Clinical Management Respiratory Diseases

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Clinical Management Respiratory Diseases

• Judith Coombes
• University of Queensland
• Brisbane, Australia

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Pathology

• major international cause of morbidity and
  mortality
• In Australia single biggest cause of days lost
  from work
• generate largest number of GP visits

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Objectives

• Be able to interpret Spirometry as a lung
  function test and monitoring tool
• Be able to interpret Peake Expiratory Flow rate
  (PEFR) as a monitoring tool
• Understand goals of treatment and be able to
  communicate pharmaceutical care plan in asthma
• Understand goals of treatment of and be able to
  communicate pharmaceutical care plan in COPD
• Not discussing infections, neoplasms or TB

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The Lungs
Trachea Bronchus(LR) Bronchi Bronchiole Alveoli
Trachea
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Respiratory Symptoms

• cough
• sputum production/haemoptysis
• dyspnoea
• wheezing
• chest/lung pain

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Measurement of ventilatory function

• Spirometry
• PEFR
• Blood Gas
• Exercise test-6 min
• chest Xray- normal is asthma and COPD

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Spirometry

• Spirometer
• FVC Forced Vital Capacity
• FEV1 Forced Expiratory Volume over 1 second
• FEV1/FVC is forced expiratory ratio
• should be gt75
• useful for diagnosis
• accurately measures degree of impairment

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Normal
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PEFR

• Peak Flow Meter
• maximum flow rate which can be forced during an
  expiration
• may differ between meters
• Submaximal effort invalidates reading
• Not a substitute for spirometry
• most useful for regular monitoring to detect
  variation
• warning signs
• sustained reduction
• gt20-25 diurnal variation

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Chest X ray

• Diagnosis is uncertain (PE, pneumonia, heart
  failure)
• symptoms may not be explained by asthma or COPD
• physical evidence of complications-pneumothorax,
  atelectasis (lung collapse)
• failure to respond to treatment

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Blood Gas (arterial)

• H rises with Pco2
• In acute hypoventilation CO2 rises and so does H
  causing respiratory acidosis
• In acute hyperventilation CO2 drops as does H
  causing respiratory alkalosis
• (in acute no time for metabolic process so
  bicarbonate is not changed)

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Oximetry

• Measure oxygen saturation
• Non invasive
• Light emiting diodes
• Expressed as where normal is 100

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Asthma

• a chronic inflammatory disorder of the airways in
  which many cells and cellular elements play a
  role, in particular, mast cells, eosinophils, T
  lymphocytes, macrophages, neutrophils and
  epithelial cells. In susceptible individuals this
  inflammation causes recurrent episodes of
  wheezing, breathlessness, chest tightness and
  coughing, particularly, at night or in the early
  morning. These episodes are usually associated
  with widespread but variable airflow obstruction
  that is often reversible either spontaneously or
  with treatment. The inflammation also causes an
  associated increase in the existing bronchial
  hyperresponsiveness to a variety of stimuli. USA97

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Airflow obstruction (Excessive airway Narrowing)

• Smooth muscle hypertrophy and hyperplasia
• Inflammatory cell infiltration
• Oedema
• Goblet cell and mucous gland hyperplasia
• Mucus hypersecretion
• Protein deposition
• Epithelial desquamation

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Asthma Diagnosis-1

• No Gold Standard
• Consensus of respiratory physicians
• History, physical examination, supportive
  diagnostic testing
• History
• Wheeze
• Chest tightness
• Shortness of breath
• cough

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Asthma Diagnosis-2

• Physical examination
• Expiratory wheeze suggests asthma (not
  pathonomonic)
• Absence of physical signs doesnt exclude asthma
• Crackles indicate concurrent or alternate
  diagnosis

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Asthma diagnosis -3

• Diagnostic testing Spirometry
• Pay Attention to technique
• Pre and post bronchodilator
• Baseline FEV1gt1.7L and increase of 12 post
  bronchodilator is significant
• Or 200ml greater than baseline
• Or same rules for FVC
• Also predicted from tables in the Asthma
  guidelines

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Spirometry for asthma management

• Assessment of severity
• Severe acute attack lt50 predicted or lt 1litre
• Back titration of medication
• Check symptomatic assessment
• Maintain best lung function

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Asthma
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PEFR with asthma

• Diagnosis-not a substitute for spirometry
• PEF increases gt15 with bronchodilator
• PEF in adult varies gt20 for 3 days in a week
  over several weeks
• Severe Acute
• lt50 predicted or lt 100 L/min
• Useful for daily home measurement
• Useful in action plan
• gt80 OK, 60-80 increase preventer, 40-60 oral
  steroids, lt40 no relief 000

