To ensure effective use of an inhaler, it is important to follow proper technique. Asthma UK provides helpful guidance on inhaler usage for different types of inhalers.

For a pressurised metered dose inhaler, it is advised to hold your breath for 10 seconds after inhaling the medication. This allows sufficient time for the medication to reach the airways, rather than being exhaled prematurely.

To use the inhaler, breathe in slowly and steadily while pressing down on the canister in one smooth motion. If a second dose is needed, wait for about 30 seconds before repeating to avoid any interference with the delivery of the medication.

Proper Inhaler Technique for Metered-Dose Inhalers

Metered-dose inhalers are commonly used to treat respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD). However, it is important to use them correctly to ensure that the medication is delivered effectively to the lungs. Here is a step-by-step guide to proper inhaler technique:

1. Remove the cap and shake the inhaler.

2. Breathe out gently.

3. Place the mouthpiece in your mouth and begin to breathe in slowly and deeply.

4. As you start to inhale, press down on the canister to release the medication. Continue to inhale steadily and deeply.

5. Hold your breath for 10 seconds, or as long as is comfortable.

6. If a second dose is needed, wait approximately 30 seconds before repeating steps 1-5.

It is important to note that inhalers should only be used for the number of doses specified on the label. Once the inhaler is empty, a new one should be started. By following these steps, patients can ensure that they are using their inhaler correctly and receiving the full benefits of their medication.

Referral to a respiratory specialist is recommended for patients who are suspected to have occupational asthma.

Occupational Asthma: Causes and Symptoms

Occupational asthma is a type of asthma that is caused by exposure to certain chemicals in the workplace. Patients may experience worsening asthma symptoms while at work or notice an improvement in symptoms when away from work. The most common cause of occupational asthma is exposure to isocyanates, which are found in spray painting and foam moulding using adhesives. Other chemicals associated with occupational asthma include platinum salts, soldering flux resin, glutaraldehyde, flour, epoxy resins, and proteolytic enzymes.

To diagnose occupational asthma, it is recommended to measure peak expiratory flow at work and away from work. If there is a significant difference in peak expiratory flow, referral to a respiratory specialist is necessary. Treatment may include avoiding exposure to the triggering chemicals and using medications to manage asthma symptoms. It is important for employers to provide a safe working environment and for employees to report any concerns about potential exposure to harmful chemicals.

Diagnosis and Management of Community-Acquired Pneumonia

When a patient presents with signs and symptoms of a lower respiratory tract infection, it is important to differentiate between non-pneumonic and pneumonic infections. In cases of non-pneumonic infections, antibiotics should not be given unless the patient is showing signs of severity. However, if chest signs are present, a diagnosis of community-acquired pneumonia should be made, and early administration of antibiotics is crucial to prevent the development of severe illness.

While chest radiography and CRP levels are not useful in the acute setting of pneumonia, they may be indicated in certain cases. A chest x-ray may be necessary if treatment response is unsatisfactory or in smokers during the convalescent period. CRP levels can be helpful in making a decision about antibiotic treatment for individuals with symptoms of LRTI but no signs.

According to NICE guidelines, antibiotic therapy should not be routinely offered if the CRP concentration is less than 20 mg/litre. A delayed antibiotic prescription should be considered if the CRP concentration is between 20 mg/litre and 100 mg/litre, and antibiotic therapy should be offered if the CRP concentration is greater than 100 mg/litre. By following these guidelines, healthcare providers can effectively diagnose and manage community-acquired pneumonia.

If a patient with COPD is still experiencing breathlessness despite using SABA/SAMA and doesn’t exhibit any features that suggest responsiveness to steroids or asthma, the recommended course of action according to the 2018 NICE guidelines is to introduce a combination of a long-acting beta2-agonist (LABA) and a long-acting muscarinic antagonist (LAMA).

The National Institute for Health and Care Excellence (NICE) updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. The guidelines recommend general management strategies such as smoking cessation advice, annual influenza vaccination, and one-off pneumococcal vaccination. Pulmonary rehabilitation is also recommended for patients who view themselves as functionally disabled by COPD.

Bronchodilator therapy is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators. The next step is determined by whether the patient has asthmatic features or features suggesting steroid responsiveness. NICE suggests several criteria to determine this, including a previous diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time, and substantial diurnal variation in peak expiratory flow.

