13. Clinical Features of COPD Flashcards
1
Q
Define COPD.
A
Chronic, slowly progressing disorder involving airflow obstruction that doesn’t change markedly over several months. Most of the time lung impairment is fixed although some reversiblity can be produced by bronchodilator (or other) thera
2
Q
What is COPD primarily defined by? What is NOT mentioned?
A
- airflow obstruction
- no mention of symptoms, bronchitis or emphysema and smoking
3
Q
What 3 important factors cause airway obstruction in COPD?
A
- Loss of elasticity (less recoil and tendency to fall in on themselves as they don’t recoil) and disrupted alveolar attachments (breakage of alveolar cell walls)
- Thickening of airway wall due to INFLAMMATION (small airways narrow causing constriction)
- Luminal occlusion by secretion of MUCUS and inflammatory exudate
4
Q
What symptoms do airway obstruction factors in COPD cause? (3)
A
- coughing
- wheezing
- breathlessness on exertion
5
Q
What defines asthma in simple terms?
A
reversible airflow obstruction
6
Q
What defines chronic bronchitis in simple terms?
A
Symptoms: sputum production on most days
7
Q
What defines emphysema in simple terms?
A
Pathology; what changes we see in tissues
8
Q
What 2 conditions do most people suffering from COPD have?
A
- chronic bronchitis
2. emphysema
9
Q
Is it possible for patients to have JUST emphysema or JUST chronic bronchitis on their own?
A
Yes, but it’s more rare
10
Q
How many people in the UK are diagnosed with COPD every year?
A
1.2 million
11
Q
What percentage of total number of COPD patients are actually diagnosed?
A
Only 50% ( many people left misdiagnosed or undiagnosed)
12
Q
What is the total UK prevalence of COPD?
A
1.5-2 millon (numbers are increasing every year)
13
Q
Is COPD mainly increasing in prevalence in men or women?
A
Mainly in men
14
Q
Why is COPD a disease of social deprivation?
A
People of basic educational status and low household income are more likely to have COPD. Due to many factors such as; smoking, industrial jobs, poor health choices, less likely to go to the doctor, pay for treatment or know symptoms.
15
Q
What place does COPD have on the commonest causes of death in the UK and worldwide?
A
6th in UK (by 2030 it will be 3rd)
5th worlwide
16
Q
How many COPD related deaths every year?
A
~30,000 (15,700 males and 14,300 females)
17
Q
Why are women’s COPD mortality rates increasing and men’s decreasing?
A
Because more women smoke nowadays
18
Q
On average, how many GP visits will a COPD patient make in a year?
A
6-7 visits
19
Q
What percentage of COPD care is covered exclusively by primary care?
A
86%
20
Q
What percentage of COPD patients are admitted to hospital each year?
A
15%
21
Q
How much does each COPD roughly cost the UK economy and NHS?
A
UK economy: £1639 per year
NHS: £819 per year
22
Q
What comes under all the costs for treating COPD?
A
- inpatient hospitalisation
- laboratory tests
- treatment
- scheduled GP and specialist care
- unscheduled GP and emergency department care
23
Q
COPD is regarded as a “miserable disease” that decreases the quality of life. What simple activities can COPD patient have difficult in doing? (5)
A
- climbing stairs
-housework
-dressing
-gardening
-general difficulty breathing
…and many more!
24
Q
What percentage of COPD causes are due to smoking?
A
85% (VAST majority)
25
What are common causes for COPD that are not asthma? (the minority 15%) (5)
1. chronic asthma
2. passive smoking
3. maternal smoking
4. air pollution (burning of biomass fuel especially)
5. occupation
26
How does maternal smoking affect lung function? (2)
- it reduces FEV1
| - increases respiratory illness
27
What percentage of COPD cases are attributable to occupation?
15-20% which can include smokers
| (30% in life-long non-smokers)
28
Occupations exposing people to what substances, increase the risk of COPD?
- coal and hard rock mining
- tunnel working
- concrete manufacturing
- construction
- farming
- plastics and textiles
- rubber and leather
- working with asbestos
29
Where is alpha-1-antitrypsin enzymes produced?
in the liver
30
Where does alpha-1-antitrypsin work?
in the lungs
31
Why do we need alpha-1-antitrypsin?
