Question 126#

You are reviewing a patient with chronic obstructive pulmonary disease (COPD) who remains breathless despite using an ipratropium bromide inhaler as required. Her FEV1 is 40%.

What are the two main options?

A. Long-acting beta2-agonist (LABA) or inhaled corticosteroid

Correct Answer B: 

COPD - still breathless despite using inhalers as required?

• FEV1 > 50%: LABA or LAMA
• FEV1 < 50%: LABA + ICS or LAMA 

COPD: stable management:

NICE updated it's guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2010.

General management: 

• Smoking cessation advice
• Annual influenza vaccination
• One-off pneumococcal vaccination

Bronchodilator therapy:

• A short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is first-line treatment
• For patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by the FEV1

FEV1 > 50%: 

• Long-acting beta2-agonist (LABA), for example salmeterol, or:
• Long-acting muscarinic antagonist (LAMA), for example tiotropium

FEV1 < 50%: 

• LABA + inhaled corticosteroid (ICS) in a combination inhaler, or:
• LAMA

For patients with persistent exacerbations or breathlessness: 

• If taking a LABA then switch to a LABA + ICS combination inhaler
• Otherwise give a LAMA and a LABA + ICS combination inhaler

Oral theophylline: 

• NICE only recommends theophylline after trials of short an long-acting bronchodilators or to people who cannot used inhaled therapy
• The dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed

Mucolytics: 

• Should be 'considered' in patients with a chronic productive cough and continued if symptoms improve

Cor pulmonale: 

• Features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2
• Use a loop diuretic for oedema, consider long-term oxygen therapy
• ACE-inhibitors, calcium channel blockers and alpha blockers are not recommended by NICE 

Factors which may improve survival in patients with stable COPD: 

• Smoking cessation - the single most important intervention in patients who are still smoking
• Long term oxygen therapy in patients who fit criteria
• Lung volume reduction surgery in selected patients

Question 127#

Non-invasive ventilation (NIV) is least likely to be successful in which one of the following scenarios?

A. COPD

Correct Answer E: The British Thoracic Society recommend that whilst a trial of NIV may be undertaken in bronchiectasis it should not be used routinely as its effectiveness is likely to be limited by excessive secretions.

Non-invasive ventilation:
The British Thoracic Society (BTS) published guidelines in 2002 on the use of non-invasive ventilation in acute respiratory failure. Following these the Royal College of Physicians published guidelines in 2008.

Non-invasive ventilation - key indications: 

• COPD with respiratory acidosis pH 7.25-7.35
• Type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
• Cardiogenic pulmonary oedema unresponsive to CPAP
• Weaning from tracheal intubation

Recommended initial settings for bi-level pressure support in COPD: 

• Expiratory Positive Airway Pressure (EPAP): 4-5 cm H₂O
• Inspiratory Positive Airway Pressure (IPAP): RCP advocate 10 cm H₂0 whilst BTS suggest 12-15 cm H₂O
• Back up rate: 15 breaths/min
• Back up inspiration:expiration ratio: 1:3

Question 128#

A 24-year-old man who has developed a chronic cough and wheeze after starting a new job presents for review. His peak flow measurements are significantly reduced whilst at work and improve at the weekend.

Which one of the following substances is most frequently associated with this kind of asthma?

A. Cadmium

Correct Answer D: Isocyanates are the most common cause of occupational asthma.

Asthma: occupational:
Causes: 

• Isocyanates - the most common cause. Example occupations include spray painting and foam moulding using adhesives
• Platinum salts
• Soldering flux resin
• Glutaraldehyde
• Flour
• Epoxy resins
• Proteolytic enzymes

Diagnosis: 

• Specific recommendations are made in the 2007 joint British Thoracic Society and SIGN guidelines
• Serial measurements of peak expiratory flow are recommended at work and away from work

Question 129#

A 27-year-old man with a history of 'brittle' asthma is admitted to the Emergency Department with an asthma attack. The paramedics have already administered high-flow oxygen and nebulized salbutamol. He is unable to complete sentences, has a tight bilateral expiratory wheeze and is unable to perform a peak flow reading. His respiratory rate is 30 / minute, sats 94% (on high-flow oxygen) and pulse 120 / minute. He is immediately given intravenous hydrocortisone and nebulized salbutamol is given continuously. After five minutes there is no improvement and intravenous magnesium sulphate is given. After another five minutes an arterial blood gas sample is taken:

• pH 7.34
• pCO₂ 6.9 kPa
• pO₂ 8.8 kPa

What is the most appropriate management?

A. Non-invasive ventilation

Correct Answer E: This question is about clinical judgement. A review of the British Thoracic Society guidelines will show that in such a scenario nebulized ipratropium bromide should have been given much earlier but this did not happen. The above arterial blood gas results for a young asthmatic patient are alarming and suggest that he is rapidly becoming tired. It is therefore inappropriate to wait a further 10 minutes. This patients needs ITU input with probable intubation and ventilation.

Asthma: acute severe:

Patients with acute severe asthma are stratified into moderate, severe or life-threatening:

British Thoracic Society guidelines: 

• Magnesium sulphate recommended as next step for patients who are not responding (e.g. 1.2 - 2g IV over 20 mins)
• Little evidence to support use of IV aminophylline (although still mentioned in management plans)
• If no response consider IV salbutamol

Question 130#

A 31-year-old man with a history of asthma presents to the Emergency Department with dyspnoea not responding to his salbutamol inhaler. On examination he is noted to have reduced breath sounds on the right side and a chest x-ray confirms a pneumothorax with a 1.5cm rim of air. A pleural aspiration is performed and the patient's dyspnoea resolves.

What advice should he be given before discharge?

A. Air travel should be avoided for the next 12 months

Correct Answer D: This man has developed a secondary spontaneous pneumothorax. The British Thoracic Society (BTS) guidelines state: 'Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.'

Air travel is acceptable once the pneumothorax has fully resolved.

Pneumothorax:

The British Thoracic Society (BTS) published updated guidelines for the management of spontaneous pneumothorax in 2010. A pneumothorax is termed primary if there is no underlying lung disease and secondary if there is.

1- Primary pneumothorax:

Recommendations include:

• If the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
• Otherwise aspiration should be attempted
• If this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted 

2- Secondary pneumothorax:

Recommendations include:

• If the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted
• Otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
• If the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
• Regarding scuba diving, the BTS guidelines state: 'Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.'

3- Iatrogenic pneumothorax:

Recommendations include:

• Less likelihood of recurrence than spontaneous pneumothorax
• Majority will resolve with observation, if treatment is required then aspiration should be used
• Ventilated patients need chest drains, as may some patients with COPD