If the patient doesn’t have asthmatic features or features suggesting steroid responsiveness, a long-acting beta2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) should be added. If the patient is already taking a short-acting muscarinic antagonist (SAMA), it should be discontinued and switched to a short-acting beta2-agonist (SABA). If the patient has asthmatic features or features suggesting steroid responsiveness, a LABA and inhaled corticosteroid (ICS) should be added. If the patient remains breathless or has exacerbations, triple therapy (LAMA + LABA + ICS) should be offered.

NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients who have optimised standard treatments and continue to have exacerbations. 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, and loud P2. Loop diuretics should be used for oedema, and long-term oxygen therapy should be considered. Smoking cessation, long-term oxygen therapy in eligible patients, and lung volume reduction surgery in selected patients may improve survival in patients with stable COPD. NICE doesn’t recommend the use of ACE-inhibitors, calcium channel blockers, or alpha blockers

Antibiotic Prophylaxis for Pertussis

When managing a suspected or confirmed case of pertussis, it is important to offer prophylactic antibiotics to reduce transmission if the case presents within 21 days of onset and a vulnerable contact is present in the household. All household contacts, regardless of age or immunisation status, should be offered antibiotics. Antibiotics may not alter the clinical course of the illness, but they can eliminate the organism from the respiratory tract, reducing person-to-person transmission. Vulnerable contacts include newborn infants, unimmunised or partially immunised infants or children up to 10 years, pregnant women, healthcare workers, immunocompromised individuals, and those with chronic illnesses. The maternal pertussis vaccine programme has been highly effective in preventing disease for infants less than 2 months of age. Therefore, the definition of vulnerable infants has been amended to include unimmunised infants born ≤32 weeks, unimmunised infants born >32 weeks whose mothers did not receive maternal pertussis vaccine after 16 weeks and at least 2 weeks before delivery, and infants aged 2 months or over who are unimmunised or partially immunised. It is important for GPs to understand and implement national guidelines for respiratory problems, including the management of pertussis.

BTS Guidance on Low Dose ICS and LABA Treatment

According to the 2016 BTS guidance, if a patient taking a low dose ICS doesn’t respond to the addition of a LABA, the LABA should be discontinued. Instead, healthcare providers should consider increasing the dose of ICS. It is important to note that options suggesting only an increase in ICS dose without stopping the LABA are incorrect.

This guidance emphasizes the importance of individualized treatment plans for patients with respiratory conditions. By carefully monitoring patient response to medication and adjusting treatment as needed, healthcare providers can help improve patient outcomes and quality of life. Proper medication management can also help reduce the risk of adverse effects and complications associated with respiratory conditions.

The patient’s peak flow has dropped to 40% of normal, indicating a severe exacerbation of asthma. According to NICE guidelines, admission is recommended if severe attack features persist after a bronchodilator trial. As the peak flow has not improved, hospitalization is necessary.

Administering another nebulizer is not advisable as the patient requires close monitoring and may need multiple nebulizers. Increasing the inhaled steroid dose and sending the patient home is also not recommended as it may lead to adverse outcomes.

Prescribing 40 mg prednisolone for 5 to 7 days is suitable for patients who can be treated at home, but not for this patient with severe asthma requiring inpatient assessment and management.

Antibiotics are only prescribed if the patient has no severe or life-threatening asthma features and shows signs of infection. As the patient’s asthma has not improved despite initial treatment, sending them home with antibiotics is not appropriate.

Understanding Acute Asthma: Symptoms and Severity

Acute asthma is a condition that is typically observed in individuals who have a history of asthma. It is characterized by worsening dyspnea, wheezing, and coughing that doesn’t respond to salbutamol. Acute asthma attacks may be triggered by respiratory tract infections. Patients with acute severe asthma are classified into three categories: moderate, severe, or life-threatening.

Moderate acute asthma is characterized by a peak expiratory flow rate (PEFR) of 50-75% of the best or predicted value, normal speech, a respiratory rate (RR) of less than 25 breaths per minute, and a pulse rate of less than 110 beats per minute. Severe acute asthma is characterized by a PEFR of 33-50% of the best or predicted value, inability to complete sentences, an RR of more than 25 breaths per minute, and a pulse rate of more than 110 beats per minute. Life-threatening acute asthma is characterized by a PEFR of less than 33% of the best or predicted value, oxygen saturation levels of less than 92%, a silent chest, cyanosis or feeble respiratory effort, bradycardia, dysrhythmia or hypotension, and exhaustion, confusion, or coma.