It neutralises and "clears up" enzymes released by neutrophils to protect lung from neutrophil damage (controls level of AAT protein)
32
People with alpha-1-antitrypsin deficiency can develop COPD as early as what age?
even less than 40 years (lung deteriorates rapidly)
33
How many alpha-1-antitrypsin variants are there?
75 variants
34
What percentage of people in the UK have the normal PiMM genotype meaning they don't have alpha-1-antitrypsin deficiency?
approx. 86%
35
What is the troublesome genotype causing alpha-1-antitrypsin deficiency called/
PiZZ (0.03% of population affected but not all have COPD)
36
What can alpha-1-antitrypsin deficiency cause?
- AAT protein builds up in the body
- lung tissue becomes damaged
- can lead to emphysema which causes COPD
37
What is the average mortality figure for a patient suffering from alpha-1-antitrypsin deficiency who is a NON-SMOKER?
67 years (they develop dyspnea in early 50s)
38
What is the average mortality figure for a patient suffering fro alpha-1-antitrypsin deficiency who is a SMOKER?
48 years ( they develop dyspnea in early 30s)
39
What percentage of smokers develop COPD?
only 20%, but 30% smokers also develop subclinical airflow obstruction ( which means 50% never develop significant airflow obstruction)
40
What are the 2 main factors which causes COPD to develop in non-smokers?
- asthma
| - alpha-1-antitrypsin deficiency
41
What is smoking measured in?
pack years
42
What is 1 peak year?
1 pack a day for a year
43
What is the usual/common smoking history in peak years?
> 20 pack year
44
What is the rate of decline of FEV1 for non-smoker and a smoker per year?
non-smoker; 30ml /year
| smoker: 50ml/year ( can even be 80ml)
45
What is the FEV1 rate decline in non-smokers or non-susceptible smokers?
- rate of loss accelerates with age but is slow and gradual
| - no clinically significant airflow obstruction developed
46
What is the FEV1 rate decline in susceptible smokers? What will happen if they stop smoking in their middle age ?
- much faster rate of FEV1 decline
- if they stop smoking, normal FEV1 will never fully be restored but subsequent rate of loss may revert back to normal (can save from premature death)
47
What are the typical features of a patient who comes in and is suspected of COPD? (4)
- patient 40+ years
- smoker or ex-smoker
- breathless on exertion (most common symptom)
- cough
48
What conditions should be used for differential diagnosis of the patient who presents with COPD signs? ( what conditions should be considered at first) (7)
- COPD
- asthma
- lung cancer
- l.ventricular failure
- fibrosing alveolitis
- bronchiectasis
- raritis: Tb, recurrent pulmonary emboli
49
What 3 steps are there for making a COPD diagnosis?
1. excluding possible diagnoses (e.g. heart failure or differential diagnosis conditions etc)
2. has none of the features of variable airflow obstruction of asthma (up and down)
3. symptoms need to be gradually worsening over time , insidious (decliningl)
50
What are 6 most common symptoms of COPD?
1. breathlessness
2. cough
3.sputum
4 wheeze
5. weight loss
6. peripheral oedema
51
What two breathlessness features appear in COPD patients?
- gradual onset
| - little variation
52
What activities can cause breathlessness in COPD patients?
1. stairs/hill
2. housework/gardening
3. dressing and washing
4. at rest
5. loads/hurrying/running
53
What cough and sputum features appear in COPD patients?
- long history of smoker's cough
- clear or mucoid sputum
- early morning in winter months
- all day in winter months
- all day and all year
54
What percentage of people find that the resolution to stopping cough and sputum in COPD is stopping smoking?
in 94% it resolves if patients stops smoking
55
What 3 conditions should be considered if patient reports of haemoptysis?
- lung cancer
- TB
- bronchectasis
56
When is wheeze heard in patient?
typically on exertion (expiration)
57
What does big weight loss in COPD patient indicate?