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Asthma treatment

• National Asthma Council in Australia
• www.nationalasthma.org.au/cms/index.php
• Reduce mortality morbidity of asthma
• Education
• Patient self monitoring
• Appropriate drug therapy
• Regular medical review
• Written asthma action plan

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Asthma management

• Acute asthma management
• Treatment depends on severity
• Mild, moderate, life threatening
• Requires emergency care
• Hospital admission
• Long term asthma management-chronic
• Minimise symptoms and need for reliever
• No exacerbations
• No limitation on physical activity
• Normal Lung Function

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Asthma Management

• Medications to treat bronchospasm
• ACUTE
• RELEIVERS
• Short acting ß2-adrenergic agonists eg salbutamol
• terbutaline
• Anticholinergic eg ipratropium

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Relievers
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Asthma Management

• Medications to treat bronchospasm
• Chronic
• SYMPTOM CONTROLLER
• Inhaled long acting ß2-adrenergic agonists eg
  salmeterol
• Also use
• Theophylline
• Oral ß2-adrenergic agonists (salbutamol syrup)

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Asthma Management

• Medications to treat inflamation
• PREVENTERS
• Inhaled sodium cromoglycate
• Inhaled nedocromil sodium
• Inhaled cortocosteroids eg beclomethasone
• Oral corticosteroids eg prednisolone
• Leukotrienne receptor antagonists eg montelukast

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Beclomethasone dipropionate
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Asthma Action plans

• Developed by doctor with patient
• Added role for pharmacist to give advice to
  patient
• Individualised Action for Deterioration in asthma
• ? in frequency, severity of symptoms
• ? use of bronchdilator
• Drop in peak flow

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Misuse of Home Nebulizers High Among Inner-City
Children with Asthma
October 25, 2006 (Salt Lake City) A study of
asthma-related deaths among inner-city children
and young adults shows that only about half use
their home nebulizers as prescribed and rarely
have an asthma action plan to manage disease
exacerbations, or if they do have a written plan
in the home, they rarely use it. The findings
were presented here yesterday at CHEST 2006, the
72nd annual meeting of the American College of
Chest Physicians.
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COPD

• smoking is major cause but susceptibility is
  variable
• directly related to exposure to tobacco smoke
• pack yearscigarettes/day x years of smoking /20
• relatively fixed airway obstruction with minimal
  reversibility from bronchodilators

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COPD

• Chronic bronchitis- productive cough for gt3
  months in 2 successive years
• emphysema-abnormal permanent enlargement of
  air-spaces distal to terminal bronchioles caused
  by destruction of alveolar walls.
• Most have a combination of both
• Elderly with reversibility has all 3

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COPD shaded bit
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Diagnosis of COPD

• symptoms
• breathlessness doesnt occur until obstruction is
  advanced (unless intercurrent infection)
• physical examination
• little until disease is severe-over inflated
  chest
• chest x rays
• over inflation, enlarged heart, bullae
• spirometry
• mild check FEV1/FVClt75
• moderate check FEV1 of predicted

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COPD
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Show ceases smoking figure
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Progression
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COPD Management

• Acute exacerbations
• Bronchodilators
• Oxygen
• Corticosteroids
• Antibiotics
• Long term treatment- chronic
• Stop smoking
• Bronchodilators
• Corticosteroids
• Immunisation-Pneumonia and flu
• Pulmonary rehabilitation

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Bronchiectasis

• defined as dilation of the bronchi-
• bronchial walls become inflamed, thickened and
  irreversibly damaged.
• Mucociliary transport is impaired-bacterial
  infections
• cough productive of sputum

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Cystic Fibrosis

• dysfunction of exocrine glands -abnormal mucus
  production
• recurrent bronchopulmonary infection
• finger clubbing
• haemoptysis

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Interstitial lung disease

• heterogeneous group involving alveolar walls and
  peri alveolar tissue
• insidious onset, chronic disease
• inflammatory process probably initiated by an
  antigen
• eventual interstitial fibrosis will cause a
  restrictive pattern

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Restrictive
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Severe Obstructive Sleep Apnoea

• 2 women , 4 men
• Recurrent episodes of airway occlusion in sleep
• Apnoea
• Arousal
• Daytime sleepiness
• Increased CO2
• Sleep lab
• Weight loss, CPAP