Focus on Respiratory Diseases and Diagnostic Investigations in General Practice

Dr Andrew Thurston

GP

Focus on AKT – RCGP Curriculum:

Investigations:



PEFR, Spirometry, Pulse Oximetry, Sputum Culture



Indications for CXR, CT, MRI, Bronchoscopy



Disease Scoring Tools e.g. CURB65

Conditions:

-

URTI, LRTI

-

 Bronchiectasis

-

Ephysema

-

 Pneumothorax

-

PE

-

 Pleural Effusion

-

Asthma

-

 COPD

-

Chronic Cough

-

 Respiratory Malignancies

-

Stridor / Hoarseness

-

 Occupational Lung Diseases

-

Fibrosis

-

 Respiratory Failure

-

Use of Oxygen

-

 Connective Tissue Disorders

Focus on AKT – RCGP Curriculum:

Investigations:



PEFR, 

Spirometry

, Pulse Oximetry, 

Sputum Culture



Indications for CXR

, CT, MRI, Bronchoscopy



Disease Scoring Tools e.g. 

CURB65

Conditions:

-

URTI, 

LRTI

-

Bronchiectasis

-

Ephysema

-

 Pneumothorax

-

PE

-

 Pleural Effusion

-

Asthma

-

COPD

-

Chronic Cough

-

Respiratory Malignancies

-

Stridor / Hoarseness

-

 Occupational Lung Diseases

-

Fibrosis

-

 Respiratory Failure

-

Use of Oxygen

-

 Connective Tissue Disorders

DISCLAIMER



I wrote all the questions to fit with the topics



They were designed to be similar to AKT questions.



Please ask if anything isn’t clear or looks wrong.

Question 1

A 56 year old woman presents with exertional breathlessness,

worsening over 6 months. Spirometry shows:

FVC

1.98 (predicted 3.51)

FEV1

1.64 (predicted 2.82)

FEV1/FVC

83% (predicted 80%)

What is the most likely diagnosis?

A)

Asthma

B)

Bronchiectasis

C)

COPD

D)

Pulmonary Fibrosis

E)

Extrinsic Allergic Alveolitis

Question 1

A 56 year old woman presents with exertional breathlessness,

worsening over 6 months. Spirometry shows:

FVC

1.98 (predicted 3.51)

FEV1

1.64 (predicted 2.82)

FEV1/FVC

83% (predicted 80%)

What is the most likely diagnosis?

A)

Asthma

B)

Bronchiectasis

C)

COPD

D)

Pulmonary Fibrosis

E)

Extrinsic Allergic Alveolitis

Spirometry



Available at most practices



Done by practice nurses



Technique dependant – check comments on report



Patient needs to be well – need to see best effort

Useful in patients with:



Chronic Breathlessness



Chronic Cough

Requesting Spirometry in GP

With or Without Reversibility?



If you think it could be asthma – ask for reversibility



Anything else – Post-Bronchodilator Spiro

Is the patient capable of performing the test?



Need to be able to follow instructions.

Is the patient well enough?



Wait 4 weeks after any chest infection

Interpreting Spirometry

Forced Vital Capacity (FVC) – total vol. expired air

Forced Expiratory Volume in 1 second (FEV1)– Vol. Air expired in 1

st

second of forced expiration

FEV1/FVC ratio – Normal FEV1 

should be >70% of FVC

Reversibility = 

>12% improvement in FEV1

Interpreting Spirometry

Example:

Pre

Predicted

FVC

2.67

      2.80

FEV1

1.48

      2.24

FEV1/FVC

54%

      80%

Diagnosis?

Interpreting Spirometry

Example:

Pre

Predicted

FVC

2.67

      2.80

FEV1

1.48

      2.24

FEV1/FVC

54%

      80%

Diagnosis?

Obstructive Airways Disease

Interpreting Spirometry

Example:

Pre

Predicted 

Post

FVC

2.67

      2.80 

2.80

FEV1

1.48

      2.24 

2.01

FEV1/FVC

54%

      80% 

71%

Diagnosis?

Interpreting Spirometry

Example:

Pre

Predicted 

Post

FVC

2.67

      2.80 

2.80

FEV1

1.48

      2.24 

2.01

FEV1/FVC

54%

      80% 

71%

Diagnosis?

Obstructive Airways Disease with Reversibility

(i.e. Asthma)

Question 2

A 66 year old man with no PMH attends with 4 days of

productive cough and SOB.  O/E there are crackles at the right

lower zone.  Temp 37.5, Pulse 86 reg, BP 100/54, RR 24, Sats

92%.  He does not appear confused.  Using CRB-65 score what

should you do?

A)

CRB=1 - Manage in the community with oral antibiotics

B)

CRB=2 – Manage in community with oral antibiotics and

arrange follow up in 24 hours.

C)

CRB=2 – Arrange admission for IV antibiotics

D)

CRB=3 – Arrange admission for IV antibiotics

E)

CRB-65 score is irrelevant in this case

Question 2

A 66 year old man with no PMH attends with a productive

cough and SOB.  O/E there are crackles at the right lower

zone.  Temp 37.5, Pulse 86 reg, BP 100/54, RR 24, Sats 92%.

He does not appear confused.  Using CRB-65 score what

should you do?

A)

CRB=1 - Manage in the community with oral antibiotics

B)

CRB=2 – Manage in community with oral antibiotics and

arrange follow up in 24 hours.

C)

CRB=2 – Arrange admission for IV antibiotics

D)

CRB=3 – Arrange admission for IV antibiotics

E)

CRB-65 score is irrelevant in this case

Symptoms of LRTI



Cough

- productive or dry

- Generally lasts 7 days – can linger for 3-4 weeks



Sputum

- Green = Dead cells

-Yellow/Brown = Bacteria



Breathlessness



Systemic Features e.g. fever



Chest Pain / Pleurisy / Abdominal Pain

CRB-65 Score for CAP – NICE CKS



“If a person has clinical symptoms and signs

suggestive of CAP, assess the severity of the illness

using the CRB-65 score for mortality risk.



The score is calculated by giving 1 point for each of the

following prognostic features:



C = 

Confusion

 (

new

 disorientation in person, place, or

time).



R = 

Raised 

respiratory rate 

(

30

 breaths per minute or

more).



B= 

Low blood pressure 

(diastolic 60 mmHg or less, or

systolic less than 90 mmHg).



65 = 

Age 65 years or more

.”

CRB-65 Score for CAP – NICE CKS

Scoring:

Management:

0 = Low Severity

0-1= Community

1-2 = Intermediate Severity

2= Admission “advised”

>2 = High Severity

3+= Urgent Admission

Cautions:

-

O2 Sats still need to be considered

-

“oxygen saturation below 94% indicates the need

for urgent hospital admission.” - NICE

-

“Mortality score doesn’t always accurately predict

mortality risk – use clinical judgement” - NICE

Question 3

A 43 year old smoker with no PMH attends with a 3 day history

of a cough productive of yellow sputum. He doesn’t appear

confused.  There are crackles at the left base, Temp 38.0, Pulse

76 reg, BP 138/78, RR 16, Sats 97%.  You decide he requires oral

antibiotics, what would you prescribe?

A)

Amoxicillin 500mg TDS for 7 days

B)

Amoxicillin 500mg TDS + Clarithromycin 500mg BD for 7

days

C)

Amoxicillin 500mg TDS for 5 days

D)

Doxycycline 200mg single dose then 100mg OD for 4 days

E)

C0-Amoxiclav 625mg TDS for 7 days

Question 3

A 43 year old smoker with no PMH attends with a 3 day history

of a cough productive of yellow sputum. He doesn’t appear

confused.  There are crackles at the left base, Temp 38.0, Pulse

76 reg, BP 138/78, RR 16, Sats 97%.  You decide he requires oral

antibiotics, what would you prescribe?