It is important to note that a normal pCO2 in an acute asthma attack indicates exhaustion and should be classified as life-threatening. Understanding the symptoms and severity of acute asthma can help healthcare professionals provide appropriate treatment and management for patients experiencing an acute asthma attack.

For this patient with pre-existing asthma, an immediate or delayed antibiotic prescription should be considered due to the higher risk of complications. The first-line antibiotic for acute bronchitis is oral doxycycline, unless the patient is pregnant or a child. As this patient has normal observations and no focal respiratory signs, same-day admission is not necessary, and treatment can be provided in the community without intravenous antibiotics or oxygen.

Reassuring the patient and prescribing carbocisteine is not recommended as mucolytics are not effective for managing acute cough caused by acute bronchitis. Administering IM amoxicillin is also not appropriate as doxycycline is the recommended first-choice antibiotic for this condition, and IM is an invasive route that is unnecessary for this patient who can swallow.

Understanding Acute Bronchitis

Acute bronchitis is a chest infection that is typically self-limiting and caused by inflammation of the trachea and major bronchi. This results in swollen airways and the production of sputum. The condition usually resolves within three weeks, but some patients may experience a cough for longer. Viral infections are the leading cause of acute bronchitis, with most cases occurring in the autumn or winter.

Symptoms of acute bronchitis include a sudden onset of cough, sore throat, runny nose, and wheezing. While most patients have a normal chest examination, some may experience a low-grade fever or wheezing. It is important to differentiate acute bronchitis from pneumonia, which may present with sputum, wheezing, and breathlessness.

Acute bronchitis is typically diagnosed based on clinical presentation, but CRP testing may be used to guide antibiotic therapy. Management of acute bronchitis includes analgesia, good fluid intake, and consideration of antibiotic therapy for patients who are systemically unwell, have pre-existing co-morbidities, or have a CRP level indicating the need for antibiotics. Doxycycline is the first-line antibiotic recommended by NICE Clinical Knowledge Summaries/BNF, but it cannot be used in children or pregnant women. Alternatives include amoxicillin.

Confirming Exercise-Induced Asthma

This patient is showing signs of exercise-induced asthma. To confirm this diagnosis, the most appropriate investigation would be spirometry before and after exercise. This is because exercise is the trigger for his asthma symptoms, and spirometry can measure any changes in lung function before and after physical activity. By comparing the results, doctors can determine if the patient has exercise-induced asthma and develop an appropriate treatment plan. It is important to confirm the diagnosis to ensure the patient receives the correct treatment and can continue to participate in physical activity safely.

Guidelines for Safe Air Travel

When it comes to air travel, there are certain guidelines that need to be followed to ensure a safe journey. One of the most important factors is the ability to walk 50 meters on level ground or climb one flight of stairs without experiencing shortness of breath. This is usually indicative of being able to fly without any issues.

Another important consideration is the hypoxic challenge test, which mimics the conditions on the plane. If the PaO2 level is less than 55 mmHg, it is not recommended to fly. At rest, the oxygen saturation level should be 95% or higher.

If you have had a pneumothorax, it is recommended to wait for at least two weeks before considering air travel. This is especially important if the pneumothorax has been conservatively managed. Only after there is evidence that the pneumothorax has resolved should you consider flying.

By following these guidelines, you can ensure a safe and comfortable air travel experience.

Symptoms of Sleep Apnoea

Sleep apnoea is a condition characterized by hypersomnolence or excessive sleepiness. Apart from this, there are other common symptoms that may be experienced by individuals with this condition. These include apparent personality changes, witnessed apnoeas, and true nocturnal polyuria. Reduced libido is a less common symptom. Sleep apnoea may also be associated with other medical conditions such as acromegaly, myxoedema, obesity, and micrognathia/retrognathia.

