Chronic lung disease in adults

Transcription

1 Includes COPD, bronchiectasis, some persistent asthma. More than one can be present in same person. Diagnosis clinical history, lung function tests (spirometry), x-ray, CT scan. First assessment Ask About smoking how many, how long, tried to stop, want to stop About petrol sniffing, past or present (associated with lung damage) Chronic cough, frequent chest infections About sputum frequency, amount, colour, blood es shortness of breath stop them moving as they would like to About activities of daily living, quality of life About sleeping problems, snoring, stopping breathing, morning headaches, fatigue, daytime sleepiness. May have breathing related sleep disorder (p352) Check File notes for Recorded diagnosis of chronic lung disease, COPD, bronchiectasis, asthma Management plan, action plan for managing exacerbations Spirometry (CPM p175) before and 15 minutes after 2 puffs salbutamol (100mcg/dose) with puffer and spacer or 5mg salbutamol with nebuliser Good response after reliever (12% or more AND at least 200ml increase in FEV1) usually means at least a component of asthma Airflow obstruction (FEV1/FVC less than 0.7) always present in COPD May not be present at time of testing in asthma In bronchiectasis lung function may be normal or may be reduced FEV1 and FVC together rather than airflow obstruction Grade severity of airflow obstruction based on % predicted FEV1 Mild 60 80%, moderate 40 59%, severe less than 40% Remember: COPD, asthma, bronchiectasis can exist together O2 sats. If less than 94% medical consult about home oxygen, may need extra oxygen for air travel BMI (CPM p129) ECG look for old heart attacks or heart failure as cause of breathlessness FBE low Hb can make breathlessness worse, Hb can be high if O2 sats low Chest x-ray look for bronchiectasis, emphysema, over-inflated lung, heart enlargement, heart failure, scarring from lung disease or old infection Flu and pneumococcal immunisation status, give if needed (Australian Immunisation Handbook) 338

2 Medical review for diagnosis if not known or if blood in sputum Show person how to use puffer (CPM p356) and spacer (CPM p354) If you suspect bronchiectasis (p340) refer for high resolution CT scan of chest. Specialist consult first If snoring, morning headache, daytime sleepiness, fatigue think about referral to sleep/respiratory service for review (p352) If severe airflow obstruction or shortness of breath worse than expected from spirometry think about referral for echocardiogram (heart failure, pulmonary hypertension) Table 6.3: Comparison of chronic lung diseases Sign Bronchiectasis COPD Asthma Young age of onset Often Almost never Often Sudden onset Almost never Almost never Often Smoking history Sometimes Almost always Sometimes Short of breath Usually Usually Sometimes Wheeze Sometimes Sometimes Often Cough Chronic Chronic Sometimes Sputum production Daily, large volume Almost always Sometimes Response to bronchodilators Small Small Usually large but can be variable Management of all chronic lung diseases Aim to improve symptoms, slow worsening of lung function so person enjoys their life. regular checks Make management/action plan with person. Give them a copy Include when to have regular checks, allied health and physician referrals, follow-up, what to do for acute episodes (exacerbations) Regular checks If chronic lung disease increased risk of coronary artery disease Every six months Ask about symptom control shortness of breath, exercise tolerance, acute episodes Pulse, BP, weight If puffer (CPM p356) and spacer (CPM p354) used check technique General topics 339

3 Yearly FBE, O2 sats Spirometry (CPM p175) FEV1 and FVC Sputum for MC&S Check for signs of depression (p214) Assess cardiovascular risk (p269) Review management and action plans. Give person written copy of updated management/action plan Encourage to QUIT smoking stopping smoking is the only thing proven to slow down lung damage AND has many other advantages Strongly encourage physical activity. Develop tailored exercise program with allied health support If bronchiectasis with productive cough or moderate-severe obstruction think about referral to physiotherapy for advice on sputum removal If unintended weight loss medical review If on corticosteroids for longer than 2 weeks test for strongyloides (p447) Give flu immunisation every year and pneumococcal immunisation as per schedule (Australian Immunisation Handbook) If PCV consistently more than 0.55% may need blood taken to reduce it (phlebotomy). Specialist consult if severe Specialist review to consider surgical options including lung transplant Talk with person and family about treatment choices and going to hospital if they become unwell. Develop advanced care directive to reflect this If uncontrolled and shortness of breath distressing talk with specialist and palliative care team about medicine to help Bronchiectasis Widening of airways caused by severe or repeated infection. Airflow obstruction (FEV1/FVC less than 0.7) may not be present. Common with COPD. Specialist review to check for underlying treatable cause. Diagnosis confirmed by high resolution computed tomography (HRCT). Think about bronchiectasis if Chronic cough and sputum in person under 35 years Diagnosis of COPD and less than 10 years of smoking 2 or more hospital admissions with pneumonia in past year, especially if under 35 years 340