A)

Amoxicillin 500mg TDS for 7 days

B)

Amoxicillin 500mg TDS + Clarithromycin 500mg BD for 7

days

C)

Amoxicillin 500mg TDS for 5 days

D)

Doxycycline 200mg single dose then 100mg OD for 4 days

E)

C0-Amoxiclav 625mg TDS for 7 days

Managing CAP



Self Care – rest, fluids, antipyretics



Advise to 

STOP SMOKING



No evidence for Cough Medicines



“Arrange a CXR for anyone over 60 and smokes” 

–

BTS/NICE - high risk group for Lung Cancer (vague

on timings – suggests definitely needed at 6 weeks

post onset but ?also at time of acute illness)

Managing CAP

Prescribe Antibiotics:

If CRB-65 = 0



Amoxicillin 500mg TDS for 5 days



Penicillin allergy – Doxycycline or Clarithromycin for

5 days



“Review at 3 days and increase to 7 day course if

response is poor” – NICE

If CRB-65 = 1-2



“Consider Dual Therapy for 7-10 days”



e.g. Amoxicillin + Clarithromycin

Managing CAP

NICE guide on prognosis:



“

Explain to the person that after starting antibiotic

treatment,

 symptoms should improve, although the rate

of improvement will vary with the severity of illness.

Discuss the natural history of pneumonia symptoms, that

by:



1 week 

- fever should have resolved.



4 weeks 

- chest pain and sputum production

should have substantially reduced.



3 months 

- most symptoms should have resolved

but fatigue might still be present.



6 months 

- symptoms should have fully resolved.”

Question 4

Which is the most common cause of Community

Acquired Pneumonia?

A)

Mycoplasma Pneumoniae

B)

Streptococcus Pneumoniae

C)

Staphlococcus Aureus

D)

Legionella Pneumophilia

E)

Haemophilus Influenzae

F)

Viral Infections

G)

Pseudomonas Aeuriginosa

Question 4

Which is the most common cause of Community

Acquired Pneumonia?

A)

Mycoplasma Pneumoniae

B)

Streptococcus Pneumoniae

C)

Staphlococcus Aureus

D)

Legionella Pneumophilia

E)

Haemophilus Influenzae

F)

Viral Infections

G)

Pseudomonas Aeuriginosa

CAP causative organisms BTS Audit

No Pathogen Identified

45.3%

Steptococcus Pneumoniae

36.0%

All Viruses

13.1%

Haemophilus Influenzae

10.2%

Mycoplasma Pneumoniae

1.3%

Staphlococcus Aureus

0.8%

Legionella Pneumophilia

0.4%

You are going through your results and a sputum result

comes through showing Pseudomonas.

What do else do you need to know?



 Any chronic respiratory conditions?



 Why was sputum sent?



 How is the patient now?



 Any previous Sputum results?

What should you do with this result?



 If they’ve had it before and are well – Nothing



 Never had it before – Treat - speak to Micro – should aim to

eradicate before it colonises.



 Had it before and unwell – Treat - speak to Micro

Pseudomonas Aeruginosa



Gram Negative Rods



Common in soil and standing water



Opportunistic infection in humans - chest, wounds, nails, otitis externa



Survivor – very hard to eradicate once it has infected



Leads to cycles of recurrent infection and “colonisation” especially in

Bronchiectasis and CF



Contributes to deterioration in chronic respiratory diseases e.g. Early

infection if CF is a bad prognostic indicator



Chronic infection is associated with worse lung function



Rust coloured sputum 

(apparently tastes metallic)



Makes nails and wounds green



Only oral antibiotic option is Ciprofloxacin – always speak to micro (or

check Respiratory clinic letters) as may need IV



IV treatment = aminoglyosides e.g. Tobramycin, Gentamycin

Question 4

A 19 year old male student has just returned home for the

holidays and now attends with a 5 week history of a persistent

dry cough, sore throat, and a rash.  He thinks a few other

students in his halls have had the same thing.  He denies

foreign travel and doesn’t smoke.  On examination his

observations are all normal.  His chest and throat are clear.

Abdomen is SNT with no organomegaly.  There is no

lymphadenopathy.  The rash is on the trunk and consists of

raised target lesions.  What is the most likely diagnosis?

A)

Glandular Fever

B)

Whooping Cough

C)

Atypical Pneumonia

D)

Tuberculosis

E)

Post Infective Cough

Question 4

A 19 year old male student has just returned home for the

holidays and now attends with a 5 week history of a persistent

dry cough, sore throat, and a rash.  He thinks a few other

students in his halls have had the same thing.  He denies

foreign travel and doesn’t smoke.  On examination his

observations are all normal.  His chest and throat are clear.

Abdomen is SNT with no organomegaly.  There is no

lymphadenopathy.  The rash is on the trunk and consists of

raised target lesions.  What is the most likely diagnosis?

A)

Glandular Fever

B)

Whooping Cough

C)

Atypical Pneumonia

D)

Tuberculosis

E)

Post Infective Cough

Question 5

A 19 year old male student has just returned home for the

holidays and now attends with a 5 week history of a persistent

dry cough, sore throat, and a rash.  He thinks a few other

students in his halls have had the same thing.  He denies

foreign travel and doesn’t smoke.  On examination his

observations are all normal.  His chest and throat are clear.

Abdomen is SNT with no organomegaly.  There is no

lymphadenopathy.  The rash is on the trunk and consists of

raised target lesions.  What is the most likely diagnosis?

A)

Legionella Pneumophilia

B)

Mycoplasma Pneumonia

C)

Chlamydia Psittaci (Psittacosis)

D)

Klebsiella

E)

Coxiella Burnetii

Question 5

A 19 year old male student has just returned home for the

holidays and now attends with a 5 week history of a persistent

dry cough, sore throat, and a rash.  He thinks a few other

students in his halls have had the same thing.  He denies

foreign travel and doesn’t smoke.  On examination his

observations are all normal.  His chest and throat are clear.

Abdomen is SNT with no organomegaly.  There is no

lymphadenopathy.  The rash is on the trunk and consists of

raised target lesions.  What is the most likely diagnosis?

A)

Legionella Pneumophilia

B)

Mycoplasma Pneumonia

C)

Chlamydia Psittaci (Psittacosis)

D)

Klebsiella

E)

Coxiella Burnetii

Atypical Pneumonia

Risk Factors:

Close community settings e.g. university halls, army barracks,

cruise ships, schools

Immunosuppression

Key Features:

Persistent Cough (can be productive or dry)

Sore throat / Pharynigitis

Recent community exposure

Age <50

Clinical signs usually mild or absent

Lungs look worse on CXR then they sound on examination

CAP that hasn’t responded to penicillin

Atypical Pneumonia – BMJ Best Practice

Investigations:



CXR – looking for consolidation



Bloods - 

↑

WCC, 

↑CRP, with mycoplasma can

sometimes get

 anaemia + 

↑ALT



Sputum culture

I would consider doing all the above in any LRTI not

responding to usual treatment

Also consider (depending on history / level of suspicion)



Legionella Urine Antigen



Serology for Mycoplasma / Chlamydia / Coxiella

Atypical Pneumonia – BMJ Best Practice

Managment:

1

st

 line – Macrolide (Azithromycin / Clarithromycin)

Alt 1

st

 line – Doxycycline

2

nd

 line – Fluroquinolone (Levoflocacin / Moxyfloxacin)

I would think about consulting microbiology for advice

Atypical Pneumonia

Mycoplasma:



Community Outbreaks – approx every 4 years



Usually late summer / autumn



Most common in children and young adults



Can have associated headache



Associated with various rahes – usually self limiting

maculopapular type – classically...



Erythema Multiforme



Chest usually sounds clear



CXR – patchy consolidation



Micro – Sputum or Throat swabs



Not a notifiable disease

Atypical Pneumonia

Legionella:



Standing water – e.g. Air conditioning, spa pools, showers/taps.



Caught from these sources rather then infected individuals.

Outbreaks often in hotels, cruise ships, hospitals, nursing

homes.



Can be associated with 

Diarrhoea



Legionella urine antigen – negative result doesn’t exclude



Sputum culture



Notifiable disease

Psitticosis:



Chlamydia Psittaci carried by 

birds



Suspect if exposure to commercial (poultry farmers) or pet birds

(parrots / budgies)



Chlamydia swab of throat – sputum testing is risk to Lab staff

Atypical Pneumonia

Coxiella Burnetti:



Associated with 

livestock

: Farmers, Vets, Abattoir

workers all at risk.  Micro lab workers also at risk



Usually as outbreaks with other workers affected.



Usually self limiting flu-like illness but...



Can cause hepatitis – hepatomegaly (less common)

and endocarditis (rarely).



Recommendation is to treat with antibiotics for 14

days in any symptomatic patient with clinical

suspicion.



Serology testing is the usual diagnostic test



I would discuss with micro if ever suspecting

Question 6

A 30 year old woman, originally from Somalia, attends

with a 3 week history of weight loss and malaise.  In last

week she has noticed a mild but productive cough.  She

had been back to Somalia 5 weeks ago to visit a relative in

hospital.

