Chronic Obstructive Lung Disease (COPD) in Older Adults
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Questions and Answers

What is the primary limitation of using lung function to adjust treatment in asthma patients?

  • Lack of correlation between FEV1 and symptoms
  • Inability to measure FEV1 accurately
  • Unavailability of lung function tests in clinics
  • Between-visit variability of FEV1 (correct)

    • How is asthma severity typically assessed?

  • Using a combination of FEV1 and symptoms
  • Prospectively based on symptoms and exacerbations
  • Retrospectively from the level of treatment required to control symptoms and exacerbations (correct)
  • Based on the degree of airflow limitation

    • What is the recommended frequency of lung function measurement for most adults?

  • Every 5 years
  • Every 1-2 years (correct)
  • Every 3-6 months
  • Only at diagnosis

    • What is the significance of low FEV1 in asthma patients?

    <p>It is an independent predictor of exacerbation risk</p> Signup and view all the answers

    Which of the following patients may benefit from long-term PEF monitoring?

    <p>Patients with severe asthma or impaired perception of airflow limitation</p> Signup and view all the answers

    Why may some asthma patients have few symptoms despite having low FEV1?

    <p>They have poor perception of airflow limitation</p> Signup and view all the answers

    What percentage of total healthcare expenditures is expected to be spent on asthma in developed economies?

    <p>1-2%</p> Signup and view all the answers

    What is the main cause of death in older adults, according to the provided information?

    <p>COPD</p> Signup and view all the answers

    What is the estimated number of individuals affected by asthma worldwide?

    <p>300 million</p> Signup and view all the answers

    What is the primary pharmacologic treatment for COPD?

    <p>Inhaled bronchodilators and steroids</p> Signup and view all the answers

    What is the effect of smoking cessation on lung function?

    <p>It slows the decline in lung function</p> Signup and view all the answers

    What is the prevalence of asthma in people ≥65 years?

    <p>5%–10%</p> Signup and view all the answers

    What is the effect of age on forced vital capacity, FEV1, and PaO2?

    <p>They decrease with age</p> Signup and view all the answers

    What is a significant consequence of asthma?

    <p>School and work absence</p> Signup and view all the answers

    What is the primary focus of STEP 1 in the stepwise approach to control asthma symptoms and reduce risk?

    <p>Diagnosis</p> Signup and view all the answers

    Which of the following is NOT a consideration in the stepwise approach to control asthma symptoms and reduce risk?

    <p>Allergen immunotherapy</p> Signup and view all the answers

    What is the main goal of STEP 2 in the stepwise approach to control asthma symptoms and reduce risk?

    <p>To adjust the controller choice based on patient preference</p> Signup and view all the answers

    Which step in the stepwise approach involves referring patients for add-on treatment?

    <p>STEP 5</p> Signup and view all the answers

    What is the primary focus of STEP 3 in the stepwise approach to control asthma symptoms and reduce risk?

    <p>Treat modifiable risk factors</p> Signup and view all the answers

    Which of the following is a consideration in STEP 4 of the stepwise approach to control asthma symptoms and reduce risk?

    <p>Medication side-effects</p> Signup and view all the answers

    What is the primary goal of the stepwise approach to control asthma symptoms and reduce risk?

    <p>To control symptoms and reduce risk</p> Signup and view all the answers

    Which step in the stepwise approach involves assessing inhaler technique and adherence?

    <p>STEP 2</p> Signup and view all the answers

    What is the primary focus of STEP 5 in the stepwise approach to control asthma symptoms and reduce risk?

    <p>Referring patients for add-on treatment</p> Signup and view all the answers

    Which of the following is a non-pharmacological strategy in the stepwise approach to control asthma symptoms and reduce risk?

    <p>Asthma education</p> Signup and view all the answers

    What is the primary goal of achieving a partnership between patient and healthcare providers in asthma management?

    <p>To minimize future risk of exacerbations and medication side-effects</p> Signup and view all the answers

    What is the definition of health literacy according to Rosas-Salazar (JACI 2012)?

    <p>The degree to which individuals have the capacity to obtain, process and understand basic health information and services to make appropriate health decisions</p> Signup and view all the answers

    Which of the following strategies is NOT recommended to reduce the impact of impaired health literacy?

    <p>Use medical language</p> Signup and view all the answers

    What is the primary goal of the control-based asthma management cycle?

