22. COPD Flashcards

1
Q

A 64-year-old man presents to A & E extremely short of breath,
initially unable to give a history. He is recognised by one of the nursing staff as a
man known to have chronic obstructive pulmonary disease and was ventilated on ICU during his last admission.

How can we classify this disease?

A
  1. Chronic bronchitis
    Defined as daily cough with sputum production for at
    least 3 months a year for at least 2 consecutive years.

‘Blue bloater’
This clinically represents the bronchitic group.
They are typically hypoxaemic and cyanosed
with cor pulmonale
(peripheral oedema, raised JVP, hepatomegaly)
but with little dyspnoea.

  1. Emphysema
    A histological diagnosis defined as enlargement of
    the air spaces distal to the terminal bronchioles with
    destructive changes in the alveolar wall.

Pink puffers
Representing the emphysematous group. These
patients have severe dyspnoea but relatively normal
gas exchange.

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2
Q

Can you tell me a little about the pathophysiology?

A

There is a combination of:

Mucosal inflammation
Excessive secretions
Bronchoconstriction.

There is a reduction in lung elasticity with a .
consequent fall in the maximum expiratory flow rate.

With increasing alveolar destruction,
the pulmonary vasculature may be damaged which,
along with hypoxic pulmonary vasoconstriction,
contributes to pulmonary hypertension.

The overall effect is that of V/Q mismatch.

Lung function tests show an obstructive picture:

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3
Q

obstructive picture

A

Reduced FEV1
Reduced FVC
Reduced FEV1/FVC ratio
Increased residual volume
Increased FRC
Increased total lung capacity
Reduced diffusing capacity

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4
Q

What signs might you elicit in this man?

A
  1. Tachypnoea
  2. Cyanosis
  3. Accessory muscle use
  4. Intercostal recession
  5. Hyperinflated lungs
  6. Pulsus paradoxus
  7. Wheeze
  8. Prolonged expiratory time

Cor pulmonale
Raised JVP, peripheral oedema, loud P2

Signs of hypercapnia
Warm peripheries, bounding pulse,
confusion, tremor, convulsions

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5
Q

What would be your initial management of this man?

A

Sit the patient up

Oxygen

Bronchodilators

Methylxanthines

Steroids

Antibiotics

NIV

Physiotherapy

Regular monitoring

Heart failure Rx

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6
Q

O2

A

Oxygen therapy should be used to prevent hypoxia
but should not worsen acidosis.

Oxygen should be started at ∼40% and titrated up
if O2 saturation <90% and down if sats >93% or
patient drowsy.

ABGs should be done to assess pH and PCO2

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7
Q

Bronchodilators

A

A proportion of these patients will have an element of reversibility to their bronchoconstriction.

Use a β-agonist (salbutamol or terbutaline)
with an anticholinergic (ipratropium bromide).

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8
Q

Methylxanthines

A

Intravenous theophylline may be considered if inadequate response to inhaled bronchodilators.

Caution should be taken with patients on oral theophylline and levels should be taken in all
patients.

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9
Q

Steroids

A

Prednisolone 30mg should be prescribed for 7–14 days.

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10
Q

Antibiotics

.NIV

Physiotherapy

Regular monitoring

A

Aminopenicillin or marcolide if increased purulent sputum

NIV should be considered in patients with pH <7.35.

Should be considered in some patients.

Clinical state and blood gases

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11
Q

BTS advocate the use of antibiotics if two or more of:

A

Increased breathlessness

Increased sputum volume

Development of purulent sputum

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12
Q

This man deteriorates despite all this treatment. What further
interventions are available to you?

A

Non-invasive ventilation
Needs specialist equipment.
Needs co-operation from the patient.
Most valuable when used early.
Reduces requirement for IPPV and length of hospital stay.

IPPV
Ventilatory support considered in patients:
With a pH <7.26
A rising PaCO2
Failing to respond to supportive treatment

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13
Q

IPPV:

Favourable

A

Remediable cause for acute decline

First episode

Good quality of life

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14
Q

Less favourable factors:

A

Documented severe COPD unresponsive to therapy

Poor quality of life, e.g. housebound on maximal therapy

Severe co-morbidities

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