Which test is most likely to be diagnostic:

A)

Sputum Culture for Acid Fast Bacilli

B)

Full blood count and CRP

C)

Thick blood film

D)

QuantiFERON

E)

Chest Radiograph

Question 6

A 30 year old woman, originally from Somalia, attends

with a 3 week history of weight loss and malaise.  In last

week she has noticed a mild but productive cough.  She

had been back to Somalia 5 weeks ago to visit a relative in

hospital.

Which test is most likely to be diagnostic:

A)

Sputum Culture for Acid Fast Bacilli

B)

Full blood count and CRP

C)

Thick blood film

D)

QuantiFERON

E)

Chest Radiograph

Tuberculosis



Mycobacterium Tuberculosis



Needs specific culture medium to grow in lab and ZN

staining – 

need to ask for AFB when requesting culture



 Spread by droplet from people with active pulmonary TB



Increasing number of cases in UK



 Many born outside UK in a high prevalence areas (India,

Pakistan, Somalia – most common)



 70% of all UK cases come from the 40% most deprived areas

– Homeless, overcrowded conditions, prison population



 Other risk factors :

 Alcohol / Drug misuse, Comorbidities

(diabetes, HIV), Immunosuppression, Previous incomplete TB

treatment,

Tuberculosis

Active Pulmonary TB 

(majority of cases – 55%)



 Persistent Productive Cough +/- Haemoptysis



 Weight Loss, Fever, Night sweats



 Infectious

Extra-pulmonary TB

 (rare)



 More likely in children from high risk areas



 CNS (Meningitis), Bone (Spinal = Pott’s Disease), Pericarditis.

Latent TB 

(10% of cases)



 No symptoms, non-infectious,



 Can become active – often when immunocompromised



 Detected during screening

Multi-drug Resistant TB 

(10% of cases – on the rise)



 Defined as resistance to 2 first line drugs

Tuberculosis

Investigations (NICE CKS)

Pulmonary TB:



 Chest X-ray



 3 x sputum cultures for AFB (at least 1 early morning)



 If positive refer all to respiratory TB clinic

Extra-pulmonary TB:



 Chest X-ray



 depends on suspected site – e.g. spine plain X-ray

Latent TB



 Don’t actively screen in primary care



 Refer to TB clinic if suspected contact



 “From 2012, all people resident in a country with high TB

prevalence applying for a UK visa for more than 6 months are

required to have pre-entry screening”

Tuberculosis

Screening Tests:

Tuberculin Skin Testing



 e.g. Heaf Test



 Liable to reader bias / error



 False positives if previous BCG vaccination

QuantiFERON



 Interferon Gamma Release Assay – detects the

immune response to TB



 Used mainly for Latent TB diagnosis



 Can’t differentiate between Active and Latent Disease



 Limitations in sensitivity and specificity mean it’s not

currently recommended for non-specialist use

Tuberculosis

Treatment:

Managed by secondary care – usually Respiratory or

Infectious Diseases.

In Bolton – TB clinic run by Respiratory

Notifiable Disease in the UK



 Contact tracing – close contacts also need treating



 6 months multi-drug therapy – usually Isoniazid and

Rifampicin.  +/- Ethambutol and Pyrazinamide



 TB nurses keep regular contact to ensure compliance –

biggest cause of treatment failure, multi-drug resistance,

and risk of spreading TB

Question 7

Following a positive sputum AFB, you referred the 30 year

old Somali woman to Respiratory, who confirmed the

diagnosis and started treatment for TB.  She has been on

treatment for 2 months and returns to see you

complaining of reduced vision.

Which drug is most likely to be responsible?

A)

Ethambutol

B)

Rifampicin

C)

Isoniazid

D)

Pyrazinamide

E)

Not likely to be a drug side effect

Question 7

Following a positive sputum AFB, you referred the 30 year

old Somali woman to Respiratory, who confirmed the

diagnosis and started treatment for TB.  She has been on

treatment for 2 months and returns to see you

complaining of reduced vision.

Which drug is most likely to be responsible?

A)

Ethambutol

B)

Rifampicin

C)

Isoniazid

D)

Pyrazinamide

E)

Not likely to be a drug side effect

TB Drug Side Effects

Ethambutol



 Visual disturbance



 Peripheral Neuropathy (common)



 Hyperuricaemia (Gout flares)

Isoniazid



 Peripheral Neuropathy (common)



 Liver Failure (rare)

Pyrazinamide



 Hyperuricaemia (Gout flares)

Rifampicin



 Turns secretions orange – will stain soft contact lenses and clothing



 Thrombocytopoenia



 Nausea / Vomiting

TB Drug Side Effects

Essentially:

If a patient on TB treatment presents with any of;



 Peripheral Neuropathy



 Visual Disturbance



 Acute Gout Flare



 Deranged LFTs

Suspect the TB drugs as a cause and advise the patient to

inform their TB clinic urgently.

Don’t stop any TB treatment without consulting the

specialist first

Symptoms:

- Wheeze

- Chest Tightness

- Cough

- Breathlessness

Quality of the Symptoms:

- Episodic

- Diurnal Variation (worse at night or early morning)

- Triggered by e.g. exercise, allergens. infection, cold air

Other Associations:

- Family History

- Atopic – Eczema, Allergic Rhinitis

- Occupation – Lab work, baking, animals, welding, paint

spraying

- Drugs e.g. NSAIDs and Beta Blockers

Asthma – Why is it so complicated?



There is no gold standard diagnostic test



Are GP’s over diagnosing asthma?



Overlap with other conditions e.g. COPD in adults,

Viral Induced Wheeze in children



In the UK there are 2 sets of guidelines:

- BTS / SIGN Guidelines – updated 2019

- NICE Guidelines – published 2017

Question 8

A 19 year old woman attends with SOB and wheeze on

exertion as well as an early morning cough ongoing for the

past year, but getting worse now that it’s winter.  She has

hayfever, was prone to wheeze as a child, and doesn’t smoke.

According to the NICE guidelines what diagnostic test should

be done first?

A)

Fractional Exhaled Nitric Oxide (FeNO)

B)

Peak Flow Diary

C)

Post Bronchodilator Spirometry

D)

Pre and Post Bronchodilator Spirometry

E)

No further tests needed – trial steroid inhaler

Question 8

A 19 year old woman attends with SOB and wheeze on

exertion as well as an early morning cough ongoing for the

past year, but getting worse now that it’s winter.  She has

hayfever, was prone to wheeze as a child, and doesn’t smoke.

According to the NICE guidelines what diagnostic test should

be done first?

A)

Fractional Exhaled Nitric Oxide (FeNO)

B)

Peak Flow Diary

C)

Post Bronchodilator Spirometry

D)

Pre and Post Bronchodilator Spirometry

E)

No further tests needed – trial steroid inhaler

What?!



It’s an unfair question because NICE don’t even seem

to know the answer



NICE published new Asthma Guidelines in November 2017



Biggest changes came in diagnosing asthma



Emphasised need for objective evidence rather then clinical

diagnosis



Added 

FeNO

 to the list of objective tests approved and

(seems to) suggests this as the first line investigation -

“should be offered to all patients 

where available

”



In reality there is still limited access to FeNO in Primary

Care so it is rarely requested.



Also states that any child over 5 years old should have an

objective test e.g. Spirometry

FeNO

Fraction of Exhaled Nitric Oxide



NO is released by Eosinophils – the primary white blood

cells involved in Asthma.



↑NO = ↑Eosinophils = Asthma



Results presented as Parts Per Billion (ppb) 

>40ppb = Asthma



Don’t need to be symptomatic at time of test



Way to check steroid compliance



Still technique dependant



Machine cost: £2000-3000



Consumables costs: £5 for 1000 filters

However:



1 in 5 with a negative test will have asthma



1 in 5 with a positive test won’t



NICE don’t recommend for routine monitoring

Asthma Diagnostic Tests

Spirometry



Patient has to be symptomatic at the time of test to give a

positive result



Technique dependent – more difficult then FeNO



Looking for obstructive picture – 

FEV1:FVC <70%



Ask for reversibility - 

>12% improvement in FEV1 after

bronchodilator PLUS an increase in volume of 200mL

PEFR Diary



Captures the diurnal variation



NICE recommends BD readings over 2-4 weeks



>20% variability suggests asthma



Relying on patient for good quality evidence

Asthma Diagnostic Tests

Direct Bronchial Challenge



Aims to trigger asthma symptoms



Histamine or Methacholine



Only done in secondary care – generally when all other

tests have been inconclusive but the clinical picture still

suggests asthma.