Managing Chronic Asthma in Adults

When managing chronic asthma in adults, it is important to consider the patient’s current treatment plan and symptoms. In this scenario, the patient is already taking a combination inhaler and is experiencing suboptimal control of her asthma. It is important to note that this is not an acute attack and the children’s guidelines do not apply. Antibiotics are not recommended as the symptoms are not consistent with an infective exacerbation. Increasing the usage of salbutamol is also not recommended as the patient needs better overall control of her symptoms. Instead, the dose of the inhaled corticosteroid should be increased, which is in line with the next step in the treatment of asthma in adults according to the British Thoracic Society guidelines. It is important for healthcare professionals to be familiar with both SIGN and NICE guidance and be able to compare and contrast their advice.

Legionnaires Disease: Symptoms, Causes, and Treatment

Legionnaires disease is a severe form of pneumonia caused by Legionella pneumophila, a Gram-negative bacillus. The disease is usually acquired from infected water supplies in cooling towers and air conditioning units. Although it is difficult to acquire, with a low attack rate of 5%, elderly individuals, smokers, and those with pre-existing chest disease are at a higher risk of developing the condition.

The symptoms of Legionnaires disease are similar to those of the flu, including high fever (usually above 40°C), myalgias, and confusion. Treatment involves the use of ciprofloxacin or macrolides, and recovery is usually complete. However, if left untreated, the mortality rate can be as high as 15-20%.

A cough that produces sputum, symptoms only after an upper respiratory tract infection, and peripheral pins and needles are all factors that make a diagnosis of asthma less likely.

When considering asthma, it is important to take into account recurrent episodes of symptoms that may be triggered by viral infections, exposure to allergens, NSAIDs/beta-blockers, and exacerbated by exercise, cold air, and emotions/laughter in children. It is also important to note recorded observations of wheezing, which should be documented by a clinician due to varying use of language. Symptom variability is another factor to consider, as asthma is typically worse at night or early in the morning. A personal history of atopy, such as eczema or allergic rhinitis, should also be taken into account. Additionally, the absence of symptoms of alternative diagnoses, such as COPD, dysfunctional breathing, or obesity, should be considered. Finally, a historical record of variable peak flows or FEV1 can also be helpful in diagnosing asthma.

Asthma diagnosis has been updated by NICE guidelines in 2017, which emphasizes the use of objective tests rather than subjective/clinical judgments. The guidance recommends the use of fractional exhaled nitric oxide (FeNO) test, which measures the level of nitric oxide produced by inflammatory cells, particularly eosinophils. Other established objective tests such as spirometry and peak flow variability are still important. All patients aged five and above should have objective tests to confirm the diagnosis. For patients aged 17 and above, spirometry with a bronchodilator reversibility (BDR) test and FeNO test should be performed. For children aged 5-16, spirometry with a BDR test and FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative BDR test. For patients under five years old, diagnosis should be made based on clinical judgment. The specific points about the tests include a FeNO level of >= 40 ppb for adults and >= 35 ppb for children considered positive, and a FEV1/FVC ratio less than 70% or below the lower limit of normal considered obstructive for spirometry. A positive reversibility test is indicated by an improvement in FEV1 of 12% or more and an increase in volume of 200 ml or more for adults, and an improvement in FEV1 of 12% or more for children.

Most Likely Cause of Bronchospasm in a Patient with Asthma

Examiners often use terms like most likely to test a candidate’s ability to reason. In primary care, where there may be multiple causes, prioritizing treatment options is crucial. In a patient with a history of asthma experiencing bronchospasm, propranolol is the most likely cause, and its use should be avoided. While bronchospasm is reported in aspirin-sensitive patients and paradoxical bronchospasm in some patients treated with salmeterol, beta-blockers like propranolol can precipitate bronchospasm and should be avoided in patients with asthma.

According to the British National Formulary, beta-blockers should be avoided in patients with a history of asthma. However, in some cases, a cardioselective beta-blocker may be necessary for a co-existing condition like heart failure or following a myocardial infarction. In such situations, a specialist should initiate treatment with a low dose of a cardioselective beta-blocker like atenolol, bisoprolol fumarate, metoprolol tartrate, nebivolol, or acebutolol. These drugs have a lesser effect on airways resistance but are not free of this side-effect.

ACE inhibitors like ramipril are inhibitors of the metabolism of bradykinin and can cause cough. Bronchospasm is also reported as an adverse event associated with ACE inhibition, although it is very rare.

