matt wong + sheila murphy dec 13 th 2011. akt mini exam nice – copd guidelines bts asthma...
TRANSCRIPT
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Matt Wong + Sheila Murphy
Dec 13th 2011
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AKT MINI EXAM NICE – COPD GUIDELINES BTS ASTHMA GUIDELINES INHALER TECHNIQUE QOF SPIROMETRY CSA EXERCISE
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Which of the following are used in assessing the severity of COPD? A. Body mass index (BMI)B. AgeC. Medical Research Council (MRC)
dyspnoea score D. Smoking pack year historyE. Lung function
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Which of the following statements apply to COPD?A. It is more common in those from upper
social classesB. It is often seen as a co-morbidity in
patients with ischaemic heart disease and lung cancer
C. Mortality from COPD is evenly spread across the UK as a whole
D. The estimated prevalence of COPD in patients over 40 years of age is 9-10%
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What percentage of patients will die within 3 months of admission for a COPD-related condition?A. 33%B. 50%C. 5%D. 20%
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Pulmonary rehabilitation should be offered to:A. All patients with moderate or severe
COPDB. All patients with COPD irrespective of
their MRC scoreC. Patients who are poorly motivatedD. All patients who meet the referral criteria
regardless of their inhaled drug therapyE. Patients with an MRC dyspnoea score of 3
or more unless they are on long-term oxygen therapy (LTOT)
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Which of the following statements about the role of inhaled corticosteroids in COPD are true? A. In patients with moderate/ severe COPD
(FEV1 <50% predicted), treatment of the lung inflammation with inhaled corticosteroids has not shown to be of benefit in reducing exacerbations
B. There is no evidence to suggest that early use of inhaled steroids in patients with COPD will reduce the decline in FEV1 seen over years
C. The use of inhaled corticosteroids has been shown to be of some benefit in reducing the decline in health status seen in patients with moderate/ severe COPD (FEV1 <50% predicted)
D. Osteoporosis is commonly seen in patients taking high dose inhaled corticosteroids
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Which of the following features suggest a patient should be admitted to hospital for management of their COPD exacerbation?A. CyanosisB. Mild peripheral oedemaC. Low oxygen saturation (<90%)D. Good level of activityE. Significant co-morbidities
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Which of the following statements about oxygen therapy in COPD exacerbations are true?A. It should be given to all patientsB. It should be started at 100% until the
oxygen saturation is >95%C. It should be monitored by pulse oximetry
until access to full arterial or capillary blood gases are available
D. In patients on LTOT it should be given at the same rate as they receive at home
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1. A, C, E 2. B, D 3. E 4. B 5. C, D 6. A, C, E 7. C, D 8. 3 9. D
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Consider COPD in smokers >35 and with exertional SOB, chronic cough, regular sputum production, winter bronchitis, wheeze
No features of asthma – unproductive cough, diurnal variation, night-time waking with wheeze/breathlessness
Ask about: weight loss, fatigue, exercise tolerance, chest pain, night waking, haemoptysis, ankle swelling, occupational hazards
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Post-bronchodilator spirometry CXR FBC – anaemia/polycythaemia BMI
FEV1/FVC < 0.7 = COPDStage 1-5 mild to very severe based on
FEV1 % >80% is mild 30% - 50% severe People must be symptomatic to make
diagnosis!
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Grade 1 – not troubled by SOB except on exercise
Grade 2 – SOB when hurrying/walking up hill
Grade 3 – walks slower on level ground due to SOB, or has to stop when walking at own pace
Grade 4 – stops for breath after 100m or a few mins on ground level
Grade 5 – too breathless to leave the house or breathless when dressing
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Smoking cessation for all Start treatment once diagnosis
confirmed Pulmonary rehab
For those with disability/recent admission
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SABA : short acting B agonist salbutamol
LABA : long acting B agonist salmeterol
SAMA : short acting muscarinic antagonist ipratropium
LAMA : long acting muscarinic antagonist Tiotropium
ICS : inhaled corticosteroids Beclometasone, fluticasone, budesonide
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Theophylline If inhaled therapy ineffective/can’t be used
Oral steroids Maintenance steroids not recommended, but if
severe COPD may be necessary, aim for low dose and monitor for osteoporosis 30mg for 7-14 days in exacerbations
LTOT used for 15 hours/day Assess need for LTOT if FEV1<30%, cyanosis,
polycythaemia, peripheral oedema, raised JVP, sats < 92% on air
2 x ABGs 2 occasions, 3 weeks apart LTOT if PaO2 < 7.3kPa or 7.3 – 8 with complications
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Increase frequency of broncholdilator use/consider use of nebuliser
Prescribe oral abx if sputum purulent/clinical signs of peumonia
Steroid 30mg 7-14 days
Self-ManagementStart abx/steroid if SOB increases/interferes
with ADLsAbx if sputum purulentAdjust bronchodilator to control symptoms
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not able to cope at home severe beathlessness, Sats <90% general condition is poor/ deteriorating cyanosis is present worsening peripheral oedema impaired level of consciousness patients on LTOT acute confusion exacerbation has had a rapid rate of onset significant comorbidity - cardiac disease
and IDDM changes on CXR arterial pH level < 7.35 arterial PaO2 < 7 kPa
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Salbutamol CFC Free 100mcg/dose 3£ / 200 doses
Ipratropium 20 mcg5£ / 200 doses
Salmeterol 50 mcg29£ / 60doses/ 1 month
Salmeterol 50 mcg and fluticasone35£ / 60 doses/ 1 month
Tiotropium32£ / 30 doses/ 1 month
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Contains a pressurised inactive gas that propels a dose of drug in each 'puff'
ADV most widely used
inhaler quick to use, small, and
convenient to carry
DISADV needs good co-
ordination to press the canister, and breathe in fully at the same time
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Used with pressurised MDIs
The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed
Valve at the mouth end ensures that the drug is kept within the spacer until you breathe in. When you breathe out, the valve closes.
Adv – No need to have good co-ordination to use a spacer device.
A facemask can be fitted on to some types of spacers, instead of a mouthpiece. This is sometimes done for young children and babies who can then use the inhaler simply by breathing in and out normally through the mask.
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Alternatives to the standard MDI Don't require you to press a
canister on top
Bottom 3 are dry powder inhalers. Dose is triggered by breathing in at the
mouthpiece. You need to breathe in fairly hard to get the powder into your lungs. Accuhalers
Clickhalers
Easyhalers
Novolizers
Turbohalers
diskhalers
Twisthalers
ADV - Require less co-ordination than the standard MDI.
DISADV - They tend to be slightly bigger than the standard MDI.
Autohaler
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Practice register of patients with COPD % with COPD in whom diagnosis has been confirmed by
spirometry with reversibility testing % with COPD with record of smoking status in the previous
15m % with COPD who smoke, who have been offered smoking
cessation advice or referral to a specialist service, where available in last 15 months
% with COPD with a record of FEV1 in the previous 27m % with COPD with record that inhaler technique has been
checked in the preceding 27m % with COPD who have had influenza immunisation in the
preceding 1 September to 31 March
PROMPTS: MRC Dysponea Score, FEV1, REVIEW EVERY 15m
OUR PRACTICE: Inhaler technique, sats, smoking, exacerbations,
immunisations, depression
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