Risks triggering severe symptoms

NICE Asthma Diagnosis Guideline

In symptomatic adults (>17) diagnose asthma if:



FeNO >40ppb PLUS either: positive reversibility, positive PEFR diary,

or positive bronchial challenge

or



FeNO 25-39ppb AND positive bronchial challenge

or



Positive Reversibility AND positive PEFR diary “irrespective of FeNO

result”

“Suspect Asthma” if Obstructive Spirometry but negative reversibility

PLUS either:



FeNO >40ppb



FeNO 25-39ppb AND positive PEFR Diary

Refer to Respiratory for a second opinion if:



Only 1 test comes back positive and others are negative

NICE Asthma Diagnosis Guideline

In symptomatic Children (>5) diagnose asthma if:



FeNO >35ppb AND positive PEFR diary

or



Obstructive Spirometry with Reversibility

“Suspect Asthma” if only 1 test is positive

Refer to Respiratory for a second opinion if:



All tests are inconclusive

Question 9

According to NICE, which of the following would confirm a

diagnosis of asthma in a 19 year old with night time cough and

exertional wheeze?  More then one may be correct:

A)

FeNO 34ppb, normal spirometry and a 25% variability in

PEFR diary

B)

FeNO 56ppb , normal PEFR diary, 15% improvement in

FEV1 post bronchodilator

C)

12% improvement in FEV1 post brochodilator and 22%

variability in PEFR diary

D)

FeNO 46ppb, FEV1:FVC 65%, 5% improvement in FEV1 post

bronchodilator, and 12% variability in PEFR diary

E)

FeNO 10ppb, 5% variability in PEFR diary, FEV1:FVC 68%,

no change post bronchodilator

Question 9

According to NICE, which of the following would confirm a

diagnosis of asthma in a 19 year old with night time cough and

exertional wheeze?  More then one may be correct:

A)

FeNO 34ppb, normal spirometry and a 25% variability in

PEFR diary

B)

FeNO 56ppb , normal PEFR diary, 15% improvement in

FEV1 post bronchodilator

C)

12% improvement in FEV1 post brochodilator and 22%

variability in PEFR diary

D)

FeNO 46ppb, FEV1:FVC 65%, 5% improvement in FEV1 post

bronchodilator, and 12% variability in PEFR diary

E)

FeNO 10ppb, 5% variability in PEFR diary, FEV1:FVC 68%,

no change post bronchodilator

Question 9

According to NICE, which of the following would confirm a

diagnosis of asthma in a 19 year old with night time cough and

exertional wheeze?  More then one may be correct:

A)

FeNO 34ppb, normal spirometry and a 25% variability in

PEFR diary

B)

FeNO 56ppb , normal PEFR diary, 15% improvement in

FEV1 post bronchodilator

C)

12% improvement in FEV1 post brochodilator and 22%

variability in PEFR diary

D)

FeNO 46ppb, FEV1:FVC 65%, 5% improvement in FEV1 post

bronchodilator, and 12% variability in PEFR diary

E)

FeNO 10ppb, 5% variability in PEFR diary, FEV1:FVC 68%,

no change post bronchodilator

BTS/SIGN Asthma Diagnosis Guideline

Published 2019

Response to treatment is key to confirming diagnosis

Based on clinical judgement does the patient have a High, Intermediate, or Low

probability of their symptoms being Asthma:

High probability of Asthma



Code as “Suspected Asthma”



Start Treatment – if responds then Asthma diagnosis confirmed



Poor response – move to Intermediate

Intermediate probability of Asthma



Test for airway obstruction (e.g. PEFR diary, Spirometry) or eosinophil activity

(i.e. FeNO)



If positive code as “Suspected Asthma” and start treatment



If responds then Asthma diagnosis confirmed



Poor Response – move to low probability

Low Probability of Asthma



Consider alternative diagnosis, or Specialist referral

SIGN / BTS

Asthma

Diagnosis

Guideline

2019

Question 10

You have (finally!) diagnosed the 19 year old with asthma.  You

assess her symptoms and find that she is being woken at night

by her cough  and is getting exertional wheeze at least 3 times

a week.

According to NICE guidelines what drug treatment should you

start?

A)

Short Acting Beta Agonist (SABA) e.g. salbutamol

B)

Inhaled Corticosteroid (ICS) e.g. beclomethasone

C)

Leukotrine Receptor Antagonist (LTRA) e.g. montelukast

D)

SABA + ICS

E)

ICS + LTRA

Question 10

You have (finally!) diagnosed the 19 year old with asthma.  You

assess her symptoms and find that she is being woken at night

by her cough  and is getting exertional wheeze at least 3 times

a week.

According to NICE guidelines what drug treatment should you

start?

A)

Short Acting Beta Agonist (SABA) e.g. salbutamol

B)

Inhaled Corticosteroid (ICS) e.g. beclomethasone

C)

Leukotrine Receptor Antagonist (LTRA) e.g. montelukast

D)

SABA + ICS

E)

ICS + LTRA

NICE Asthma Treatment Guideline

1. Offer all patients a SABA (salbutamol)

2. Assess symptoms 

at diagnosis

:

- If night time waking or asthma symptoms >3 times a week then offer 

ICS

- Otherwise treat with SABA alone (step up to ICS if uncontrolled)

3. Remain uncontrolled on ICS?

- Add 

LTRA

 (montelukast)

4. Still uncontrolled on ICS and LTRA?

- Either add 

LABA

 (e.g. salmeterol) or swap LTRA for LABA

- NICE advises “discuss with patient about whether to continue LTRA”

5. Still uncontrolled on ICS, LABA +/- LTRA?

- Consider 

MART

 (Maintenance and Reliever Therapy) regimen.

- stop SABA and use low dose ICS + LABA combination for both maintenance

and reliever

6. Still uncontrolled  on MART regimen +/- LTRA?

- Increase steroid dose (either as MART or fixed doses + SABA reliever)

7. Still uncontrolled?

- Consider specialist referral – may need oral steroids

Consider decreasing therapy once symptoms have been stable for 3 months

BTS/SIGN Asthma Treatment Guideline

1. SABA + “Consider” ICS – when “suspected asthma”

If good response to either SABA alone or SABA + ICS = Asthma

confirmed:

2. Maintenance low dose ICS + SABA

↕

3. Add LABA to low dose ICS (combination e.g. Sirdupla)

↕

4. Increase ICS or add any of LTRA, oral Theophylline, or LAMA (e.g.

Tiotropium)

↕

5. Add 4

th

 agent / Consider Specialist referral

↕

6. Specialist Referral - Oral Steroids

NICE vs BTS/SIGN on Treatment



NICE gives more options BUT is difficult to follow

compared to the simple structure set by BTS/SIGN



NICE suggests LTRA at earlier stage for adults – critics

suggest this will encourage patients to underuse their

inhalers



BTS/SIGN is easy to follow step up / step down system -

hence much easier to implement in primary care

Guide to Asthma Drugs

SABA

LABA

 - Salbutamol (Ventolin)

- Formeterol

 - Terbutaline

(Bricanyl)

- Salmeterol (Serevent)

ICS

- Beclometasone (Clenil 200-1000mcg BD, Qvar 50-400mcg BD)

- Budesonide (Pulmicort 100-800mcg BD)

- Fluticasone (Flixotide 100-500mcg BD)

- Ciclesonide (Alvesco 80-320mcg BD)

Combinations

- Fluticasone + Salmeterol (Seretide, Sirdupla, Seriflo, AirFluSal)

- Beclometasone + Formeterol (Fostair)

- Budesonide + Formeterol (Symbicort)

Guide to Asthma Drugs

Leukotrine Receptor Antagonists

- Montelukast (Singulair) 10mg at night (4-10mg depending on

age for kids)

- Side effects = Diarrhoea, Headache, Nausea

Theophylline

- Usually initiated in secondary care

- Potent bronchodilator

- Usually modified release (Slo-Phyllin, Uniphyllin, Nuelin)

- Need to monitor blood levels – 3 days after any dose increase –

effective range 10-20mg/L, SE’s common >20mg/L

- Enzyme Inhibitors raise levels 

(Macrolides, 

allopurinol

)

- Side effects = Nausea, Tachycardia, Arrhythmia, Tremor,

Hyperuricaemia, Seizures

- In combination with Beta Agonists can lead to severe

Hypokalaemia

Secondary Care Treatments

Omalizumab (Xolair)



Anti IgE monoclonal antibody



Monthly subcutaneous injection



Need high levels of IgE to qualify for treament

Mepolizumab (Nucala) + Reslizumab (Cinqaero)



Anti-Interleukin 5 (anti-IL-5) monoclonal antibody



Monthly subcutaneous injection (Nucala) or IV infusion (Cinqaero)



Only for severe eosinophilic asthma

Bronchial Thermoplasty



Aims to shrink bronchial wall smooth muscle



Bronchoscopy under sedation or GA



Small catheter then administers short pulses of radiofrequency

energy



Treat approx 1/3 of airways over 3 sessions (3-4 weeks between

sessions)

New Asthma Diagnosis

Which of these should you (or the practice nurse) arrange / offer your

patient?