- serious and severe disease
- TNF; tumour necrosis factor produced by macrophages in response to fighting tumour cells (produced when stimulated by endotoxins)
58
What does pulmonary oedema in COPD patient indicate? (3)
- cor pulmonale
- severe disease
- respiratory failure
59
What is cor pulmonale?
- condition causing right side of the heart to failure due to primary disorder of the respiratory system
- longterm pulmonary hypertension (high blood pressure in pulmonary arteries and r.ventricle) can lead to cor pulmonale
60
What do you look for in patient's past medical history when looking for COPD diagnosis? (3)
1. asthma as a child/adolescence
2. respiratory diseases
3. ischaemic heart disease (restriction of blood supply to tissue)
61
What do you look for in patient's drug history when looking for COPD diagnosis? (2)
1. list of current inhalers and doses (micrograms NOT puffs)
| 2. previous medications and effects on breathing (steroids)
62
What do you look for in patient's personal and social history when looking for COPD diagnosis? (3)
1. occupation
2. smoking history (age started and stopped)
3. how many cigarettes per day (pack years)
63
What common symptoms can be seen in COPD patients which can be identified straight away? (7)
1. breathlessness walking into clinic/ undressing
2. pursed lip breathing (to generate more pressure in lungs)
3. use of accessory muscles to generate more expiration (diaphragm more sucked in when breathing)
4. cyanosis (bluish discolouration of skin, mucous membranes or nail beds)
5. CO2 flap
6. tremor (due to beta agonists)
7. Effects of steroids ( tissue skin, bruising and cushingoid (excess cortisol hormone which can lead to weight gain and facial puffiness, but much more complex)
64
What common signs can the doctor identify in COPD patients? (3)
1. hyperextened chest (decreased expansion), can be counted using fingers from manubrium
2. laryngeal descent
3. paradoxical movement of ribs +abdomen (impairs gas exchange, opposite chest movement)
65
What is heard through percussion is COPD patients?
decrease in cardiac dullness
66
What type of breath sounds are heard in COPD patients?
decreased breath sounds (NO crackles)
67
Describe expiration of a COPD patient. (2)
- prolonged expiration
| - wheeze
68
Is the liver palpable in COPD patients?
Yes:
69
Why is liver palpable in COPD patients?
If painful: r. side of heart failure leading to hepatomegaly
If unpainful: descending of liver due to hyperinflated chest
70
What test is done to help diagnose COPD?
Spirometry (FEV1 and FVC readings taken)
| -FEV1 decrease in COPD
71
What is the predicted FEV1 in COPD patients?
<80% predicted
72
What is the FEV1:FVC ratio in COPD patients?
<70%
73
What FEV1 value means patient has mild airflow obstruction? What would be the patient's symptoms?
FEV1>= 80% of predicted value
No clear symptoms but patient "at risk"
74
What FEV1 value means patient has moderate airflow obstruction? What would be the patient's symptoms? (2)
FEV1= 50-79%
cough, shortness of breath on exertion (moderate)
75
What FEV1 value means patient has severe airflow obstruction? What would be the patient's symptoms? (3)
FEV1= 30-49%
shortness of breath on exertion (mild), cough and sputum.
76
Wha FEV1 value means patient has very severe airflow obstruction? What would be the patient's symptoms?
FEV1 < 30%
shortness of breath on exertion (all extremes), wheeze, cough and cor pulmonale
77
What is the general rule between breathlessness and FEV1?
- Breathlessness ALWAYS needs to be proportional to FEV1
| - If someone is breathless but has normal FEV1, then it's not COPD (both HAVE to be linked)
78
What ESSENTIAL investigations need to be done when diagnosing a patient WITH emphysema to rule out differential diagnoses? (5)
1. spirometry reading (FEV1/FVC)
2. lung volumes (gas trapping; RV/TLC)
3. CO gas transfer
4. minimal bronchodilator reversibility (to rule out asthma)
5. minimal response to oral corticosteroids (to rule out asthma)
79
Describe the pattern in RV (residual volume) and TLC (total lung capacity) in Lung Volumes test during gas trapping? (occurs in emphysema)
-increase in RV
-increase in TLC
RV/TLC> 30%
Emphysema makes inspiration easier but expiration VERY difficult
80
Describe the pattern in TLCO (transfer factor in lung of CO) and KCO ( tissue destruction) in CO gas transfer test where gas transfer is reduced. (occurs in emphysema)
- decrease in TLCO
- decrease in KCO (tissue destruction)
- reduced function in emphysema
81
Does asthma have reduced gas transfer?
