Acidosis
What further management should be considered?

Noninvasive positive-pressure ventilation (sometimes called CPAP or BiPAP) or a

breathing machine, if needed.

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What would be the best initial management step for the admitting doctor to take in this
case?
0

Give ipratropium bromide 500mcg by nebuliser.

Give salbutamol 500mcg by nebuliser.
Make an urgent referral to ICU for non-invasive ventilation.
Prescribe prednisolone 40mg orally.
Start supplemental oxygen 60% by venturi mask.

Rick recieves non-invasive ventilation in addition to bronchodilator, steroid and antibiotic therapy and makes a
good recovery from the acute exacerbation.
During his convalescence Rick enquires about the possibility of having a nebuliser at home, as he has found
his nebuliser treatment very effective during his hospital stay.
Discussion Point
What are the advantages and disadvantages of home nebuliser therapy?
Advantages:
Patient is treated at home
Continue daily activity normally
Little skill is required
Disadvantages:
Compliance
High doses bronchodilator may cause systemic effects

Expensive
Regular maintenance
May delay seeking medical advice in a severe attack
Not portable

What alternatives are available?

Spacer

How might he be assessed for home nebuliser therapy?

NoPs0TWm8xux3

The following week Rick attends his GP's surgery for review. The GP wonders whether he might be a
candidate for long term oxygen therapy (LTOT) and resolves to discuss the possibility with the respiratory
medicine consultant.

What would be the most appropriate advice for the respiratory physician to give the GP?
0

LTOT is contraindicated as the patient is reliant on hypoxic drive to stimulate breathing.

LTOT is contraindicated as the patient is still smoking.
LTOT is indicated as the patient's Pao2 was <7.3 kPa during his hospital admission.
The patient should be reassessed for LTOT after a period without acute exacerbations.
The patient should receive LTOT only at night.