- Personalised Asthma Action Plan

- Teach Inhaler Technique and advise when to use

- Ensure they have a PEFR meter

- Provide advice on weight loss

- Provide advice on stopping smoking

- Advise they avoid known triggers

- Advise they avoid potential triggers e.g. NSAIDs

- Refer to Respiratory if Occupational Asthma is suspected

- Ensure childhood vaccinations were completed

- Yearly influenza vaccine

- Pneumococcal vaccination

- Assess for Anxiety / Depression

- Provide sources of information and support e.g. Asthma UK

- Annual Asthma review

New Asthma Diagnosis

Which of these should you (or the practice nurse) arrange / offer your

patient?

- Personalised Asthma Action Plan

- Teach Inhaler Technique and advise when to use

- Ensure they have a PEFR meter

- Provide advice on weight loss

- Provide advice on stopping smoking

- Advise they avoid known triggers

- Advise they avoid potential triggers e.g. NSAIDs

- Refer to Respiratory if Occupational Asthma is suspected

- Ensure childhood vaccinations were completed

- Yearly influenza vaccine

- Pneumococcal vaccination

- Assess for Anxiety / Depression

- Provide sources of information and support e.g. Asthma UK

- Annual Asthma review

All of these!

Asthma – Patient Education



Key to effective long term control



Better patient understanding = less exacerbations and less

hospitalisations.



However, often left to practices nurses to fit in during annual

asthma reviews.



More efficient ways? – e.g. group patient education seminars



Good resources:

- Asthma UK website

- 

www.bolton.orcha.co.uk

 – rates health apps

Asthma Deaths

•

 1,400 asthma deaths in 2018 (

↑

8% on 2017)

•

 3 people die every day as a result of an asthma attack

•

 Between 2008-18 – 12,700 deaths (33% increase)

National Review of Asthma Deaths published 2014

•

 46% of deaths preventable

•

 Made 19 recommendations – only 1 had been implemented up to 2017

•

 Some claim the controversial new NICE guidelines have distracted

from targeting preventable asthma admissions / deaths

Asthma Action Plans

•

 With a robust action plan patients are

4 times less likely to end up in

hospital

•

 Only 42% of asthmatics have one as of

2017

•

 Can be found on Asthma UK website

Question 11

A 27 year old asthmatic man attends with 1 day history of wheeze

and chest tightness.  This was preceded by 4 days of a mild

coryzal illness.  He takes montelukast and Qvar 100mcg BD.

Today he has used 8 puffs of salbutamol every 4 hours.  There is

bilateral wheeze but no crackles. His PEFR reading is 180 (usual

best 410).  Other then a RR 18, his other obs are normal.

What should you do?

A)

Prescribe prednisolone 40mg, advise 4 puffs salbutamol 4

hourly until he improves

B)

Call 999 and bring the emergency oxygen to the room just in

case

C)

Give 4 puffs of Salbutamol via spacer and repeat PEFR

D)

Give 5mg Salbutamol via nebuliser and repeat PEFR

E)

Admit to Medics but will need ambulance transfer

Question 11

A 27 year old asthmatic man attends with 1 day history of wheeze

and chest tightness.  This was preceded by 4 days of a mild

coryzal illness.  He takes montelukast and Qvar 100mcg BD.

Today he has used 8 puffs of salbutamol every 4 hours.  There is

bilateral wheeze but no crackles. His PEFR reading is 180 (usual

best 410).  Other then a RR 18, his other obs are normal.

What should you do?

A)

Prescribe prednisolone 40mg, advise 4 puffs salbutamol 4

hourly until he improves

B)

Call 999 and bring the emergency oxygen to the room just in

case

C)

Give 4 puffs of Salbutamol via spacer and repeat PEFR

D)

Give 5mg Salbutamol via nebuliser and repeat PEFR

E)

Admit to Medics but will need ambulance transfer

Question 12

After an appropriate bronchodilator has been given and the

PEFR is now up to 200 (usual best 410) and RR is now 16.

What should you do?

A)

Prescribe prednisolone 40mg, advise 4 puffs salbutamol

4 hourly until he improves

B)

Call 999 – this is a life threatening asthma attack

C)

Give more bronchodilator

D)

Admit to Medics with ambulance transfer

E)

Refer to community respiratory nurses  and prescribe

prednisolone

Question 12

After an appropriate bronchodilator has been given and the

PEFR is now up to 200 (usual best 410) and RR is now 16

What should you do?

A)

Prescribe prednisolone 40mg, advise 4 puffs salbutamol

4 hourly until he improves

B)

Call 999 – this is a life threatening asthma attack

C)

Give more bronchodilator

D)

Admit to Medics with ambulance transfer

E)

Refer to community respiratory nurses  and prescribe

prednisolone

Acute Asthma Exacerbations

Signs of severe asthma attack:



Drowsiness / Agitation



Signs of exhaustion: can’t complete sentences, cyanosis,

accessory muscle use

For all patients:



Examine chest – wheeze, ?crackles, air entry,



Record RR, pulse, BP, and O2 Sats



Measure PEFR – best of 3, compare to usual best



Find out about previous admissions, ever been on ICU?

Acute Asthma Exacerbations

Classify severity based on PEFR:

Moderate = PEFR >50-75%

Severe = PEFR 33-50%

or any of: RR >25 in adults, Pulse >110 in adults

Life Threatening = PEFR <33%

or any of: Sats <92%, signs of exhaustion, hypotension, poor

respiratory effort, cardiac arrhythmia, altered consiousness

Acute Asthma Exacerbations

Managing Moderate Exacerbations (PEFR >50-75%)



Short course of Salbutamol

:

4 puffs followed by 2 puffs every 2 minutes up to max 10 puffs to

achieve relief of symptoms. Initially can repeat after 10-20 minutes

In first 1-2 days can repeat every 4 hours and reduce to PRN when

able – if needing <4 hourly then needs further review



Short course of oral steroids:

e.g. Prednisolone 40mg for 5 days.  Don’t adjust ICS dose



Are Antibiotics needed? E.g. Amoxicillin



Advise they monitor PEFR + Safety net



Consider offering follow up to check response to treatment

Acute Asthma Exacerbations

Managing Severe Exacerbations (PEFR 33-50%)



Give appropriate bronchodilator immediately and

reassess

 - 5mg Salbutamol Neb is better option



If PEFR now >50% and no other concerning features can

treat as a moderate exacerbation in the community.



If no improvement – need to admit to hospital

Acute Asthma Exacerbations

Managing Life Threatening Exacerbations (PEFR <33%)



Get help – emergency alarm, call 999



Give Oxygen – aim sats >94%



Give Salbutamol 5mg Neb (2.5mg if <5)– oxygen

driven preferable.  Repeat every 20-30 mins if needed



If no improvement give Ipratropium 500mcg Neb (if

available, 250mcg if <12) – can only use every 4 hours



Monitor Obs and PEFR until ambulance arrives

Question 13

Annual seasonal Influenza vaccination is recommended to all

over the age of 65, children aged 2-10 years and anyone aged 6

months to 65 years who fall into a “Clinical Risk Group”.

Which of the following diagnoses do 

not

 fit into a “Clinical Risk

Group” and would 

not

 qualify for an NHS flu vaccination?