No, not at all
82
What method confirms fixed airflow obstruction?
spirometry
83
What is the method for minimal bronchodilator reversibility? (for confirming COPD diagnosis)
baseline to 15 or 30minutes post neb 2.5-5mg salbutamol + 500micrograms of ipratropium (opens airways)
84
What is the method for minimal response to oral corticosteroids? (for confirming COPD diagnosis and ruling out asthma)
- 30-40mg prednisolone daily for 2 weeks (0.6mg/kg)
- measure baseline and final FEV1
- increasing trend= not to do trials of steroids
85
What is reversibility in terms o FEV1 values in volume and comparing to its baseline?
- FEV1>200ml
| - FEV1>15% baseline
86
What does significant bronchodilator and steroid response suggest?
asthma (asthmatic component)
87
What does insignificant bronchodilator and steroid response suggest?
COPD
88
What does the response to bronchodilators and steroid NOT predict?
- They don't predict symptomatic effect of long term use of these (don't predict the response to treatment)
- it's only a therapeutic trial to test if they work
89
What are other useful investigations for diagnosing COPD?
1. chest radiograph
2. blood gases
3. full blod count
4. ECG
5. sputum
90
What would you expect to find in a chest radiograph of a COPD patient?
1. hyperinflated lung field (>10 posterior ribs)
2. flattened diaphragm
3. lucent lung field (glowing)
4. bullae ( blister containing serous fluid)
91
What conditions is a chest radiograph useful for diagnosing, that isn't COPD? (3)
- bronchogenic carcinoma
- interstitial disease
- l. ventricular failure
92
What would blood gases look like in terms of PaO2 and PaCO2 in type 1 respiratory failure?
decrease in PaO2 (hypoxia)
| normal PaCO2
93
What would blood gases look like in terms of PaO2 and PaCO2 in type 2 respiratory failure?
decrease in PaO2 (hypoxia)
| increase in PaCO2 (hypercapnia)
94
What disease can a full blood count help find in COPD patients?
```
secondary polycythaemia (cancer of bone marrow), too many RBCs made
hct> 0.52 (haemocrit blood test)
```
95
What can ECG show in COPD patients? (3)
- right axis deviation
- p pulmonale
- t wave inversion (v1-v4)
96
What 3 main bacteria can be found in sputum of COPD patient?
1. S.pneumoniae
2. H. influenzae
3. M. catarrhalis
97
What is the sequence in diagnosing a patient with COPD?
1. patient history
2. fixed airflow obstruction tests (essential tests)
3. other useful investigation (for further confirmation)
98
What is the main cause of acute exacerbations of COPD?
usually precipitated/ triggered by viral/bacterial infection
99
What 3 possible causes should be considered at all times when looking at acute exacerbations of COPD?
1. sedative drugs
2. pneumothorax
3. trauma
100
What is meant by acute exacerbations of COPD?
Sustained worsening of patient's symptoms from their usual state beyond their normal variations (airflow obstruction becomes progressively worse)
101
What are common symptoms of acute exacerbations of COPD? (11)
1. increase in cough
2. increase in sputum and sputum purulence (more pus;pyogenesis)
3. increase shortness of breath
4. increase in wheeze
5. unable to sleep
6. increase in oedema
7. more confusion and drowsiness
8. cyanosis
9. increase wheeze
10. flapping tremor
11. pyrexial
102
What tests should be done for acute exacerbations of COPD?
1. chest radiograph
2. blood gases
3. full blood count (FBC)
4. urea+electrolytes (U&E) tests kidney function
5. sputum culture
103
What should be used to manage acute exacerbations of COPD?
1. nebulised bronchodilator B2 and anti-muscarining
2. O2 oral/IV corticosteroid
3. antibiotics
4. diuretic IV aminophylline (increases urine production)
5. respiratory stimulant
6. NIV (non-invasive mechanical ventilation)