If a patient with COPD continues to smoke, it is not advisable to provide them with azithromycin prophylaxis. Instead, they should be offered smoking cessation. The use of high-dose inhaled corticosteroids is no longer recommended due to the increased risk of infections such as pneumonia. Long-term oral corticosteroids should only be used at low doses and on the advice of the respiratory team. Beta-carotene supplements are not recommended for the management of COPD due to limited evidence of their effectiveness.

The National Institute for Health and Care Excellence (NICE) updated its guidelines on the management of chronic obstructive pulmonary disease (COPD) in 2018. The guidelines recommend general management strategies such as smoking cessation advice, annual influenza vaccination, and one-off pneumococcal vaccination. Pulmonary rehabilitation is also recommended for patients who view themselves as functionally disabled by COPD.

Bronchodilator therapy is the first-line treatment for patients who remain breathless or have exacerbations despite using short-acting bronchodilators. The next step is determined by whether the patient has asthmatic features or features suggesting steroid responsiveness. NICE suggests several criteria to determine this, including a previous diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time, and substantial diurnal variation in peak expiratory flow.

If the patient doesn’t have asthmatic features or features suggesting steroid responsiveness, a long-acting beta2-agonist (LABA) and long-acting muscarinic antagonist (LAMA) should be added. If the patient is already taking a short-acting muscarinic antagonist (SAMA), it should be discontinued and switched to a short-acting beta2-agonist (SABA). If the patient has asthmatic features or features suggesting steroid responsiveness, a LABA and inhaled corticosteroid (ICS) should be added. If the patient remains breathless or has exacerbations, triple therapy (LAMA + LABA + ICS) should be offered.

NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy. Azithromycin prophylaxis is recommended in select patients who have optimised standard treatments and continue to have exacerbations. 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, and loud P2. Loop diuretics should be used for oedema, and long-term oxygen therapy should be considered. Smoking cessation, long-term oxygen therapy in eligible patients, and lung volume reduction surgery in selected patients may improve survival in patients with stable COPD. NICE doesn’t recommend the use of ACE-inhibitors, calcium channel blockers, or alpha blockers

According to NICE guidelines, the diagnosis of asthma in adults should include bronchodilator reversibility testing, while children aged 5-16 should also undergo this test if feasible. Fractional exhaled nitrous oxide (FeNO) testing is not recommended as the initial step for diagnosing asthma in children, but may be considered in cases of diagnostic uncertainty where spirometry is normal or obstructive with negative bronchodilator reversibility. Methacholine bronchial challenge is not used in children and should only be considered in adults if other tests have not provided a clear diagnosis. Peak flow readings may be offered in children aged 5-16 with normal or obstructive spirometry and positive FeNO. While symptoms may indicate asthma, further objective testing is necessary, starting with spirometry and bronchodilator reversibility testing in children aged 5-16. A diagnosis of asthma in this age group may be made with positive bronchodilator reversibility or positive FeNO with positive peak flow variability.

Asthma diagnosis has been updated by NICE guidelines in 2017, which emphasizes the use of objective tests rather than subjective/clinical judgments. The guidance recommends the use of fractional exhaled nitric oxide (FeNO) test, which measures the level of nitric oxide produced by inflammatory cells, particularly eosinophils. Other established objective tests such as spirometry and peak flow variability are still important. All patients aged five and above should have objective tests to confirm the diagnosis. For patients aged 17 and above, spirometry with a bronchodilator reversibility (BDR) test and FeNO test should be performed. For children aged 5-16, spirometry with a BDR test and FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative BDR test. For patients under five years old, diagnosis should be made based on clinical judgment. The specific points about the tests include a FeNO level of >= 40 ppb for adults and >= 35 ppb for children considered positive, and a FEV1/FVC ratio less than 70% or below the lower limit of normal considered obstructive for spirometry. A positive reversibility test is indicated by an improvement in FEV1 of 12% or more and an increase in volume of 200 ml or more for adults, and an improvement in FEV1 of 12% or more for children.

NICE Guidelines for Referral of Suspected Lung Cancer Patients

The National Institute for Health and Care Excellence (NICE) has issued guidelines for the recognition and referral of suspected lung cancer patients. According to the guidelines, patients aged 40 and over with unexplained haemoptysis should be referred urgently for an appointment within two weeks, even if their chest x-ray is normal. Additionally, patients with two or more unexplained symptoms such as cough, fatigue, shortness of breath, chest pain, weight loss, or appetite loss, or those with persistent or recurrent chest infection, finger clubbing, supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, chest signs consistent with lung cancer, or thrombocytosis should be offered an urgent chest x-ray within two weeks to assess for lung cancer. These guidelines aim to ensure timely diagnosis and treatment of lung cancer, which is crucial for improving patient outcomes.

