Update on management of respiratory symptoms. Dr Farid Bazari Consultant Respiratory Physician Kingston Hospital NHS FT

Transcription

1 Update on management of respiratory symptoms Dr Farid Bazari Consultant Respiratory Physician Kingston Hospital NHS FT

2 Topics The common respiratory symptoms Cough: causes, diagnosis and therapy Update on management of asthma

3 Cough Frequency Causes Investigations Treatments Outcome Diagnostic algorithm

4 Aetiology of cough: defence mechanism or symptom? Involuntary cough controlled by vagal afferent nerves Higher cortical control of reflex Cortical control can lead to cough inhibition or voluntary cough

5 Acute cough Commonest presentation to primary care Defined as cough < 3 weeks Often assoc with viral URTI Most frequent symptom of AE airways disease Cost to UK economy: 979 million!

6 Acute cough - recommendation Refer if haemoptysis, weight loss, prominent systemic symptoms Consider inhaled foreign body Risk assessment for lung cancer If URTI assoc self limiting, no role for pharmacological therapy

7 Eating and laughing

8 Chronic cough Lasts > 8 weeks Affects 10-20% of adult population! Excess in females/ obesity Decrement in QOL similar to severe COPD If sputum always indicates lung pathology Heightened cough reflex often present

9 Chronic cough Detailed history Include meds, occupation, pets Assess upper, middle and lower airway Always perform Chest x-ray Always perform Spirometry

10 Aetiology Upper airways cough syndrome Asthma Bronchiectasis GORD Iatrogenic medications Lung cancer Lung fibrosis

11 Chronic cough Most cases of troublesome cough reflect the presence of an aggravant (asthma, drugs, environmental, gastro-oesophageal reflux, upper airway pathology) in a susceptible individual.

12 Upper airways cough syndrome Rhinitis/sinusitis Possible atopy Empirical nasal steroid Further Ix

13 Asthma related cough Associated Airways symptoms Cough variant asthma Trial of ICS and SABA Further Ix Spirometry Peak flow diary

14 GORD related cough Positional or reflux symptoms Trial of PPI appropriate HH/ obesity Consider sleep apnoea Further Ix 24 hour ph manometry Barium swallow

15 Post-infectious cough Temporally follows, within 3 weeks Due to mucous impaction, AHR, UACS Consider Pertussis If wheezy use SABA and ICS

16 Other causes - neoplastic Lung cancer Risk factors: smoking, COPD, >40 Signs or symptoms: Clubbing, Stridor, Haemoptysis Obtain early Chest x-ray < 3 weeks Benefit of early diagnosis Future screening program

17 Treatment Inhaled steroids if airways PPI if GORD suspected Nasal steroid If no clear precipitant or cause appropriate referral

18 Chronic cough

19 When to refer? New chronic cough Acute cough with red flag symptoms If high risk for malignancy If diagnostic uncertainty If additional symptoms

20 Asthma Frequency Diagnosis Treatment goals Difficult asthma management

21 Asthma incidence 5.2 million sufferers in UK 55% are under-controlled 70,000 hospitalisation, up to 70% avoidable 1300 asthma deaths per annum

22 Asthma, diagnosis Cough, wheeze, chest tightness Allergen, cold air, exercise induced NSAID, Aspirin, beta-blocker induced Atopy Fhx

23 Diagnostic Criteria Characteristic symptoms Obstructive Spirometry Peak Flow (PEF) variability Bronchodilator reversibility

24 Spirometric reversibility

25 Peak flow variability

26 Peak flow diary for occupational asthma

27 Treatment Treatment goal Treatment ladder Treatment options

28 What is asthma control? Minimal daytime asthma symptoms No limitations on activities No nocturnal symptoms or awakenings Minimal need for reliever or rescue therapy Normal lung function (FEV 1 or PEF) No exacerbations

29 Airways remodelling Undertreated chronic asthma leads to airways remodelling Fixed airways disease without reversibility Early diagnosis and adequate treatment reduces risk

30 Adults

31 Treatment failure Non-adherence Poor technique Persistent exacerbating factor The nose GORD/ aspiration Wrong or confounding diagnoses Severe asthma

32 Treatment failure Always check inhaler technique 70% patients inadequate technique Ensure inhaler technique review Always use spacer

33 Additional diagnoses Cardiac disease Upper airways Vocal cord dysfunction Bronchiectasis Chronic infection Aspiration Obstructive sleep apnoea

34 Additional steps Further investigation CT chest Bronchial provocation test Sputum microbiology FeNO Provocation bronchoscopy

35 Bronchial provocation: AHR

36 Provocation bronchoscopy: VCD

37 Asthma treatment failure: HRCT

38 Asthma treatment failure: alt diagnosis

39 When to refer If on step 3 and symptomatic If diagnostic uncertainty for investigation If more than 2 exacerbations Multiple rescue medication use If A&E or hospital attendance For additional therapies

40 Summary Cough is a common respiratory symptom Majority of cough should resolve within 3 weeks If persistent cough > 3 weeks, obtain early chest x-ray, consider referral

41 Summary Asthma is common and rising in incidence Persistent symptomatic asthma should be stepped up or referred for management

42 Thank you for listening. Queries: