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FM16 Family Medicine
Common Presenting Problems
Toronto Notes 2019
8 6 4 2 0
Obstructive
FEV 1 VC
Normal Restrictive
Management
• patienteducation:emphasizeprevalence,goodrecoveryrateofanxietyconditions
• lifestyleadvice:exercise,decreasecaffeineandalcoholintake
• psychological:CBT,includingexposuretherapy,relaxationtechniques,andmindfulnessstrategies • pharmacotherapy:seePsychiatry,PS42
• provideself-helpmaterials,connectwithcommunityresources(e.g.supportgroups),andprovide
support to family and caregivers
Asthma/COPD
• seeRespirology,R7
Definition
• asthma
■ chronic, reversible airway inflammation characterized by periodic attacks of wheezing, SOB, chest
tightness, and coughing
■ airways are hyper-responsive to triggers/antigens leading to acute obstructive symptoms by
bronchoconstriction, mucous plugs and increased inflammation
■ cannot be diagnosed at first presentation; is called reactive airway disease until recurrent
presentations
■ PFTs can be done starting at age 6 or when child is able to follow testing instructions ■ peak flow meters are useful in the office and at home for monitoring
• chronicobstructivepulmonarydisease(COPD)
■ group of chronic, progressive, non-reversible lung diseases characterized by limited airflow with
variable degrees of air sac enlargement and lung tissue destruction ■ emphysema and chronic bronchitis are the most common forms
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LUNG VOLUME (L)
Figure 8. Expiratory flow volume curves
(obstructive, normal, and restrictive disease) See Respirology, R2 Adapted from: Weinberger SE. Prin- ciples of pulmonary medicine, 5th ed. With permission from Elsevier. ©2008
Signs of Poorly Controlled Asthma
• β2-agonistuse>4x/wk
• Asthma-related absence from work/school • Exercise induced asthma
• Night-time symptoms >1x/wk
What Colour is Your Inhaler?
Name
β2-Agonists salbutamol – Ventolin® salmeterol – Serevent® terbutaline – Bricanyl®
ICS
fluticasone – Flovent® budesonide – Pulmicort®
Body/Cap Colour
light blue/navy teal/light teal blue/white
orange/peach white/brown
Table 9. Differentiating COPD from Asthma
Combined Long-Acting β2-Agonist + ICS
Age of Onset
Role of Smoking
Reversibility of Airflow Obstruction
Evolution
History of Allergy Precipitators
Symptoms/Signs
Diffusion Capacity Hypoxemia
Spirometry Chest X-Ray
Management
COPD
Usually in 6th decade
>10 pack yr
Airflow obstruction is chronic and persistent
Slow, progressive worsening (with periodic exacerbations)
Infrequent
Environmental irritants (air pollution), cigarette
smoking, α-1 antitrypsin deficiency, viral infection, occupational exposure (firefighters, dusty jobs)
Chronic cough, sputum, and/or dyspnea
Decreased (more so in pure emphysema) Chronic in advanced stages
May have improvement with bronchodilators but not universally seen
Often normal
Increased bronchial markings (chronic bronchitis) and chronic hyperinflation (emphysema) often co- exist, bullae
Mild
Step 1: SABA prn (salbutamol)
Step 2: SABA prn + LAAC (i.e. tiotropium)
or + LABA (e.g. salmeterol)
Moderate
Step 3: SABA prn + LAAC + low-dose combined ICS/LABA; consider inhaled vs. oral steroids Severe
Step 4: ± theophylline
Pneumococcal vaccination, annual influenza immunization
Asthma
Any age (but 50% of cases are diagnosed in children age <10)
Not causal, known trigger
Airflow obstruction is episodic and usually reversible with therapy
Stable, episodic, <50% will outgrow
>50% patients
Environmental irritants (dust, pollen), animal fur, cold air, exercise, URTIs, cigarette smoke, use of β-blockers/ASA
Wheeze (hallmark symptom), dyspnea, chest tightness, prolonged expiration, cough which is worse in the cold, at night, and in the early AM
Normal (for pure asthma)
Not usually present
Episodic with severe attacks
Marked improvement with bronchodilators or steroids
Often normal or episodic hyperinflation Hyperinflation during asthma attack
Ongoing patient education, and environmental control SABA taken prn as rescue medication + maintenance meds
Maintenance medications
fluticasone/salmeterol – Advair® budesonide/formoterol – Symbicort® ipratropium/albuterol – Combivent®
Anticholinergics
ipratropium – Atrovent® tiotropium – Spiriva®
More About Inhalers
purple discus red/white clear/orange
clear/green white/turquoise
• Aerosols (puffers=MDI, MDI + spacer) MDIs should be used with spacers to: • Reduce side effects
• Improve amount inhaled
• Increase efficiency of use
• Dry Powder Inhalers (discus, turbuhaler,
and diskhaler) require deep and fast
breathing (may not be ideal for children)
• Nebulizers can be used to convert liquid
medications into a fine mist: recommended for use if contraindications to MDIs
Differential Diagnosis of Wheezing
• Allergies, anaphylaxis
• Asthma, reactive airway disease
• GERD
• Infections (bronchitis, pneumonia)
• Obstructive Sleep Apnea
• COPD
• Less common: congestive heart disease,
foreign body, malignancy, cystic fibrosis, vocal cord dysfunction
When prescribing salbutamol, watch
out for signs of hypokalemia: lethargy, irritability, paresthesias, myalgias, weakness, palpitations, N/V, polyuria
Step 1: Step 2:
Step 3: Step 4:
Low-dose ICS
Medium/high-dose ICS or low-dose ICS plus either LABA, LT modifier, or long-acting theophylline
Medium/high-dose ICS + either LABA, LT modifier, or long-acting theophylline
As above + immunotherapy ± oral glucocorticosteroids + pneumococcal vaccination, annual influenza immunization
1 second time marker
ICS = inhaled corticosteroids; LAAC = long-acting anticholinergic; LABA = long-acting β-agonist; LT modifier = leukotriene modifier; SABA = short-acting β-agonist
FLOW RATE (L/sec)