More then one answer may apply

A)

Bronchiectasis

B)

Stroke

C)

Immunosuppression

D)

Diabetes Mellitus

E)

Epilepsy

F)

CKD stage 3

G)

Obesity (BMI>30)

H)

Pregnant Women

Question 13

Annual seasonal Influenza vaccination is recommended to all

over the age of 65, children aged 2-9 years and anyone aged 6

months to 65 years who fall into a “Clinical Risk Group”.

Which of the following diagnoses do 

not

 fit into a “Clinical Risk

Group and would 

not

 qualify for an NHS flu vaccination?

More then one answer may apply

A)

Bronchiectasis

B)

Stroke

C)

Immunosuppression

D)

Diabetes Mellitus

E)

Epilepsy

F)

CKD stage 3

G)

Obesity (BMI>30)

H)

Pregnant Women

Seasonal Influenza Vaccination

Clinical Risk Groups:



Chronic Respiratory Disease



Chronic Heart Disease



Chronic Kidney Disease



Chronic Liver Disease



Chronic Neurological Disease – includes TIA but 

not Epilepsy



Diabetes Mellitus



Immunosuppression



Splenectomy



Pregnant Women – at any stage



Morbid Obesity BMI 

> 40

 – “use clinical judgement”

Certain Healthy Individuals also qualify



Over 65 years of age



Children aged 2-3 (done via GP) and 4-9 (done via school)



People in long stay care facilities e.g. Residential Homes



Carer’s



Household contacts of immuno-compromised individuals



Healthcare and Social Workers involved in patient care – includes students



Hajj and Umrah Pilgrims – advised by Saudi Ministry of Health - ?on NHS

Seasonal Influenza Vaccination

Influenza types A and B



 sub-strains of each  alternate in prevalence every winter



Type A causes more severe infections and epidemics



Type B – smaller outbreaks, more common in children

Vaccines



All (but 1) are Inactivated Vaccines via IM injection



Trivalent – covers 2 strains of A, 1 strain of B



Quadrivalent – covers 2 strains of A, 2 strains of B



Fluenz Tetra – Quadrivalent Attenuated Live Vaccine –

Nasal administration

Seasonal Influenza Vaccination

Contraindications:



Previous Anaphylactic Reaction or Angioedema to the flu

vaccine



Egg protein (Ovalbumin) Allergy – tiny amounts in all flu

vaccines, but varies between brands, safe to give unless known to

have severe allergic reaction.



Postpone if person acutely unwell – However, 

“minor

illnesses without fever or systemic upset are not valid

reasons to postpone immunisation”

CI’s Specific to Fluenz Tetra Nasal Vaccine:



Severe Asthma or Acute Wheeze (within last 72 hrs)



Taking or taken oral steroids in last 14 days



Severely Immunocompromised



Heavy Nasal Congestion

Seasonal Influenza Vaccination

Advise of common side effects:

All usually disappear within 1-2 days without treatment



Pain, redness, or swelling at injection site



Low grade fever, malaise, shivering, or fatigue



Headache, myalgia, or arthralgia



Nasal congestion and rhinorrhoa – with nasal vaccine



Basically; mild symptoms of the body’s usual reaction to any

infection

Rare side effects:



Neuralgia, paraesthesia, convulsions



Transient thrombocytopoenia



Vasculitis with renal involvement (very rare)



Encephalomyelitis (very rare)

Impossible side effects:



Getting the flu from the vaccine!

Symptoms:

- Wheeze

- Chest Tightness

- Cough

- Breathlessness

- Sputum

- Recurrent chest infections

Quality of the Symptoms:

- Progressive – inevitable and incurable

- >35 years old

- No clear pattern of Variation (but can be worse at night)

- Poor response to bronchodilators

- Exacerbations triggered by e.g. Exercise, infection, cold air

Complications:

- Disability

- Impaired Quality of Life

- Depression

- Anxiety

- Cor Pulmonale

- Secondary Polycythaemia

- Lung Cancer

- Type 2 Respiratory Failure

Question 14

Which of the following is 

not

 a recognised risk factor for

developing COPD?

More then one answer may apply

A)

Occupational Exposure (e.g. Welder) in non-smokers

B)

Occupational Exposure (e.g. Welder) in smokers

C)

Homozygous alpha-1 antitrypsin deficiency

D)

Heterozygous alpha-1 antitrypsin deficiency

E)

Passive smoking

F)

E-cigarettes

G)

Obesity (BMI>30)

H)

Air pollution

Question 14

Which of the following is 

not

 a recognised risk factor for

developing COPD?

More then one answer may apply

A)

Occupational Exposure (e.g. Welder) in non-smokers

B)

Occupational Exposure (e.g. Welder) in smokers

C)

Homozygous alpha-1 antitrypsin deficiency

D)

Heterozygous alpha-1 antitrypsin deficiency

E)

Passive smoking

F)

E-cigarettes 

(not yet anyway)

G)

Obesity (BMI>30)

H)

Air pollution

Risk Factors for COPD

1.

SMOKING

But non-smokers can get COPD too:

Occupation exposures



Dust, noxious chemicals, welding fumes, particles of

grains or silica, coal



20% COPD cases linked to occupational causes

Air Pollution



Particularly in developing countries that use wood or coal

for household heating



Less of a factor in UK



However – vehicle pollution is linked to 

↓

lung function

Risk Factors for COPD

Alpha-1 Antitrypsin Deficiency



Only confirmed genetic cause of COPD



WBC’s produce Trypsin enzyme to move between other cells and to break

down bacteria or react to toxins e.g. Tobacco smoke



Antitrypsin stops trypsin damaging healthy lung tissue.

Genetics:

Autosomal Co-dominent – 

severity of disease depends on combination of genes

inherited as both will be expressed

Simplified verion- Three forms of the A1A gene:

M = normal levels, Z = deficiency, S = mild deficiency

Homozygous A1AD (ZZ genotype)



Develop COPD under age of 45



Liver disease – (tends to be in most severe form and presents in childhood)

Heterozygous or mild homozygous A1AD (MZ, SZ, MS, SS genotypes)



rarely diagnosed but 

may explain why some people are more prone to COPD



Won’t necessarily develop COPD or any lung disease

E-cigarettes



Big gaps in evidence



Big opportunity for misinformation to thrive



Big opportunity to make money in the confusion

Key points:



They are safe: 

In that they meet the minimum requirements of

safety in order to be sold.  

But so does tobacco



Produce less carcinogenic substances then tobacco 

–therefore

the RCP and NICE support their use in smoking cessation (but not as a

“safe” alternative to smoking)



Liquid cartridge usually contain nicotine, propylene glycol, glycerol,

water, and “flavourings” – 

No evidence on the long term

effects

 of

these (alone or in combination)



Battery powered heater produces the vapour – 

no evidence on

environmental impact

E-cigarettes – Deaths in USA

Centre for Disease Control and Prevention (CDC) update:



As of Oct 2019 – 1,479 case of “lung injury” reported



79% of patients were under 35 years old



33 deaths confirmed related to e-cigarettes



Most of these patients reported use of THC containing

products (either shop bought or off the street)



Advise against use of all e-cigarettes 

as exact cause not yet

known



Flavoured liquids / devices are suspected to be a cause –

lawmakers planning to temporarily remove from sale (possibly a

move to encourage tighter regulation - FDA pretty relaxed so far)



UK / EU have tighter regulation – hence RCP/PHE still advise

that e-cigarettes are safe and advocate their use in tobacco

smoking cessation

Question 15

You are suspecting COPD in a 60 year old smoker with

progressive exertional breathlessness over 6 months.

What tests should be performed 

in all cases

 according to

NICE?  More than one answer may be correct

A)

Post Bronchodilator Spirometry

B)

Chest X-ray

C)

FeNO

D)

PEFR

E)

Pre and Post Bronchodilator Spirometry

F)

ECG

G)

Full Blood Count

H)

Pulse Oximetry

Question 15

You are suspecting COPD in a 60 year old smoker with

progressive exertional breathlessness over 6 months.

What tests should be performed 

in all cases

 according to

NICE?  More than one answer may be correct

A)

Post Bronchodilator Spirometry

B)

Chest X-ray

C)

FeNO

D)

PEFR

E)

Pre and Post Bronchodilator Spirometry

F)

ECG

G)

Full Blood Count

H)

Pulse Oximetry

Diagnosing COPD – NICE Guidelines

Arrange the following for all people with suspected COPD:



Post Bronchodilator Spirometry

- FEV1:FVC <70% (<0.7) confirms diagnosis

- Reversibility testing not recommended



Chest X-ray

- Exclude differential diagnoses



Full Blood Count

- Pick up anaemia or secondary polycythaemia

Arrange the following additional investigations where appropriate:



Pulse Oximetry 

– What’s normal?



ECG + Echocardiogram 

– if signs of cor pulmonale



Sputum Culture 

– if purulent sputum is persistent feature

COPD Severity

Graded using the FEV1



Stage 1 – Mild

FEV1 >80% predicted



Stage 2 – Moderate

FEV1 50-79% predicted



Stage 3 – Severe

FEV1 30-49% predicted



Stage 4 – Very Severe

FEV1 <30% predicted

COPD Severity

MRC Dyspnoea Scale is also helpful (recommended by NICE)

Question 16

You review a 65 year old COPD sufferer who is having persistent

breathlessness despite using Terbutaline (SABA) PRN.

According to NICE guidance, which of the following could be

added next?

A)

LABA (e.g. Salmeterol)

B)

ICS (e.g. Budesonide)

C)

SAMA (e.g. Ipratropium)

D)

LABA + ICS (e.g. Sirdupla)

E)

LAMA (e.g. Tiotropium – Spiriva)

F)

LAMA + LABA (e.g. Spiolto Respimat)

G)

LTRA (e.g. Montelukast)

H)

LABA + LAMA + ICS (e.g. Trelegy)

Question 16

You review a 65 year old COPD sufferer who is having persistent

breathlessness despite using Terbutaline (SABA) PRN.

According to NICE guidance, which of the following could be

added next?

A)

LABA (e.g. Salmeterol)

B)

ICS (e.g. Budesonide)

C)

SAMA (e.g. Ipratropium)

D)

LABA + ICS (e.g. Sirdupla)

E)

LAMA (e.g. Tiotropium – Spiriva)

F)

LAMA + LABA (e.g. Spiolto Respimat)

G)

LTRA (e.g. Montelukast)

H)

LABA + LAMA + ICS (e.g. Trelegy)

Managing COPD – NICE Guidelines

Managing COPD – NICE Guidelines

What about LABA or LAMA alone?



Combination inhalers more effective



Should not be prescribing LABA or LAMA alone

When to step up treatment?



>2 exacerbations in last year



1 hospitalisation as a result of COPD exacerbation



Still symptomatic (use MRC scale to judge)

What to check before stepping up?



Smoking?



Inhaler technique - ?need different device

Managing COPD

Lifestyle Advice



Stop Smoking



Promote Exercise



Dietary Advice

Preventation + Screening



Immunisation – Seasonal Flu + Pneumococcal (single dose)



Screen for Depression + Anxiety



Screen for Heart Failure



Social, Physio, Occupational Therapy needs?

Pulmonary Rehabilitation



Consider for anyone suffering with breathlessness



https://www.youtube.com/watch?v=8x6Er-ifaXM

Managing COPD – Other Therapies

Mucolytics



Consider if chronic productive cough with difficulty expectorating



Carbocisteine

- 750mg TDS for 4 weeks

- if “successful” then continue but reduce to 750mg BD

- if no response – STOP



Macrolides e.g. Azithromycin

 - Only initiated by Secondary Care



Nebulised Saline

- 

Only initiated by Secondary Care

- 

Minimal impact with normal (0.9%) saline

- Need Hypertonic for significant effect

Managing COPD – Other Therapies

Theophylline



Consider when persistent bronchospasm (wheeze) despite

max inhaled therapy.



E.g. Uniphyllin MR – starting dose 200mg BD



Need to monitor levels (target 10-20mg/L)



Toxicity can cause: Nausea, Tachycardia, Arrhytmia,

Hypokalaemia, Irritability, Seizures

Managing COPD – Other Therapies

Phosphodiesterase type-4 inhibitors



E.g. Roflumilast (only PDE4i licensed for severe COPD)



PDE4 breaks down anti-inflammatory enzymes and therefore

promotes inflammation



In severe COPD – reduces exacerbations and improves FEV1



Only started by secondary care



Roflumilast 500mcg OD – 30 tablets cost £37



Side effects: Weight loss, insomnia, headache, GI upset



Interacts with Theophylline – don’t co-prescribe

COPD – When to Refer (Bolton CCG)



Diagnostic Uncertainty



Severe/Worsening COPD



Haemoptysis



Frequent respiratory infections



Suspected Cor Pulmonale



Symptoms don’t match Spirometry results



Age <40 or FH of A1AD



Assessment for Nebuliser / Home Oxygen Therapy

Question 17

Which of the following is a benefit of Long Term Oxygen

Therapy in COPD?

More then one answer may be correct

A)

Improved sleep

B)

Reduced anxiety

C)

Reduced breathlessness

D)

Improved mood

E)

Improved life expectancy

F)

Reduced cough

G)

Reduced hospital admissions

Question 17

Which of the following is a benefit of Long Term Oxygen

Therapy in COPD?

More then one answer may be correct

A)

Improved sleep

B)

Reduced anxiety

C)

Reduced breathlessness

D)

Improved mood

E)

Improved life expectancy

F)

Reduced cough

G)

Reduced hospital admissions

COPD – Oxygen Therapy (BTS)

Treatment for Chronic Hypoxaemia (PaO2 <7.3kPa)

Does not relieve breathlessness

Different types:

LTOT – Long Term Oxygen Therapy

- at least 15 hours a day.  0.5-2L flow rate

- 

increases life expectancy and improves sleep

- improves outcomes in Cor Pulmonale, Polcythaemia, and

Pulmonary Hypertension

- Use in Hypercapnic patients does not increase mortality

- No impact on hospitalizations or mood/anxiety

Ambulatory Oxygen

- Portable, improves quality of life

- Rarely used if patient doesn’t qualify for LTOT

Oxygen Therapy (BTS) – other uses

Short Burst Oxygen

- 10-20 minute bursts of high flow oxygen e.g. 12L

- Not recommended for use in exertional breathlessness by BTS

- But NICE say “consider for people not eligible for LTOT who have

episodes of severe breathlessness not relieved by other treatments”

- used for symptomatic relief in 

Cluster Headache

Palliative Oxygen

- Considered for breathlessness in terminal disease

- Only of benefit in hypoxaemic breathless patients

- Even then studies show little benefit on reducing symptoms

Other options for Dyspnoea in Palliative Care:

- Opiates e.g. Low doses of morphine PRN

- Clonazepam drops

- Fan therapy and CBT are other options

- Refer to palliative care

Question 18

The receptionist asks you to urgently see a COPD patient with 2

days of breathlessness, who has become more SOB in the waiting

room.  They take Trelegy and are getting no relief from

salbutamol.  Their observations are: T 36.7, pulse 86 reg, BP

109/62, RR 28, O2 sats 86%.  They look tired, are pursed lip

breathing, and using accessory muscles.  On auscultation there is

wide spread wheeze and prolonged expiration.

What should you do first?

A)

Give 10 puffs Salbutamol via spacer

B)

Call 999

C)

Give oxygen – target sats >94%

D)

Give oxygen – target sats 88-92%

E)

Give Salbutamol 5mg Neb

Question 18

The receptionist asks you to urgently see a COPD patient with 2

days of breathlessness, who has become more SOB in the waiting

room.  They take Trelegy and are getting no relief from

salbutamol.  Their observations are: T 36.7, pulse 86 reg, BP

109/62, RR 28, O2 sats 86%.  They look tired, are pursed lip

breathing, and using accessory muscles.  On auscultation there is

wide spread wheeze and prolonged expiration.

What should you do first?

A)

Give 10 puffs Salbutamol via spacer

B)

Call 999

C)

Give oxygen – target sats >94%

D)

Give oxygen – target sats 88-92%

E)

Give Salbutamol 5mg Neb

Acute Exacerbations of COPD

Signs of Severe Exacerbation

- O2 sats <90%

- use of accessory muscles

- RR >25

- pursed lip breathing

- Confusion

- Cyanosis

- Peripheral oedema

- 

↓ ↓ET

Emergency Management

- Nebulised Salbutamol 5mg

- Oxygen – aim sats 88-92% (NICE)

- Most will need admission

- If stabilising can consider community management e.g.

Admissions Avoidance Team

- Should there be a bigger push towards community

management?