    <p>To assess and adjust treatment</p> Signup and view all the answers

    What is the role of the 'teach-back' method in asthma management?

    <p>To ask patients to repeat instructions</p> Signup and view all the answers

    What is a key component of guided self-management education in asthma?

    <p>All of the above</p> Signup and view all the answers

    What is the primary goal of treating to control symptoms and minimize risk in asthma management?

    <p>To minimize future risk of exacerbations and medication side-effects</p> Signup and view all the answers

    What is the role of the healthcare system in asthma management?

    <p>To consider cultural and personal preferences</p> Signup and view all the answers

    What is the primary goal of assessing patient health literacy in asthma management?

    <p>To reduce the impact of impaired health literacy</p> Signup and view all the answers

    What is the primary goal of the 'Rules of Two' in asthma management?

    <p>To determine the appropriateness of asthma treatment</p> Signup and view all the answers

    What is the primary consideration before stepping up treatment for uncontrolled symptoms in asthma patients?

    <p>Verifying diagnosis, inhaler technique, and adherence</p> Signup and view all the answers

    In which group of patients may SLIT therapy be considered?

    <p>Adult HDM-sensitive patients with allergic rhinitis and exacerbations despite ICS treatment</p> Signup and view all the answers

    What is the minimum FEV1 requirement for considering SLIT therapy in adult HDM-sensitive patients with allergic rhinitis?

    <p>70% predicted</p> Signup and view all the answers

    What is the recommended duration of symptom control before considering stepping down treatment?

    <p>3 months</p> Signup and view all the answers

    Which of the following is a contraindication for ceasing ICS treatment?

    <p>Any of the above</p> Signup and view all the answers

    What is the primary goal of advising about non-pharmacological therapies and strategies?

    <p>To manage comorbidities and modifiable risk factors</p> Signup and view all the answers

    What are the two domains of asthma control?

    <p>Assess symptom control over the last 4 weeks and assess risk factors for poor outcomes</p> Signup and view all the answers

    What is the primary purpose of assessing inhaler technique and adherence?

    <p>To improve treatment effectiveness</p> Signup and view all the answers

    What is the significance of asking about side-effects in asthma management?

    <p>To improve treatment adherence</p> Signup and view all the answers

    Which of the following comorbidities may contribute to symptoms and poor quality of life in asthma patients?

    <p>Rhinosinusitis, GERD, obesity, obstructive sleep apnea, depression, and anxiety</p> Signup and view all the answers

    What is the purpose of the GINA assessment of symptom control?

    <p>To assess symptom control over the last 4 weeks</p> Signup and view all the answers

    What is the significance of asking about activity limitation due to asthma in the GINA assessment of symptom control?

    <p>To assess symptom control over the last 4 weeks</p> Signup and view all the answers

    What is the primary goal of assessing patient attitudes and goals for their asthma?

    <p>To develop a personalized treatment plan</p> Signup and view all the answers

    What is the significance of having a written asthma action plan?

    <p>To provide personalized guidance for asthma management</p> Signup and view all the answers

    What type of inflammation is often associated with allergic asthma?

    <p>Type 2 inflammation</p> Signup and view all the answers

    Which of the following is a characteristic of asthma with fixed airway obstruction?

    <p>Lack of inflammation</p> Signup and view all the answers

    What is a key feature of ASA-sensitive asthma?

    <p>Leukotriene-mediated inflammation</p> Signup and view all the answers

    Which of the following is NOT a differential diagnosis for asthma?

    <p>Hypertension</p> Signup and view all the answers

    What is a necessary component of the diagnosis of asthma?

    <p>A history of characteristic symptom patterns</p> Signup and view all the answers

    Which of the following is a characteristic of non-allergic asthma?

    <p>Neutrophilic inflammation</p> Signup and view all the answers

    What is a key feature of asthma with obesity?

    <p>Non-eosinophilic inflammation</p> Signup and view all the answers

    Which of the following is a goal of the diagnosis of asthma?

    <p>To document evidence for the diagnosis</p> Signup and view all the answers

    What is the recommended add-on therapy for patients with moderate asthma who are not controlled on low dose ICS?

    <p>Leukotriene receptor antagonists (LTRA)</p> Signup and view all the answers

    In which step of the stepwise approach to control asthma symptoms and reduce risk is it recommended to consider adding tiotropium?

    <p>STEP 3</p> Signup and view all the answers

    What is the recommended therapy for patients with severe asthma who are not controlled on high dose ICS and LABA?

    <p>Add-on anti-IgE</p> Signup and view all the answers

    Which of the following medications is recommended as a reliever therapy in asthma patients?

    <p>Short-acting beta2-agonist (SABA)</p> Signup and view all the answers

    What is the primary goal of providing guided self-management education to asthma patients?

    <p>To enhance self-monitoring and written action plan</p> Signup and view all the answers

    In which step of the stepwise approach to control asthma symptoms and reduce risk is it recommended to consider adding low dose ICS/formoterol?

    <p>STEP 2</p> Signup and view all the answers

    What is the recommended therapy for patients with mild asthma who are not controlled on as-needed SABA?

    <p>Low dose ICS/formoterol</p> Signup and view all the answers

    What should be considered in adult patients with allergic rhinitis who have exacerbations despite ICS treatment and a FEV1 of 70% predicted?

    <p>SLIT as an add-on therapy</p> Signup and view all the answers

    What is the primary goal of assessing modifiable risk factors and comorbidities in asthma patients?

    <p>To treat modifiable risk factors and comorbidities</p> Signup and view all the answers

    Why should patients with adult-onset asthma be asked about their work history?

    <p>To identify sensitizers and remove them as soon as possible</p> Signup and view all the answers

    What is the benefit of remediation of dampness or mold in homes?

    <p>It reduces asthma symptoms and medication use in adults</p> Signup and view all the answers

    What should be avoided in patients with asthma?

    <p>Medications that may worsen asthma</p> Signup and view all the answers

    What is a consideration for referral in patients with asthma?

    <p>Frequent asthma-related health care visits</p> Signup and view all the answers

    What should be considered in patients with asthma and a history of near-fatal exacerbation?

    <p>Risk factors for asthma-related death</p> Signup and view all the answers

    What is an essential component of guided asthma self-management and skills training?

    <p>All of the above, including skills training to use inhaler devices correctly</p> Signup and view all the answers

    What should be done before prescribing an inhaler device?

    <p>Choose an appropriate device for the patient</p> Signup and view all the answers

    Why is it important to address patients' fears and misconceptions about medications?

    <p>To increase medication adherence</p> Signup and view all the answers

    What should clinicians consider when patients think asthma is not serious?

    <p>They are less likely to follow the treatment plan</p> Signup and view all the answers

    What is the primary consideration for a patient to be on an ICS as a controller?

    <p>Symptoms more than twice a day</p> Signup and view all the answers

    What is the basis for selecting the preferred treatment at each step in population-level decisions?

    <p>Efficacy, effectiveness, safety, and availability</p> Signup and view all the answers

    What is the primary consideration when making individual patient decisions about controller options?

    <p>Patient preference and characteristics</p> Signup and view all the answers

    What is the purpose of discussing patient characteristics with the patient/parent/carer in individual patient decisions?

    <p>To identify known predictors of risk or response</p> Signup and view all the answers

    What is the primary goal of involving the patient/parent/carer in shared decision-making?

    <p>To discuss the patient's goals and concerns</p> Signup and view all the answers

    What is the purpose of considering patient preference in individual patient decisions?

    <p>To discuss the patient's goals and concerns</p> Signup and view all the answers

    What is the primary consideration when choosing between controller options at a population level?

    <p>Efficacy, effectiveness, safety, and availability</p> Signup and view all the answers

    What is the purpose of discussing preferred treatment options with the patient/parent/carer in individual patient decisions?

    <p>To discuss the preferred treatment for symptom control and risk reduction</p> Signup and view all the answers

    What is the primary challenge in treating COPD patients with multi-morbidity?

    <p>Managing complex symptoms and signs from multiple diseases</p> Signup and view all the answers

    What is the implication of most evidence coming from trials in patients with COPD as the only significant disease?

    <p>Treatments may not be effective for patients with multi-morbidity</p> Signup and view all the answers

    What is the primary reason for keeping treatments simple in patients with multi-morbidity?

    <p>To minimize the burden of polypharmacy</p> Signup and view all the answers

    What is the characteristic of multi-morbid patients?

    <p>They have multiple chronic conditions</p> Signup and view all the answers

    What is the implication of the presence of COPD in the majority of multi-morbid patients?

    <p>COPD is a common comorbidity in multi-morbid patients</p> Signup and view all the answers

    What is the primary goal of treating COPD patients with multi-morbidity?

    <p>To manage complex symptoms and signs from multiple diseases</p> Signup and view all the answers

    What is the primary focus of the initial assessment of a patient with a cough?

    <p>Conducting a thorough history</p> Signup and view all the answers

    Which of the following is a common complaint in geriatric patients with pulmonary disease?

    <p>Dyspnea</p> Signup and view all the answers

    What is a potential differential diagnosis for a patient with a cough?

    <p>All of the above</p> Signup and view all the answers

    What is a characteristic of a patient's cough that may indicate asthma?

    <p>Nonproductive cough</p> Signup and view all the answers

    What is a potential underlying cause of a cough in a geriatric patient?

    <p>All of the above</p> Signup and view all the answers

    What is an important aspect of the initial assessment of a patient with dyspnea?

    <p>Conducting a thorough history</p> Signup and view all the answers

    What is a characteristic of asthma?

    <p>A chronic disease that can be controlled but not cured</p> Signup and view all the answers

    What is the main cause of symptoms in asthma?

    <p>Variable expiratory airflow limitation</p> Signup and view all the answers

    What is a factor that can trigger or worsen asthma symptoms?

    <p>Exercise</p> Signup and view all the answers

    What is a benefit of well-controlled asthma?

    <p>Patients have fewer symptoms during the day and night</p> Signup and view all the answers

    What is the definition of asthma?

    <p>A heterogeneous disease characterized by chronic airway inflammation</p> Signup and view all the answers

    What is a characteristic of asthma symptoms?

    <p>They vary over time in their occurrence, frequency, and intensity</p> Signup and view all the answers

    What is associated with variable expiratory airflow limitation in asthma?

    <p>Bronchoconstriction, airway wall thickening, and increased mucus</p> Signup and view all the answers

    What is the goal of treating asthma?

    <p>To control asthma symptoms and minimize risk</p> Signup and view all the answers

    What is the primary focus of advising about non-pharmacological therapies and strategies in asthma management?

    <p>To treat modifiable risk factors and comorbidities</p> Signup and view all the answers

    Which of the following is a consideration before stepping up treatment for uncontrolled symptoms in asthma patients?

    <p>Checking diagnosis and inhaler technique</p> Signup and view all the answers

    What is the recommended duration of symptom control before considering stepping down treatment in asthma patients?

    <p>3 months</p> Signup and view all the answers

    What is the primary goal of guided self-management education in asthma?

    <p>To provide education on inhaler technique and adherence</p> Signup and view all the answers

    Which of the following comorbidities may contribute to symptoms and poor quality of life in asthma patients?

    <p>Smoking, obesity, and anxiety</p> Signup and view all the answers

    What is the primary role of SLIT therapy in asthma management?

    <p>To provide adjunctive therapy for patients with allergic rhinitis and uncontrolled symptoms</p> Signup and view all the answers

    What is the primary consideration before adding SLIT therapy in adult HDM-sensitive patients with allergic rhinitis?

    <p>The patient's FEV1 level</p> Signup and view all the answers

    What is the primary goal of treating modifiable risk factors and comorbidities in asthma management?

    <p>To improve overall health and quality of life</p> Signup and view all the answers

    What is the primary cause of mortality in older adults with CAP?

    <p>Sepsis</p> Signup and view all the answers

    Which of the following is a characteristic of Mycoplasma pneumoniae?

    <p>No cell wall</p> Signup and view all the answers

    What is the recommended duration of antibiotic therapy for CAP?

    <p>Minimum of 5 days, with extension based on clinical response</p> Signup and view all the answers

    Which of the following is a common cause of chronic cough in smokers?

    <p>Chronic bronchitis</p> Signup and view all the answers

    What is the definition of bronchiectasis?

    <p>Dilation of the airways with chronic infection</p> Signup and view all the answers

    What is the primary goal of the CURB-65 mortality prediction tool?

    <p>To predict mortality risk in patients with CAP</p> Signup and view all the answers

    Which of the following is a characteristic of obstructive sleep apnea (OSA)?

    <p>Pause in breathing for 10-90 seconds</p> Signup and view all the answers

    What is the primary goal of the Fleischner Society guidelines for the management of incidental pulmonary nodules?

    <p>To guide the management of incidental pulmonary nodules</p> Signup and view all the answers

    What is the definition of a single pulmonary nodule?

