[2] COPD NO DRUGS Flashcards
What is COPD?
A common, progressive disorder characterised by airflow obstruction, which is not fully reversible and does not change markedly over several months.
What does the umbrella term of COPD encompass?
Emphysema and chronic bronchitis, of which patients can have features of either or both
What is the pathological process in emphysema?
Destruction of terminal bronchioles and distal airspaces, as well as supporting tissue surrounding the small airways
What does the destruction of terminal bronchioles and distal airspaces in emphysema lead to?
The loss of alveolar surface area, and therefore impairment of gas exchange
How does the process of destruction of the terminal bronchiole and distal airspaces in emphysema often progress?
To the development of large redundant airspaces within the lung, called bullae.
What is the result of the destruction of supporting tissue surrounding the small airways in emphysema?
It causes the small airways to close/collapse during expiration when the pressure outside the airway rises
What does the collapse of small airways during expiration in emphysema result in?
Airflow obstruction, particularly affecting the small airways
What does loss of elastic tissue in emphysema lead to?
Hyperinflation of the lungs
Why does loss of elastic tissue in the lungs in emphysema lead to hyperinflation of the lungs?
Because the lungs are unable to resist the natural tendency of the ribcage to expand outwards
How is emphysema defined histologically?
As enlarged airspaces distal to the terminal bronchioles, with destruction of the alveolar walls
On which imaging modality can emphysema often be visualised?
CT
What is chronic bronchitis?
Chronic mucus hypersecretion
What causes chronic mucus hypersecretion in chronic bronchitis?
Inflammation in the large airways, usually due to cigarette smoke, leading to proliferation of mucus producing cells in the respiratory epithelium
What is the clinical consequence of chronic bronchitis?
Chronic productive cough and frequent respiratory infections
How does chronic bronchitis result in airflow obstruction?
Remodelling and narrowing fo the airways
What is the clinical definition of chronic bronchitis?
Cough and sputum production on most days for 3 months of 2 successive years
What are the causes of COPD?
- Smoking
- Occupational exposure
- Air pollution
- Alpha-1 anti-trypsin deficiency
Describe the relationship between air pollution and COPD
Exposure to air pollution over a long period of time can affect how well the lungs work, and some research has suggested it could increase the risk of COPD, however at present the link isn’t conculsive, and research is continuing
What is alpha-1-antitrypsin deficiency (AATD)?
A rare, inherited condition which can cause lung and liver problems
What is the mechanism of disease of AATD?
Patients lack the protective enzyme inhibitor alpha-1-antitrypsin, which makes them more vulnerable to effects of inhaling smoke or other toxic materials like dust, fumes, or chemicals
How is diagnosis of AATD made?
Blood test, which measures the level of alpha-1 antitrypsin
How is AATD managed?
At present, there is no specific treatment, and so treatment is focused around treating the lung and liver conditions if they arise
What are the symptoms of COPD?
- Cough and sputum production
- Wheeze
- Dyspnoea, that is progressive
- Frequent chest infections
What are the investigations into COPD?
- History and examination
- Spirometry
- Chest x-rays
- Blood tests
- Peak flow tests
- Sputum sample
What history features would suggest a diagnosis of COPD rather than asthma?
- Age of onset over 35 years
- Smoking history
- Chronic dyspnoea
- Sputum production
- Minimal diurnal or day-to-day FEV1 variation
What are the examination features of COPD?
- Tachypnoea
- Use of accessory muscles of respiration
- Hyperinflation
- Decreased cricosternal distance
- Reduced expansion
- Resonant or hyperresonant percussion note
- Quiet breath sounds
- Wheeze
- Cyanosis
- Cor pulmonae
What is cor pulmonale defined as?
An alteration in the structure and function of the right ventricle of the heart, caused by a primary disorder of the respiratory system
How fast is the onset of cor pulmonale?
Usually has a chronic and slowly progressing course, however acute onset and worsening can occur
What are the symptoms of cor pulmonale?
- Fatigue
- Tachypnoea
- Exertional dyspnoea
- Cough
- Haemoptysis
- Anginal chest pain that does not respond to nitrates
What is the treatment of cor pulmonale?
- Treatment of underlying condition
- In more advanced cases, more aggressive treatments such as heart and lung transplants may be required
What are the findings of spirometry in COPD?
- FEV1 <80% predicted
- FEV1/FVC ratio <70%
- Increased total lung capacity
- Increased residual volume
What does the chest x-ray show in COPD?
- Hyperinflation
- Flat hemidiaphragms
- Large central pulmonary arteries
- Decreased peripheral vascular markings
- Bullae
What does a severity assessment have implications for in COPD?
Therapy and prognosis
What does the BODE index consider?
- Body mass index
- Airflow obstruction
- Dyspnoea
- Exercise capacity
How is the BODE index used clinically in COPD?
It helps predict outcome, and number and severity of exacerbations
What stages did the Global Initiative for COPD (GOLD) categorise COPD into?
Mild, moderate, severe, and very severe, based on post-bronchodilator FEV1% predicted
How is COPD managed?
- Stopping smoking
- Inhalers and medication
- Pulmonary rehabilitation
- Surgery or lung transplant
What are the first-line treatments in COPD?
Short acting bronchodilator inhalers
How do bronchodilators help relieve the symptoms of COPD?
They decrease the work of breathing by relaxing and widening the airways
What types of short acting bronchodilators are used in COPD?
- ß2 agonist inhalers, such as salbutamol and terbutaline
- Antimuscarinic inhalers, such as ipratropium
At what frequency should short-acting bronchodilator inhalers be used in COPD?
They should be used when a patient is feeling breathless, up to 4 times a day
When will long-acting bronchodilators be recommended for COPD patients?
If they experience symptoms regularly throughout the day
How long does each dose of long-acting bronchodilator last in COPD?
At least 12 hours
What are the types of long acting bronchodialtors used in COPD?
- ß2 agonist inhalers
- Antimuscarinic inhalers
Give three examples of long-acting ß2 agonist inhalers used in COPD?
- Salmeterol
- Formoterol
- Indacaterol
Give three examples of antimuscarinic inhalers used as long-acting bronchodilators in COPD
- Tiotropium
- Glycopronium
- Acildinum
When are corticosteroid inhalers recommended for use in COPD?
When patients still get breathless when taking long-acting inhalers, or have frequent flare ups
How do corticosteroid inhalers act in COPD?
They reduce the amount of inflammation in the airways
What medications are used in the treatment of COPD?
- Theophylline
- Mucolytic tablets or capsules
- Steroid tablets
- Antibiotics
How often is theophylline taken?
Twice daily
What is the effect of theophylline in COPD?
It relaxes and opens up the airways
What monitoring is required with theophylline?
Regular monitoring of blood levels of the drug
What are the possible side effects of theophylline?
- Nausea and vomiting
- Headaches
- Insomnia
- Palpitations
When might mucolytic tablets and capsules be recommended in COPD?
When a patient has a persistent chesty cough with lots of thick phlegm
How do mucolytic tablets and capsules work in COPD?
They make mucus in the throat thinner, and easier to cough up
When are steroid tablets used in COPD?
When the patient has had a severe exacerbation of their COPD
How do steroid tablets work in COPD?
They reduce inflammation in the airways
How long are steroid tablets taken for in COPD?
A 7 to 14-day course is usually recommended
Why are steroid tablets only recommended for use for 7-14 days in COPD?
Long-term use of steroids can cause side effects including weight gain, mood swings, and osteoporosis
What is required when a patient needs to be prescribed a longer course of steroids in COPD?
Must be prescribed by a COPD specialist, with the lowest effective dose given, and the patient must be monitored closely for side effects
What is pulmonary rehabilitation?
A specialised programme of exercise and education, aimed to improve exercise capacity, symptoms, self-confidence, and emotional well being.
How often does a patient require pulmonary rehabilitation
2 or more group sessions a week, for at least 6 weeks
What does a typical pulmonary rehabilitation programme include?
Physical exercise tailored to patients needs and ability, such as walking, cycling, and strength exercises, education about the condition for the patient and family, and psychological and emotional support
When is long-term oxygen therapy advised in COPD?
When COPD results in hypoxia
How is long-term oxygen therapy delivered in COPD?
Can be delivered at home, through nasal tubes or a mask
How much of the day should long-term oxygen therapy be delivered for in COPD?
At least 16 hours a day
Which patients does NICE recommend long-term oxygen therapy for?
- Clinically stable non-smokers with a PaO2 of <7.3kPa (value stable on 2 occassions, at least 3 weeks apart)
- If PaO2 is 7.3-8.0, and the patient has pulmonary hypertension, polycythaemia, peripheral oedema, or noctural hypoxia
- Terminally ill patients
Who is suitable for surgery in COPD?
Only a small number of people, who have severe symptoms that cannot be controlled with medications
What are the surgical options in COPD?
- Bullectomy
- Lung volume reduction surgery
- Lung transplant
What is a bullectomy?
Surgery to remove bullae from the lungs, allowing increased efficiency and more comfortable breathing
What is lung volume reduction surgery?
Removal of a badly damaged section of the lung to allow the healthier parts to work better, and make breathing more comfortable
What are the indications for specialist referral in COPD?
- Uncertain diagnosis
- Suspected severe COPD
- Rapid decline in FEV1
- Onset of cor pulmonae
- Bullous lung disease
- Assessment for oral corticosteroids, nebuliser therapy, or long-term oxygen therapy
- <10 years pack smoking, or COPD patient <40 years
- Symptoms disproportionate to lung function tests
- Frequent infections
