02.01 Resp

02.01 Respiratory [PDF link]: Asthma, Chronic obstructive pulmonary disease (COPD, AECOPD, IECOPD, NIECOPD), Pulmonary tests – PEFR, FeNO, spirometry, methacholine challenge

External links

• Asthma – management toolkit from Scotland NHS

• COPD – NICE CKS recommendations for acute exacerbation

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More on asthma

• NICE guidelines NG245 (published Nov 2024 as collaborative effort between BTS, NICE and SIGN)

• Diagnostic tests – there are some quite nice algorithms to run through (Algorithm A for >16yos, Algorithm B for 5-16yos)

• Treatment algorithms – Algorithm C for tx in ≥12yo, Algorithm D in tx for 5-11yo, and Algorithm E for <5yo

• Salbutamol toxicity – tachycardia++ and lactate rise

  • (From my experience of watching asthma treatment) Esp in children, if unable to “stretch” more than 1hly 10 puffs for ≥2-3h, consider moving to next step of treatment, otherwise risk of salbutamol toxicity

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More on COPD

• NICE guidelines NG115 (last updated Jul 2019)

• One page summary on treatment guidelines for stable COPD

COPD exacerbations – management using AECOPDR2D2 tool

1. Antibiotics (if sputum yellow/green) – send off sputum culture + doxycycline 5d course

   • If not, treat as non-infective exacerbation of COPD (NIECOPD) – similar anyway just without antibiotics

2. Embolism – thrombosis Ax ± enoxaparin

3. Corticosteroids – prednisolone 30 mg 5-7d

4. Oxygen – prescribe O₂, initially with scale 2 sats (target 88-92%)

   • Do ABG – if retainer (pCO₂ ≥6 kPa), then continue scale 2. If not retainer (pCO₂ in normal range), switch to normal scale oxygen (≥94%)

   • Repeat ABG 30-60min after maximal medical therapy – if in respiratory acidosis, RR >23 → refer to on-call physio for consideration of NIV

5. Patches – offer nicotine replacement / smoking cessation service

6. Dilator drugs – ipratropium bromide 500 mcg nebulised QDS + salbutamol 2.5 mg QDS PRN

   • Pause LAMAs whilst on ipratropium

   • May require back-to-back nebs initially to stabilise

   • Beware risk of salbutamol toxicity if giving a lot (see above)

7. Risk stratify – using DECAF score [MD-Calc]

   • Takes into account dyspnoea, eosinophilia, consolidation on CXR, acidemia (pH ≤7.35), atrial fibrillation

8. Respiratory failure?

   • If in respiratory acidosis (pH <7.35, pCO₂ ≥6.5 kPA, RR >23 after 1h of maximal medical therapy), consider NIV

9. Destination: Respiratory ward (or ITU if rapidly dying)

10. Discharge bundle – resp review (COPD nurses / resp SpR/Cons)