4 Chest x-ray changes suggest dilated airways or scarring Persisting crackles in lungs and no heart failure Diagnosis of CSLD as child (p132) Clubbing of fingers Unusual organisms on sputum culture, eg Pseudomonas, aspergillus, atypical mycobacteria such as Mycobacterium avium complex Spirometry may be normal or have reduced FEV1 and FVC together Symptoms Chronic cough with daily sputum, not responding to standard treatment Often abnormal sounds in lungs May have shortness of breath, wheeze, chest pain May cough up blood (haemoptysis) May have sinus/nasal inflammation, tiredness, weight loss First assessment for chronic lung disease (p338) Acute episode (exacerbation) Increased cough, amount and colour of sputum (darker yellow or green) Often wheezing, more short of breath, fever May cough up blood (haemoptysis), have chest pain Spirometry may get worse Check Temp, pulse, BP, RR, O2 sats Sputum (CPM p376) for MC&S, check for blood If chest pain or history of heart disease do ECG Check results of last sputum culture use antibiotic advised If no recent results give amoxycillin oral 1g twice a day for 14 days If allergic to penicillin give doxycycline 5mg/kg/dose single dose THEN 2.5mg/kg/dose once a day for 13 days (doses p457) If pregnant medical consult Check sputum results as soon as possible If not improving change antibiotics If positive Pseudomonas give ciprofloxacin oral twice a day (bd) for 14 days (doses p456) Chest physiotherapy (CPM p178). Avoid head down postural drainage if history or symptoms of reflux General topics 341

5 Relievers may be helpful give if they provide symptomatic relief Medical consult if Very unwell may need to send to hospital Coughing up blood (haemoptysis) Marked wheeze or previous diagnosis of co-existing asthma may need prednisolone New onset of O2 sats less than 94% Can't look after themself at home, eg washing, toileting, dressing, eating Ongoing management Regular checks (p339) To help removal of sputum refer to physio for coughing techniques and aids, eg PEP valve, flutter valve Inhaled corticosteroid may help if a component of asthma, ie 12% or more AND at least 200ml increase in FEV1 on spirometry 15 minutes after 2 puffs (200mcg) of salbutamol OR Marked wheeze COPD chronic obstructive pulmonary disease Airway obstruction not fully reversible. Think about COPD if over 35 years and current or ex-smoker, even if no symptoms. Long history of smoking most common cause of COPD BUT can have COPD if never smoked, especially if long exposure to second hand smoke. Diagnosis based on spirometry Poor response (less than 12% improvement or 200ml in FEV1) with inhaled salbutamol Ratio of FEV1 to FVC less than 0.7 Symptoms Short of breath often late sign when lot of lung damage or obstruction May have wheeze Cough with sputum most days for several months at a time over 2 or more years. Often worse in morning, amount of sputum can be small First assessment for chronic lung disease (p338) Assess severity. See Table 6.4 (p343) 342

6 Table 6.4: Grading severity of COPD Grade FEV1 Symptoms/signs Impact Mild 60 80% of predicted Chronic bronchitis May be short of breath May be minimal ongoing symptoms Exacerbations may affect work Moderate 40 59% of predicted Breathless, wheezing with moderate physical activity, eg walking up hills/steps Breathlessness may affect work and physical activity Exacerbations may be more severe and need hospitalisation Severe Less than 40% of predicted Breathless with minor activity, eg walking on flat, getting dressed Can develop complications, eg pulmonary hypertension/right heart failure (cor pulmonale), high Hb (polycythemia) Quality of life very poor Exacerbations may be life-threatening Acute episode (exacerbation) Looks and feels worse than usual At least 2 of Increased shortness of breath Increased sputum production or cough Change in colour of sputum (clear/white to yellow-green) Check Temp, pulse, BP, RR, O2 sats If chest pain or history of heart disease do ECG If O2 sats less than 92% give oxygen. Start with nasal prongs at 2L/min THEN give only enough oxygen to keep O2 sats at 88 92% Monitor every 15 minutes Give salbutamol (100mcg puffer with spacer) 8 10 puffs, 1 4 hourly until responding If symptoms not well controlled or severe add ipratropium (20mcg puffer with spacer) 4 6 puffs as needed General topics 343

7 Give prednisolone oral once a day for 5 days (doses p465) then review If person also has diabetes may need extra blood glucose control medicine when taking prednisolone If signs of infection, eg fever, change in colour of sputum give amoxycillin oral 1g twice a day (bd) for 5 days If allergic to penicillin Give doxycycline 2.5mg/kg/dose twice a day (bd) for 5 days (doses p457) OR Medical consult Medical consult if O2 sats less than 94% and this is new Person needs more oxygen than by 28% Venturi mask or 4L/min by nasal prongs, or becoming sleepy often needs to go to hospital RR less than 12/min OR more than 26/min after first dose of salbutamol Other medical problems, eg diabetes, heart disease, kidney disease Not improving with treatment Known moderate or severe COPD based on earlier spirometry Using home oxygen History of being in ICU for exacerbations (especially if non-invasive ventilation or intubation) Severe exacerbation and/or waiting for evacuation Check pulse, BP, RR every 15 minutes Monitor O2 sats continuously by oximeter Continue oxygen aim to keep levels at 92 94% Watch for drowsiness, may indicate slowing breathing (CO2 retention). Urgent medical consult Sit person up use wheelchair to move them Give nebulised salbutamol 5mg as needed Give nebulised ipratropium 500mcg as needed can mix with salbutamol Give hydrocortisone IV 100mg 6 hourly Ongoing management Education and self-management including stopping smoking (p246), pulmonary rehabilitation Regular checks (p339) Stepwise progression of medicines (Table 6.5 p345) Severe If O2 sats less than 94% refer to specialist for blood gases, echocardiogram, assessment for home oxygen 344

8 May need oxygen if flying in plane or being transported in ambulance include in management plan If on home oxygen increase flow rate by 2L/min when flying Refer to allied health and palliative care for home assessment and support, eg bedding, wheelchair, respiratory education, advice on advanced care plan Remember: May also have heart failure (p300), ischaemic heart disease (p288), RHD (p415), asthma (p346), strongyloides (p447) think about these when person with chronic lung disease very short of breath. Table 6.5: Progression of medicines for COPD Step 1 Step 2 Step 3 Reliever for Reliever for symptoms Reliever for symptoms symptoms AND Regular longer AND Regular longer acting (p349) acting controller controller AND Combined preventer (inhaled corticosteroid) and controller (long acting beta2 agonist [LABA]) Example Salbutamol 2 puffs as needed (100mcg puffer with spacer) OR Ipratropium 2 puffs as Example Salbutamol 2 puffs as needed (100mcg puffer with spacer) AND Tiotropium 18mcg (1 capsule) inhaled daily (dry Example Salbutamol 2 puffs as needed (100mcg puffer with spacer) AND Tiotropium 18mcg (1 capsule) inhaled daily (dry powder inhaler) needed (20mcg powder inhaler) AND Fluticasone and puffer with salmeterol (eg Seretide) spacer) 2 puffs twice a day (bd) (250/25mcg puffer with spacer) OR 500/50 mcg dry powder twice a day (bd) (accuhaler) If no change in symptoms go to Step 2 Go to step 3 if No improvement after 4 weeks with both regular reliever and regular controller FEV1 less than 50% predicted 3 or more acute exacerbations in a year If no change in symptoms, exacerbation frequency, or FEV1 after 6 months think about stopping inhaled corticosteroid/laba combination General topics 345