Diagnostic Tests for COPD

In addition to spirometry, it is recommended that patients with COPD undergo several diagnostic tests at the time of diagnosis. These tests include a chest x-ray to rule out other potential lung pathologies, a full blood count to assess for anemia or polycythemia, and a calculation of body mass index.

Depending on the patient’s history and examination findings, other diagnostic tests may be necessary. For example, if asthma is suspected, serial peak flow measurements may be indicated. If signs or symptoms of cor pulmonale are present, an ECG or echocardiogram may be necessary. By conducting these diagnostic tests, healthcare professionals can accurately diagnose and manage COPD in their patients.

Treating Infective Exacerbation of Bronchiectasis

When managing a suspected infective exacerbation of bronchiectasis, it is crucial to obtain a sputum culture before initiating antibiotics. However, treatment should not be delayed until the culture results are available. It is also recommended to administer a more extended course of antibiotics than what is typically prescribed for a lower respiratory tract infection.

NICE provides specific guidance on the selection and duration of antibiotics based on the identified organism. Additionally, hospital admission should be considered if there are indications of a more severe illness, such as cyanosis, confusion, respiratory rate exceeding 25 breaths per minute, significant breathlessness, or a temperature of 38°C or higher.

As an ex-smoker, this woman is experiencing a gradual improvement in her consolidation, but she still has a persistent cough. It is recommended that she be referred for further evaluation under the 2 week wait rule to rule out the possibility of lung cancer.

Referral Guidelines for Lung Cancer

Lung cancer is a serious condition that requires prompt diagnosis and treatment. The 2015 NICE cancer referral guidelines provide clear advice on when to refer patients for suspected lung cancer. According to these guidelines, patients should be referred using a suspected cancer pathway referral for an appointment within 2 weeks if they have chest x-ray findings that suggest lung cancer or are aged 40 and over with unexplained haemoptysis.

For patients aged 40 and over who have 2 or more unexplained symptoms such as cough, fatigue, shortness of breath, chest pain, weight loss, or appetite loss, an urgent chest x-ray should be offered within 2 weeks to assess for lung cancer. This recommendation also applies to patients who have ever smoked and have 1 or more of these unexplained symptoms.

In addition, patients aged 40 and over with persistent or recurrent chest infection, finger clubbing, supraclavicular lymphadenopathy or persistent cervical lymphadenopathy, chest signs consistent with lung cancer, or thrombocytosis should be considered for an urgent chest x-ray within 2 weeks to assess for lung cancer.

Overall, these guidelines provide clear and specific recommendations for healthcare professionals to identify and refer patients with suspected lung cancer for prompt diagnosis and treatment.

A patient with COPD who is persistently breathless despite regular SABA use needs inhaled treatment added to improve symptom control and prevent exacerbations. The options for add-on inhaled treatment are a LABA+ICS combination inhaler or a LAMA. Adding a regular ICS on its own has no role in the COPD treatment ladder. A regular SAMA can be used instead of a SABA but is not an option for add-in treatment. Adding a LABA can be used in some patients with COPD but is not the priority here. A LABA is usually indicated in patients with an FEV1 of ≥ to 50%. NICE CKS COPD guidelines recommend inhaled bronchodilators as the first-line drugs for the treatment of COPD.

For reference:
SABA – short acting beta agonist
LABA – long acting beta agonist
SAMA – short acting muscarinic antagonist
LAMA – long acting muscarinic antagonist
ICS – inhaled corticosteroid.

It is recommended to provide daily vitamin D supplements to all patients who are confined to their homes.

Vitamin D supplementation has been a topic of interest for several years, and recent releases have provided some clarity on the matter. The Chief Medical Officer’s 2012 letter and the National Osteoporosis Society’s 2013 UK Vitamin D guideline recommend that certain groups take vitamin D supplements. These groups include pregnant and breastfeeding women, children aged 6 months to 5 years, adults over 65 years, and individuals who are not exposed to much sun, such as housebound patients.

