Adult COPD

Question 1

COPD should be suspected in anyone over the age of 40 with….

Answer 1

• smoking history (or ex-smoker)
• dyspnoea that is progressive, persistent and worse with exercise
• chronic cough
• chronic sputum production
• family history of COPD.

Question 2

COPD exacerbation S+S

Answer 2

• increased dyspnoea
• increased cough
• increased sputum production
• complete removal of wheeze in these patients may not be possible due to chronic airway disease

Question 3

Indications for the removal of Bi-PAP or CPAP include:

Answer 3

• Ineffective (cardiac/respiratory arrest, mask intolerance, decreasing respiratory effort, nil improvement after 1 hour of treatment)
• Deteriorating vital signs
• Risk to patient (loss of airway control, copious secretions, active vomiting, paramedic judgement of clinical deterioration)

Question 4

Mgx SD3 Exacerbation of COPD

Answer 4

1) R+R
2) Position - Seated/Upright
3) O2 - Nebuliser 8-10L/min initial
4) Salbutamol 10mg NEB
5) Ipratropium Bromide 500mcg NEB
6) IV Access
7) Dexamethasone 8mg IV
8) Sitrep MICA - up/downgrade/cancel
9) O2 Reassess - NP titrate 88-92%
10) Reassess VSS 5/60
11) Extrication - Wheelchair to stretcher
12) Load Signal? MICA?

Question 5

COPD Differential Diagnosis

Answer 5

1) COPD
2) Asthma
3) Anxiety
4) Hyperventilation
5) Chest Infection
6) Pneumonia

Question 6

Mgx of Deteriorating COPD pt

Answer 6

MICA - CPAP/BiPAP
Assisted Ventilations with 100%O2 if inadequate TV or RR
Load Signal 1 to nearest appropriate hospital

Question 7

Definition of COPD

Answer 7

Chronic, progressive, reversible obstructive pulmonary disease characterised by difficult expiration. Three common pulmonary obstructive diseases: asthma, chronic bronchitis, emphysema

Question 8

Pathophysiology of Chronic Bronchitis

Answer 8

Prolonged exposure to irritants
↓
Hyper secretions of thick and sticky mucous due to enlargement of goblet cells and mucous glands
↓
Fibrosis, bronchospasm and oedema with impaired mucocillary function
↓
Increased size and number of mucous glands – susceptible to infections
↓
Bronchial wall thickening – obstruction
↓
Difficulty with expansion
↓
Gas trapping – Co2 retention

Question 9

Chronic Bronchitis Definition

Answer 9

• Abnormal permanent enlargement of gas exchange in airways due to inflammatory changes and excessive mucous production. Mainly affects the bronchi
• Characterised by a chronic cough for three consecutive months over the space of two years

Question 10

Emphysema Definition

Answer 10

Lung tissue destruction and abnormal permanent enlargement of gas exchange airways. Mainly affects alveoli

Question 11

Emphysema Pathophysiology

Answer 11

Prolonged exposure to irritants
↓
Toxins cause airway epithelial inflammation and activation of macrophages and neutrophils
↓
Elastin breakdown and loss of elastic recoil
↓
Pulmonary capillary destruction causes V/Q mismatch
↓
Decreased expiratory flow rate and increased WOB
↓
Compensate SOB by hyperventilating
↓
Gas trapping causes resp acidosis
↓
SHOCK, COMA, DEATH

Question 12

Oxygen Therapy Critical Illnesses

Answer 12

• Cardiac Arrest and/or Resuscitation
• Major Trauma/Head Injury
• Shock
• Severe Sepsis
• Anaphylaxis
• Status Epilepticus
• Ketamine Sedation

Question 13

Oxygen Therapy Chronic Illnesses

Answer 13

• COPD
• Neuromuscular Disorders
• Cystic Fibrosis
• Bronchiectasis
• Severe Kyphoscoliosis
• Obesity

Question 14

Salbutamol Presentation

Answer 14

5 mg in 2.5 mL polyamp
pMDI (100 mcg per actuation)

Question 15

Salbutamol Pharmacology

Answer 15

A synthetic beta adrenergic stimulant with primarily beta 2 effects

Actions: Causes bronchodilatation

Question 16

Salbutamol Indications

Answer 16

Respiratory distress with suspected bronchospasm:
- asthma
- severe allergic reactions
- COPD
- smoke inhalation
- oleoresin capsicum spray exposure

Question 17

Salbutamol Contraindications

Answer 17

Nil

Question 18

Salbutamol Precautions

Answer 18

Large doses of Salbutamol have been reported to cause intracellular metabolic acidosis

Question 19

Salbutamol Side Effects

Answer 19

Sinus tachycardia
Muscle tremor (common)

Question 20

Salbutamol Onset/Peak/Duration Times

Answer 20

Onset: 5 – 15 minutes
Peak: n/a
Duration: 15 – 50 minutes

Question 21

Ipratropium Bromide Presentation

Answer 21

250 mcg in 1 mL nebule or polyamp

Question 22

Ipratropium Bromide Pharmacology

Answer 22

Anticholinergic bronchodilator

Actions: Allows bronchodilatation by inhibiting cholinergic bronchomotor tone (i.e. blocks vagal reflexes which mediate bronchoconstriction)

Question 23

Ipratropium Bromide Indications

Answer 23

1. Severe respiratory distress associated with bronchospasm
2. Exacerbation of COPD irrespective of severity

Question 24

Ipratropium Bromide Contraindications

Answer 24

Known hypersensitivity to Atropine or its derivatives

Question 25

Ipratropium Bromide Precautions

Answer 25

1. Glaucoma
2. Avoid contact with eyes

Question 26

Ipratropium Bromide Side Effects

Answer 26

Headache
Nausea
Dry mouth
Skin rash
Tachycardia (rare)
Palpitations (rare)
Acute angle closure glaucoma secondary to direct eye contact (rare)

Question 27

Ipratropium Bromide Onset/Duration/Peak times

Answer 27

Onset: 3 - 5 minutes
Peak: 1.5 - 2 hours
Duration: 6 hours

Question 28

Difference between Salbutamol and Ipratropium Bromide?

Answer 28

Salbutamol is a synthetic beta adrenergic stimulant with primarily beta 2 effects which causes bronchodilatation

Ipratropium Bromide is an anticholinergic bronchodilator which promotes bronchodilatation by inhibiting cholinergic bronchomotor tone (i.e.
blocks vagal reflexes which mediate bronchoconstriction)

Question 29

Why do Emphysema patients become hypoxic?

Answer 29

• Emphysema is caused by the destruction of alveoli and small bronchioles in the lung
• Gas exchange is inhibited as a result
• CO2 builds up in the blood stream resulting in hypoxia

Question 30

Why are there no repeat doses of nebulised medications in the AV COPD guideline?

Answer 30

• COPD is an irreversible condition which is the result of destruction of the alveoli
• Nebulised medications aim to reduce smooth muscle constriction which is not the
  primary problem of this disease state unlike asthma
• Therefore giving high doses of bronchodilators in short periods of time is not beneficial

Question 31

Name two signs/symptoms that would lead you to suspect COPD in an adult > 40 years of age?

Answer 31

• Smoking history (or ex-smoker)
• Dyspnoea that is progressive, persistent and worse with exercise
• Chronic cough
• Chronic sputum production
• Family history of COPD