Acute Exacerbations of COPD

Managing in Primary Care



Increase dose/freqency of SABA

e.g. 4 puffs 4 hourly – best via spacer



Oral Corticosteroids

Prednisolone 30mg OD for 7-14 days



Oral Antibiotics

Only if purulent sputum

1

st

 line – Amoxicillin 500mg TDS for 5 days

Pen Allergy – Clarithromycin

2

nd

 line – Doxycycline 200mg then 100mg OD 5 day course

Don’t prescribe without educating:



How to recognise an exacerbation

- SOB, wheeze, cough, 

↓ET, ↑sputum



Infective vs Non-infective?

- Purulent sputum (yellow/brown) 

- change in sputum



What to do before starting the rescue pack?

- increase SABA

- Breathing exercises



When to start steroids?

- if the above measures aren’t helping



When to start antibiotics?

- only if purulent sputum

Important points:



Never put on repeat prescription



If had >3 courses of steroids in 12 months and >65 – will need

bone protection

What is it?



Chronic - Dilated, thick walled bronchi



Excess sputum and cilliary dysfunction

What causes it?



Any prolonged condition that damages the lungs



Affects up to 30% of COPD sufferers



Commonest cause is severe LRTI



Other causes: CF, aspiration, ABPA, Asthma, RA, Immune

deficiency

When to suspect it?



Chronic excess sputum production – persistent cough



Unusual sputum results e.g. Pseudamonas



Prolonged LRTIs – requiring extended courses of antibiotics

Bronchiectasis

Diagnosis



Can only be confirmed by High Resolution CT



But do we need to refer everyone to respiratory?

- NICE says yes, especially if young

- All will need: CXR, Spirometry, and sputum cultures to exclude

alternative causes first

But e.g.

- COPD patient with prolonged exacerbations – confirming the

diagnosis won’t change much – can suspect bronchiectasis and

manage by checking sputum and Rx longer courses of antibiotics

Worth remembering that up to 30% COPD sufferers may need 10-14

day courses of antibiotics and better to send sputum before treating

Question 19

A 59 year old male smoker attends with a 3 week history of cough.

He is frequently coughing up small amounts of blood.  He denies

breathlessness, chest pain, or sputum production.  He has not

had any fever or coryzal symptoms.  He has not travelled abroad

in the last 12 months and has never been exposed to TB.  He has

no PMH and is not on any medications.  Chest examination and

all observations are normal.

What should you do?

A)

Admit to medics as suspected PE

B)

Arrange an urgent chest x-ray

C)

2 week wait referral to respiratory

D)

Treat as suspected LRTI and arrange follow up in 1 week

E)

Watch and wait (with safety netting advice)

Question 19

A 59 year old male smoker attends with a 3 week history of cough.

He is frequently coughing up small amounts of blood.  He denies

breathlessness, chest pain, or sputum production.  He has not

had any fever or coryzal symptoms.  He has not travelled abroad

in the last 12 months and has never been exposed to TB.  He has

no PMH and is not on any medications.  Chest examination and

all observations are normal.

What should you do?

A)

Admit to medics as suspected PE

B)

Arrange an urgent chest x-ray

C)

2 week wait referral to respiratory

D)

Treat as suspected LRTI and arrange follow up in 1 week

E)

Watch and wait (with safety netting advice)

Suspected Lung Cancer - NICE

Refer people using a suspected cancer pathway referral

(for an appointment within 2 weeks) for lung cancer if

they:



Have chest X-ray findings that suggest lung cancer

or



Are aged 40 and over with unexplained

haemoptysis

Suspected Lung Cancer - NICE

Offer urgent Chest X-ray to the following:

Anyone >40 with:

- Finger Clubbing

- Persistent chest infection

- Chest signs suggestive of Lung Ca (bronchial BS, unilat ?effusion)

- Thrombocytosis

- Supraclavicular lymphadenopathy

Anyone >40 with 2 of, or any smoking history with 1 of;

Unexplained:

- Cough

- Fatigue

- Weight Loss

- SOB

- Chest Pain

- Appetite loss

Question 20

A 53 year old woman attends with a persistent irritating dry cough

for the last 5 weeks.  It tends to be worse at night and  she reports

constantly having a dry throat.  She has well controlled

hypertension on 5mg Ramipril and has intermittent heart burn

for which she occasionally takes OTC Ranitidine.  She denies

haemoptysis and has never smoked.

What would be the best initial management plan?

A)

Stop the Ramipril and reassess in 2 weeks

B)

Trial regular inhaled corticosteroid

C)

2 week wait referral to respiratory

D)

5 day course of Amoxicillin 500mg TDS

E)

Start Omeprazole 20mg OD regularly and reassess in 1 month

Question 20

A 53 year old woman attends with a persistent irritating dry cough

for the last 5 weeks.  It tends to be worse at night and  she reports

constantly having a dry throat.  She has well controlled

hypertension on 5mg Ramipril and has intermittent heart burn

for which she occasionally takes OTC Ranitidine.  She denies

haemoptysis and has never smoked.

What would be the best initial management plan?

A)

Stop the Ramipril and reassess in 2 weeks

B)

Trial regular inhaled corticosteroid

C)

2 week wait referral to respiratory

D)

5 day course of Amoxicillin 500mg TDS

E)

Start Omeprazole 20mg OD regularly and reassess in 1

month

NICE divides into:

I tend to simplify to:

-

Acute = 0-3 weeks

- Acute = 0-4 weeks

-

Subacute = 3-8 weeks

- Persistant = >4 weeks

-

Chronic = >8 weeks

There is no effective treatment for cough – but can treat the causes

There are lots of potential causes of a persistent cough:

- Asthma

- COPD

- Post Infective

- Bronchiectasis

- Lung Ca

- Tuberculosis

- Pertussis

- Pneumonia

- Bronchitis

- GORD (silent)

- ACEi

- Post Nasal Drip

- Smoking related

- ILD

- Heart Failure

- Foreign Body Aspiration

- Atypical Pneumonia

Cough

NICE divides into:

I tend to simplify to:

-

Acute = 0-3 weeks

- Acute = 0-4 weeks

-

Subacute = 3-8 weeks

- Persistant = >4 weeks

-

Chronic = >8 weeks

There is no effective treatment for cough – but can treat the causes

There are lots of potential causes of a persistent cough:

- Asthma

- COPD

- Post Infective

- Bronchiectasis

- Lung Ca

- Tuberculosis

- Pertussis

- Pneumonia

- Bronchitis

- 

GORD (silent)

- 

ACEi

- 

Post Nasal Drip

- Smoking related

- ILD

- Heart Failure

- Foreign Body Aspiration

- Atypical Pneumonia

Good history is key:



Smoker?  - think Lung Cancer or Smoking related



Dry or Productive?



Improving, worsening or stable?



Coughing bouts?

- think Pertussis (+/- inspiratory “whoop” or vomiting)



Any illness at onset

- think Infective (prolonged or post)



Associated symptoms

- Acid brash, heartburn? – think Reflux

- Blocked nose / rhinorrhoea? – think Post nasal drip

- Swallowing difficulty? – think Aspiration

- Cardiac History? – think Heart Failure

- Breathlessness? – think COPD / ILD / Heart Failure



Timing

- Diurnal variation? – think Asthma

- Seasonal? – think Allergic (asthma or rhinitis)

Good history is key:



Triggers

- Laying on back / bending forward? – think Reflux

- Allergens – pets? dust? temperature?



Occupation

- Asbestos exposure? – think ILD / Mesothelioma

- Coal Miner? – think Pneumoconiosis

- Baker? – Occupational Asthma



Foreign Travel

- Cruise/Hotel – anyone else unwell? – think Legionella

- TB exposure?



Drugs

- ACEi – short or long term us

- Long term Nitrofurantoin – cause of Pulmonary Fibrosis



Red Flags:

- Haemoptysis

-Weight loss

Investigations – my approach:



Chest X-ray

- Consider for any cough lasting >4 weeks

- Rule out Lung Ca, Pneumonia, ILD



Spirometry

- If any features of asthma

- If any exertional breathlessness suggestive of COPD/ILD



Sputum Culture

- If any sputum production

Normal CXR +/- Normal Spirometry:



Features of Reflux?

- Trial PPI for 1-2 months

- e.g. Omeprazole 20mg OD



Features of Post Nasal Drip / Allergic Rhinitis

- Trial steroid nasal spray for 3 months

- e.g. Mometasone 50mcg OD

- Other options – Ipratropium Nasal Spray (Rinatec)