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CCC - Respiratory - Coggle Diagram

- - - - Spirometry / PEFR: > 15% increase in FEV1 or PEFR post inhaled bronchodilator
      - FeNO test >40ppb in adults
      - Trial of treatment
      - Bloods - May show eosinophilia
      - CXR: Usually normal, occasionally hyperinflation, excludes other causes
      - Serial PEFR measurements over 2 week TD
    - - PEFR measurements - Peak expiratory flow measurement
        
        Over 15% increase post bronchodilator
      - Spirometry
        
        Over 15% increased of FEV1 post bronchodilator
      - FeNO - Fractional exhaled nitric oxide
        Over 40ppb in adults
        Tests eosinophilic airway inflammation
    - - FBC : may shor Eosinophilia
    - - CXR
        
        Hyperinflation
        
        r/o other causes
  - - - Abolish symptoms
      - Restore normal / best possible long term airway function
      - Reduce risk of severe attacks
      - Enable normal growth in children
    - - Primary prevention - breast feeding
      - Allergen avoidance
      - Weight loss if indicated
    - - Aims
        
        Start most appropriate to initial severity of symptoms
        
        Aim to achieve early control, and then step down treatment
        
        Ensure proper inhaler technique and trigger avoidance
        
        Before increase treatment – consider triggers, adherence, inhaler technique
      - Selection of Inhaler
        
        Use MDI if possible (dry powder inhalers are an alternative)
        
        75% of users have inadequate technique
        
        Spacers / breath-activated devices are best
      - Drugs
        
        SABA Short-acting b2-agonists – e.g. salbutamol (Ventolin), terbutaline(Bricanyl)
        
        Anticholinergic bronchodilators – e.g ipratropium bromide (Atrovent) preferred to salbutamol < 1y.o.
        
        LABA Long-acting b2-agonists – e.g. salmeterol (Serevent)
        
        ICS Inhaled corticosteroids – e.g. beclomethasone (Becotide), fluticasone (Flixotide), budesonide (Pulmicort)
        Often available in combination with a long-acting b2-agonist – e.g. Seretide (salmeterol + fluticasone), Symbicort (formoterol + budesonide)
        
        LTRA Leukotriene receptor antagonists – e.g. montelukast (Singulair)
        
        Sodium cromoglycate and nedocromil sodium (Intal, Cromogen)
      - Stepwise
        
        https://d1z8zkw1yi6kd7.cloudfront.net/uploads/ckeditor/pictures/data/000/001/597//content/chronic_management_of_asthma.jpg
        SABA PRN
        ICS → + LABA → ↑ ICS or LRTA → Specialist referal
  - - - PEFR
        
        HR
        
        RR
        
        O2 sats
        
        Exam
      - Moderate PEFR
        
        50-75% of best, increasing symptoms
      - Severe: PEFR
        
        <33-50% inability to complete sentences, HR>110, RR>25
      - https://d1z8zkw1yi6kd7.cloudfront.net/uploads/ckeditor/pictures/data/000/001/942//content/acute_asthma_categorisation.jpg
    - - O2, aim for >94% SpO2
      - SABA High dose inhaled beta agonist - Salbutamol 10 puffs
      - Oral steroids 5 days adult, 3 days child
        Steroids underused and strong evidence of effectiveness
      - Refer ED if severe attack persists despite treatment
        Review treatment
      - https://d1z8zkw1yi6kd7.cloudfront.net/uploads/ckeditor/pictures/data/000/001/715//content/management_of_acute_asthma.jpg
- - - - Cough
      - Sputum production
      - Dyspnoea
      - Episodicexacerbations
      - https://d1z8zkw1yi6kd7.cloudfront.net/uploads/ckeditor/pictures/data/000/001/719//content/clinical_features_of_stable_copd.jpg
    - - Tachypnoea
      - Prolonged expiration
      - Use of accessory muscles
      - Intercostal in-drawing
      - Pursing of lips
      - Poor chest exapnsion
      - Hyper resonant chets
  - - - Chronic cough
      - Chronic sputum production
      - Repeated episodes of acute bronchitis
      - Dyspnoea - progressive, persistent, worse on exercise, worse during resp infx
      - Hx of exposure to risk factors - esp smoking
    - - 4 stages
        
        https://d1z8zkw1yi6kd7.cloudfront.net/uploads/ckeditor/pictures/data/000/001/723//content/copd_classification.jpg
      - ↓ FEV and FEV1/ FVC ratio < 0.7
      - Orange line
        https://d1z8zkw1yi6kd7.cloudfront.net/uploads/ckeditor/pictures/data/000/002/537//content/spirometry_-_obstructive_restrictive.jpg
  - - - Prevent disease progression
      - Relieve symptoms
      - Improve exercise tolerance
      - Smoking cessation
    - - Assess and monitor symptoms : MRC Dyspnoea scale
      - Consider number exacerbation
      - Reduce risk factors
    - - Assess & Manage Stable COPD
        
        https://bestpractice.bmj.com/topics/en-gb/7/treatment-algorithm
        https://bestpractice.bmj.com/api/image/7/en-gb/normal/7-190523-row-inline.gif
      - Step 1: SABA
        Step 2: LABA + LAMA
        Step 3: LAMA + LABA + ICS
        Step 4: Refer, consider maintenance Azithromycin
      - https://d1z8zkw1yi6kd7.cloudfront.net/uploads/ckeditor/pictures/data/000/001/721//content/copd_management.jpg
    - - Influenza annual
      - Pneumococcus every 5 yrs >65
        One dose or booster if last dose was 5 yr earlier <65
    - - Rehab
        
        Exercise training
        
        Nutritional counselling
        
        Pt education
      - Self-management
        
        Individualised plans
        
        Home rescue packs
  - - - Consider if need hospital admission (O2 sats) or red flags
    - - ↑ Dose / frequency of bronchodilators
      - Add anticholingergics
      - If baselin FEV1 < 505% predicted → PO Pprednisolone 30-40mg 7 days
      - ABx if ↑ SOB / cough / purulent sputum
      - Safety Net Advice