    <p>A solitary lesion in the lung parenchyma</p> Signup and view all the answers

    Which of the following is a consideration in the diagnosis of rhinosinusitis in older adults?

    <p>The presence of multiple comorbidities</p> Signup and view all the answers

    Study Notes

    Aging and COPD

    • With age, there is a decline in forced vital capacity, FEV1, and PaO2, while the A-a gradient increases.
    • Clinically significant dyspnea is often under-reported and unrecognized in older adults.
    • 5%–10% of people ≥65 years meet criteria for asthma.
    • COPD is the third leading cause of death in older adults.
    • Pharmacologic treatment for COPD chiefly consists of inhaled bronchodilators and steroids.
    • Smoking cessation will slow the decline in lung function at any age.

    Burden of Asthma

    • Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals.
    • Prevalence is increasing in many countries, especially in children.
    • Asthma is a major cause of school and work absence.
    • Health care expenditure on asthma is very high, with developed economies expecting to spend 1-2% of total health care expenditures on asthma.

    Stepwise Approach to Control Asthma Symptoms and Reduce Risk

    • Diagnosis involves symptom control, risk factors, inhaler technique, adherence, and patient preference.
    • Assess symptoms, exacerbations, side effects, patient satisfaction, and lung function.
    • Asthma medications and non-pharmacological strategies are used to treat modifiable risk factors.
    • Refer for add-on treatment if necessary.

    Assessing Asthma Severity

    • Asthma severity is assessed retrospectively from the level of treatment required to control symptoms and exacerbations.
    • Risk reduction is necessary to minimize future risk of exacerbations, fixed airflow limitation, and medication side-effects.
    • A partnership between patient and healthcare provider is essential for achieving this goal.

    Reducing the Impact of Impaired Health Literacy

    • Health literacy affects health outcomes, including in asthma.
    • Strategies for reducing the impact of impaired health literacy include:
      • Prioritizing information
      • Speaking slowly and avoiding medical language
      • Simplifying numeric concepts
      • Using anecdotes, drawings, pictures, tables, and graphs
      • Using the 'teach-back' method
      • Asking a second person to repeat main messages
      • Paying attention to non-verbal communication

    Treating to Control Symptoms and Minimize Risk

    • Establish a patient-provider partnership
    • Manage asthma in a continuous cycle: assess, adjust treatment, and review response
    • Teach and reinforce essential skills, including inhaler skills, adherence, and guided self-management education
    • Use a written asthma action plan and self-monitoring with regular medical review

    Asthma Treatment

    • Low-dose ICS/LABA or tiotropium, anti-IgE, or anti-IL5 are treatment options
    • Low-dose ICS can be used as a controller, or add tiotropium or low-dose theophylline
    • Leukotriene receptor antagonists (LTRA) can be used as an alternative
    • High-dose ICS or OCS can be used for severe cases

    Asthma Phenotypes

    • Allergic (extrinsic) asthma: IgE mediated or mast cell mediated, may respond to specific targeted therapies
    • Non-allergic (intrinsic) asthma: eosinophilic or neutrophilic, may be ICS responsive or resistant
    • Asthma with fixed airway obstruction: lack of inflammation, defective repair mechanisms, and airway smooth muscle abnormalities
    • Asthma with obesity: non-eosinophilic, obesity required

    Differential Diagnoses

    • Foreign body, viral infections, pulmonary infections, MVP, PE, CHF, COPD, drugs (ACE inhibitors, Beta blockers, NSAIDS, ASA)

    Diagnosis of Asthma

    • Based on history of characteristic symptom patterns and evidence of variable airflow limitation
    • Document evidence for diagnosis in patient's notes before starting controller treatment
    • Asthma is characterized by airway inflammation and airway hyperresponsiveness

    Asthma Control

    • Assess symptom control over the last 4 weeks
    • Assess risk factors for poor outcomes, including low lung function
    • Asthma control has two domains: symptom control and risk factors

    Treatment Issues

    • Check inhaler technique and adherence
    • Ask about side-effects
    • Does the patient have a written asthma action plan?
    • What are the patient's attitudes and goals for their asthma?