Testing for vitamin D deficiency is not necessary for most people. The NOS guidelines suggest that testing may be appropriate for patients with bone diseases that may be improved with vitamin D treatment, such as osteomalacia or Paget’s disease, and for patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency, such as bone pain. However, patients with osteoporosis should always be given calcium/vitamin D supplements, and individuals at higher risk of vitamin D deficiency should be treated regardless of testing. Overall, vitamin D supplementation is recommended for certain groups, while testing for deficiency is only necessary in specific situations.

Occupational Asthma: Causes and Symptoms

Occupational asthma is a type of asthma that is caused by exposure to certain chemicals in the workplace. Patients may experience worsening asthma symptoms while at work or notice an improvement in symptoms when away from work. The most common cause of occupational asthma is exposure to isocyanates, which are found in spray painting and foam moulding using adhesives. Other chemicals associated with occupational asthma include platinum salts, soldering flux resin, glutaraldehyde, flour, epoxy resins, and proteolytic enzymes.

To diagnose occupational asthma, it is recommended to measure peak expiratory flow at work and away from work. If there is a significant difference in peak expiratory flow, referral to a respiratory specialist is necessary. Treatment may include avoiding exposure to the triggering chemicals and using medications to manage asthma symptoms. It is important for employers to provide a safe working environment and for employees to report any concerns about potential exposure to harmful chemicals.

NICE Guidance on Hospital Admission for Acute Asthma Exacerbations

When it comes to acute asthma exacerbations, it is important to know when hospital admission is necessary. According to NICE guidance, a life-threatening asthma exacerbation is an obvious reason for hospitalization. However, there are cases where a severe or even moderate attack may require hospital monitoring and treatment.

NICE advises clinicians to consider hospital admission for patients with severe asthma attacks that persist after initial bronchodilator treatment. This also applies to patients with moderate asthma exacerbations who have had a previous near-fatal asthma attack.

For example, if a patient is experiencing a moderate exacerbation that may be developing into an acute severe exacerbation, hospital referral should be considered. This is evidenced by a PEFR of 50%, which is the lower end of a moderate attack, along with a potentially rising respiratory rate and heart rate. Even if the patient is not bordering on an acute severe exacerbation, a referral should be considered if they have previously had a life-threatening attack and have not responded adequately to nebulizers.

While amoxicillin and prednisolone may be options, it is important to review the patient earlier than 48 hours if a referral to the hospital is not felt to be appropriate. Intramuscular methylprednisolone is considered as an alternative to oral prednisolone if the patient cannot swallow the medication. It is not recommended to increase the inhaled corticosteroid dose during an exacerbation as an alternative to oral corticosteroids.

In summary, understanding NICE guidance on hospital admission for acute asthma exacerbations is crucial for clinicians to provide appropriate care for their patients.

The National Review of Asthma Deaths (NRAD) found that only 23% of the 195 people who died from asthma had personal asthma action plans, and 43% had not had an asthma review in general practice in the year before their death. The report identified factors that could have avoided death in relation to the implementation of asthma guidelines by health professionals, including lack of specific asthma expertise and knowledge of UK asthma guidelines. The report recommended referral to secondary care for patients requiring BTS stepwise treatment 4 or 5, assessment of inhaler technique at annual review, monitoring of non-adherence to inhaled corticosteroids, and the use of combination inhalers.

It is important to note that a patient’s decision to continue smoking should not be a reason to deny them treatment for their asthma. As a healthcare professional, it is your responsibility to bring this to the attention of the doctor involved and discuss the situation with them. This will also give the doctor an opportunity to explain their perspective on the matter. It is not recommended to bring this up during a practice meeting as it may come across as confrontational.

Simply changing the patient’s inhaler treatment will not address the issue of treatment being withheld. It is not acceptable to refuse to adjust their inhalers until they agree to seek smoking cessation treatment, as this can be seen as blackmail. Additionally, removing the patient from the practice list for not quitting smoking is not an appropriate course of action.

Management of Moderate COPD

Patients with an FEV1/FVC ratio <0.70 and an FEV1 of 50-79% predicted are classified as having stage 2 moderate COPD. The initial management for this condition is a short acting beta agonist or a short acting muscarinic antagonist. However, if symptoms persist, a long acting beta agonist or a long acting muscarinic antagonist may be used. Inhaled corticosteroids alone are not recommended, but may be used in combination with a long acting beta agonist as a second line treatment for patients with FEV1 <50% and asthmatic features. Maintenance use of oral corticosteroid therapy is not recommended, and antitussive therapy should also be avoided.

According to NICE guidelines, oral antibiotics should only be given to patients with acute exacerbation of COPD if they have purulent sputum or clinical signs of pneumonia. Since the patient in question doesn’t exhibit any signs of bacterial pneumonia, such as a change in cough or clinical signs of consolidation, NICE recommends a trial of steroids with increased inhaler use as the first line of treatment.

Based on the information provided, the patient’s observations are reasonable, and hospital admission is not necessary. However, she should be monitored for any deterioration, and a tool like CURB65 can be used to guide decisions regarding hospital admission.

If there are specific markers of infection clinically, such as focal consolidation or purulent sputum, a combination of amoxicillin and prednisolone may be indicated. It is important for patients with COPD to continue using their inhalers, especially when they are unwell.

Acute exacerbations of COPD are a common reason for hospitalization in developed countries. The most common causes of these exacerbations are bacterial infections, such as Haemophilus influenza, Streptococcus pneumoniae, and Moraxella catarrhalis, as well as respiratory viruses, with human rhinovirus being the most important pathogen. Symptoms of an exacerbation include an increase in dyspnea, cough, and wheezing, as well as hypoxia and acute confusion in some cases.

NICE guidelines recommend increasing the frequency of bronchodilator use and giving prednisolone for five days. Antibiotics should only be given if sputum is purulent or there are clinical signs of pneumonia. Admission to the hospital is recommended for patients with severe breathlessness, acute confusion or impaired consciousness, cyanosis, oxygen saturation less than 90%, social reasons, or significant comorbidity.

For severe exacerbations requiring secondary care, oxygen therapy should be used with an initial saturation target of 88-92%. Nebulized bronchodilators, such as beta adrenergic agonists and muscarinic antagonists, should also be used. Steroid therapy and IV theophylline may be considered, and non-invasive ventilation may be used for patients with type 2 respiratory failure. BiPAP is typically used with initial settings of EPAP at 4-5 cm H2O and IPAP at 10-15 cm H2O.

According to NICE guidelines, oral antibiotics should only be prescribed in cases of acute exacerbation of COPD if there is purulent sputum or clinical signs of pneumonia. As this patient doesn’t exhibit these symptoms, prescribing oral antibiotics is not recommended.

Instead, increasing the frequency of inhaled bronchodilators is a suitable step in managing this patient’s acute exacerbation of COPD. The patient’s mild wheeze should improve with this treatment.

NICE recommends a review in 6 weeks if there is no rapid or significant worsening of symptoms. However, if symptoms worsen rapidly or significantly, the patient should be reviewed sooner by the appropriate healthcare provider.

Prescribing oral steroids is appropriate for managing this patient’s acute exacerbation of COPD as it can reduce inflammation and improve symptoms.

It is also appropriate to discuss smoking cessation with the patient, as they are still smoking. However, it should be documented if the patient is not interested in considering smoking cessation. Any opportunity for smoking cessation advice should be utilized.

Acute exacerbations of COPD are a common reason for hospitalization in developed countries. The most common causes of these exacerbations are bacterial infections, such as Haemophilus influenza, Streptococcus pneumoniae, and Moraxella catarrhalis, as well as respiratory viruses, with human rhinovirus being the most important pathogen. Symptoms of an exacerbation include an increase in dyspnea, cough, and wheezing, as well as hypoxia and acute confusion in some cases.

NICE guidelines recommend increasing the frequency of bronchodilator use and giving prednisolone for five days. Antibiotics should only be given if sputum is purulent or there are clinical signs of pneumonia. Admission to the hospital is recommended for patients with severe breathlessness, acute confusion or impaired consciousness, cyanosis, oxygen saturation less than 90%, social reasons, or significant comorbidity.

For severe exacerbations requiring secondary care, oxygen therapy should be used with an initial saturation target of 88-92%. Nebulized bronchodilators, such as beta adrenergic agonists and muscarinic antagonists, should also be used. Steroid therapy and IV theophylline may be considered, and non-invasive ventilation may be used for patients with type 2 respiratory failure. BiPAP is typically used with initial settings of EPAP at 4-5 cm H2O and IPAP at 10-15 cm H2O.