Spirometry in shortness of breath

1. Respiratory Whirlwind
Dr Sanjay Ramakrishnan
Respiratory and Sleep Medicine Trainee
27 April 2017

2. Outline
• Spirometry is a gift
• Asthma update and discharge
• ILD update
• PE update
• NIV challenge

3. Spirometry
• Bedside test
• Should be mandatory for everyone with breathlessness
• “It only takes 6 seconds!”
• Only way to confirm obstructive spirometry

4. Differential diagnosis for wheeze?

5. WE ARE BAD AT IT
• Wrong in 25-33% of the time!
• Esp if female, obese or white

6. Why is spirometry useful?
• Diagnosis
• Severity
• Treatment response/Monitoring
• Measure of arterial stiffness!
• Motivation

7. SPIROMETRY PRACTICE

8. Asthma Update
• Omalizumab (Anti-IgE)
• Mepolizumab (Anti- IL5)

9. COPD drug update

10. Asthma Discharge
• <40% of expected or personal best Peak flow – admit
• 40-70% - Discharge if supportive environment
• >70% - Discharge

14. My rule of thumb (For adults)
• PEFR <100 L/Min – Admit
• PEFR 100-150 – Probably admit
• PEFR 150-200 – Unlikely admit
• PEFR 200-250 – Probably discharge
• PEFR >250 – Discharge
• PEFR >300 - Reconsider asthma diagnosis!

15. ILD update
• Pirfenidone – severe skin rash and liver dysfunction
• Nintedanib – Severe GI upset

16. PE Update
• Up to 71% of presentations to ED in the era of DOACs are suitable for
discharge. We are only discharging 2% (American Data)

17. Comparing Agents
Agent Warfarin Apixaban Rivaroxaban Dabigatran
Dosage INR 2-3 10mg BD for 7D
5mg BD for 3-6mo
2.5mg BD thereafter
15mg BD for 3W
20mg daily for 3-6m
10mg d thereafter
150mg BD after 5
days of heparin
Renal adjustment Yes No* No No
Low dose option No (NEJM 2003) Yes Yes No
Bleeding risk
(Major)
8.8% (1.9%) 3.2%-4.3% (0.1%) 2.4-3.3% (0.5%) 5.6% (1.4%)
Monitoring Easy Anti Xa levels Anti Xa levels Specialised
Reversal Very available No No Idaricizumab
Adapted from multiple sources. RCT level evidence

18. Recurrent thrombosis risk
Patient demographic Risk
VTE provoked by surgery 3% recurrence at 5 years
VTE provoked by a non surgical transient risk factor 15% recurrence at 5 years
Unprovoked VTE 30% recurrence at 5 years
VTE associated with cancer 15% annualised risk of recurrence
A second unprovoked VTE after 1st unprovoked 50% (1.5 fold) higher than for after 1st
Risk of recurrence after 6-12 months 8.8% in the year after Rx (AMPLIFY-XT data)
Risk of recurrence on aspirin 100mg 4.4% in the year after Rx (EINSTEIN-CHOICE)
Male 1.75 fold higher risk
Positive D Dimer at the end of treatment 2.00 fold higher risk
All data from AT10 unless specified

19. NIV
• What is the department’s biggest bug bear?
• Clue: It is not ABGs
• Read Prof Anne Maree Kelly’s work. Illuminating!

20. Gold Standard in NIV delivery
AJRCCM April 2017

22. • Look up Prof Michael Dreher, Dutch ED physician/pulmonologist who
is doing some very interesting work in NIV for COPD

23. Questions?