    GINA Assessment of Symptom Control

    • Assess daytime asthma symptoms, night waking, reliever use, and activity limitation
    • GINA assessment has three levels: well-controlled, partly controlled, and uncontrolled

    Choosing Between Controller Options

    • Population-level decisions: based on efficacy, effectiveness, safety, availability, and cost
    • Individual patient decisions: based on shared decision-making, patient characteristics, patient preference, and advice about exercise-induced bronchoconstriction

    Important Considerations

    • Occupational asthma: ask about work history, remove sensitizers, and refer for expert advice
    • Avoid medications that may worsen asthma (NSAIDs, beta-blockers)
    • Remediation of dampness or mold in homes reduces asthma symptoms and medication use
    • Sublingual immunotherapy (SLIT) can be used as add-on therapy

    Indications for Referral

    • Difficulty confirming the diagnosis of asthma
    • Symptoms suggesting chronic infection, cardiac disease, etc.
    • Suspected occupational asthma
    • Persistent uncontrolled asthma or frequent exacerbations
    • Risk factors for asthma-related death
    • Significant side-effects (or risk of side-effects)
    • Symptoms suggesting complications or sub-types of asthma

    Pulmonary Disease Management

    • Pulmonary disease management involves understanding common complaints, geriatric specific considerations, and the major players in the disease.

    Common Complaints

    • Cough is a common complaint, with differential diagnoses including prescription drugs, cerumen impaction, post nasal drip, COPD, asthma, postinfection, GERD, and occupational or environmental factors.
    • Dyspnea is a common complaint, with underlying causes to be identified.
    • Hemoptysis is a common complaint, with underlying causes to be identified.

    Cough

    • A thorough history is necessary to diagnose the cause of a cough, including:
      • When did it begin?
      • When does it occur?
      • What stimulates it/aggravates it?
      • What makes it better?
      • Describe the quality (productive or nonproductive?)
    • Cough can be a symptom of various conditions, including URIs, acute and chronic bronchitis, pneumonia, single pulmonary nodule, and obstructive sleep apnea.

    The Major Players

    • Asthma is a major player in pulmonary disease management.
    • COPD is a major player in pulmonary disease management.### Pneumococcal Pneumonia
    • Caused by Streptococcus pneumoniae (gram-positive)
    • Abrupt onset
    • Common symptoms:
      • Productive cough with rusty-colored sputum
      • Fever
      • Chills
      • Pleuritic chest pain
      • More subtle presentation in older patients (e.g., altered mental status, weakness)

    Atypical Pneumonia

    • Caused by Mycoplasma pneumoniae (no cell wall)
    • Common symptoms:
      • Headache
      • Sore throat
      • Myalgia
      • Dry hacking cough
      • May be clinically indistinguishable from pneumococcal pneumonia

    Differences in Presentation

    • Mycoplasma pneumonia:
      • Sore throat, fever, dry hacking cough
      • Complications: sinusitis, otitis media, erythema multiforme, or erythema nodosum
      • Persistent hacking cough for up to 6 weeks
      • Relapse occurs in 10% of cases
    • Chlamydia pneumonia:
      • Biphasic illness
      • Younger individuals affected
      • Severe pharyngitis and laryngitis
      • Fever
      • Cough

    Physical Exam

    • No specific signs can confirm pneumonia
    • Physical exam cannot reliably distinguish type of pneumonia
    • Tachypnea more common in older adults
    • Pulse oximetry screening should be performed if suspecting CAP
    • Other signs: fever, increased tactile fremitus, dullness to percussion, egophony, crackles (rales), bronchial breath sounds

    Diagnostic Testing

    • CXR required to differentiate
    • Normal CXR does not exclude diagnosis
    • Additional tests:
      • Pulse oximetry
      • CBC with differential
      • Electrolytes
      • Rapid test for influenza (if suspected)
      • Sputum culture and gram stain (for severely ill, immunosuppressed, or HIV+ patients)
      • Blood cultures (for severely ill, immunosuppressed, or HIV+ patients)
      • Urinary antigen testing for Legionella and pneumococcus (for severely ill, immunosuppressed, or HIV+ patients)
      • CRP and procalcitonin level (if suspected inadequate response to treatment)

    CAP Treatment

    • Hydration
    • Respiratory hygiene
    • ASA or acetaminophen for fever and headache
    • Smoking cessation
    • Prevention: pneumococcal and influenza vaccine
    • Empiric treatment:
      • Outpatient: azithromycin, clarithromycin, or doxycycline
      • Inpatient (non-ICU): levofloxacin, moxifloxacin, or combination of beta-lactam and azithromycin
      • Inpatient (ICU): combination of beta-lactam and azithromycin or levofloxacin or moxifloxacin
      • Duration of therapy: minimum 5 days, should be afebrile for 48-72 hours

    CURB-65 Mortality Prediction Tool

    • Urea (BUN ≥ 20 mg/dL)
    • Respiratory rate (≥ 30/min)
    • Blood pressure (systolic ≤ 90 mmHg or diastolic ≤ 60 mmHg)
    • Confusion (altered mental status)
    • Age (≥ 65 years)

    Follow-up

    • Telephone follow-up in 24 hours
    • Office visit in 3-4 days
    • Repeat CXR in 2-4 weeks
    • Clinical failures: poor compliance with medications, resistant organisms, unusual pathogens, non-infectious causes

    Chronic Cough

    • Subacute cough: 3-8 weeks
    • Chronic cough: > 8 weeks
    • Common causes:
      • Postnasal drip
      • GERD
      • Asthma
      • Cigarette smoking
      • Postnasal drip, allergies, chronic sinusitis
    • Evaluation:
      • History: development, duration, character, precipitants
      • Physical exam: ENT, lungs, cardiac, abdomen
      • CXR: excludes malignant disease, bronchiectasis, persistent pneumonia, sarcoidosis, TB
      • Spirometry

    Bronchiectasis

    • Chronic cough
    • Overproduction of secretions
    • Reduced clearance of secretions
    • Result: excess airway secretions

    Sleep Apnea

    • Pause in breathing for 10-90 seconds
    • Central apneas: absent airflow and respiratory efforts
    • Obstructive apneas: tongue and soft palate fall backward
    • Mixed apneas
    • Consequences: pulmonary hypertension, hypertension with LV dysfunction, cardiac dysrhythmias, psychomotor defects, hypoxia and hypercapnia

    Geriatric Specific Considerations

    • Age-related pulmonary changes:

      • Reduced airway size
      • Shallow alveolar sacs
      • Decline in chest wall compliance
      • Intercostal muscle atrophy
      • Reduction in diaphragmatic strength

    • Difficulties in recognizing respiratory symptoms

    • Rhinosinusitis: approaches to diagnosis, treatment do not differ with age

    • Dyspnea: common causes include COPD, cardiac disease, asthma, interstitial lung disease, deconditioning### COPD and Comorbidities

    • COPD is often present in patients with multi-morbidity, defined as having two or more chronic conditions.

    • Multi-morbid patients have complex symptoms and signs that can be attributed to several causes during chronic and acute events.

    • There is no evidence to suggest that COPD should be treated differently in patients with multi-morbidity.

    • Treatments for multi-morbid patients should be kept simple to avoid polypharmacy.

    Non-Pharmacological Therapies and Strategies

    • Advise patients on non-pharmacological therapies and strategies, such as physical activity, weight loss, and avoidance of sensitizers.
    • Consider stepping up treatment if patients experience uncontrolled symptoms, exacerbations, or risks.
    • Check diagnosis, inhaler technique, and adherence before stepping up treatment.
    • Consider adding SLIT (Sublingual Immunotherapy) in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite ICS treatment, if FEV1 is >70% predicted.

    Asthma Definition and Facts

    • Asthma is a common and potentially serious chronic disease that can be controlled but not cured.
    • Symptoms of asthma include wheezing, shortness of breath, chest tightness, and cough, which vary over time in their occurrence, frequency, and intensity.
    • Symptoms are associated with variable expiratory airflow limitation due to bronchoconstriction, airway wall thickening, and increased mucus.
    • Factors that can trigger or worsen symptoms include viral infections, allergens, tobacco smoke, exercise, and stress.

    Effective Treatment of Asthma

    • Asthma can be effectively treated to:
      • Avoid troublesome symptoms during the day and night
      • Need little or no reliever medication
      • Have productive, physically active lives
      • Have normal or near-normal lung function
      • Avoid serious asthma flare-ups (exacerbations or severe attacks)

    Key Reminders

    • Provide guided self-management education to patients
    • Treat modifiable risk factors and comorbidities
    • Consider stepping up or down treatment based on symptoms and risk of exacerbations
    • Ceasing ICS is not advised

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    Related Documents

    Respiratory Update Spring 2019 PDF

    Description

    This quiz covers the changes in lung function with age, the prevalence of asthma and COPD in older adults, and the importance of recognizing dyspnea.

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