case 10 - breathlessness Flashcards
which lung diseases does COPD include?
emphysema and chronic bronchitis
what is emphysema?
damage to the air sacs (alveoli) in the lungs
what is chronic bronchitis?
long-term inflammation of the bronchi/airways
how does COPD develop?
develops gradually over many years such that patients often do not realise they have it
(no noticeable symptoms until late 40s/50s)
which lifestyle factor is most commonly linked to an increased risk of developing COPD?
long-term exposure to harmful substances such as cigarette smoke (most commonly)
at what age is COPD most likely to develop?
develops gradually but no noticeable symptoms until the age late 40/50
what are the most common symptoms of COPD?
- increased breathlessness - during exercise or at night
- a persistent chesty cough with phlegm
- frequent chest infections
- persistent wheezing
how do symptoms of COPD progress over time?
gradually get progressively worse over time
what is a COPD flare-up/exacerbation?
short periods of time where symptoms of COPD suddenly worsen
how common are flare-ups and when do they occur?
quite common, most occur during the winter
what are some less common symptoms of COPD?
- weight loss
- tiredness
- swollen ankles from build-up of fluid (oedema)
- chest pain/coughing up blood (could be sign of something else)
what are the risk factors for COPD?
- smoking (even passive smoking)
- fumes and dust at work (occupational causes)
- air pollution
- genetics
how is smoking a risk factor for COPD?
around 9 in 10 COPD cases are due to smoking
= the carcinogens can damage the lining of the airways and alveoli and increase COPD risk
how are fumes and dust at work a risk factor for COPD?
the fumes and dust contain chemicals that can damage the airways/alveoli and increase COPD risk (e.g. cadmium, grain, silica and welding fumes, isocyanates)
how is air pollution a risk factor for COPD?
inconclusive link
some evidence suggests that the chemicals in the air can damage the lungs and increase the risk of COPD
how are genetics a risk factor for COPD?
people who have a close relative with the condition OR people who have alpha-1 antitrypsin deficiency
= increases risk of COPD
what is alpha-1 antitrypsin?
a protein produced by the liver that protects the lungs from being damaged
what tests can a GP do to diagnose COPD?
physical examination patient history spirometry chest x-ray blood tests ECG echocardiogram peak flow test blood oxygen phlegm sample CT scan
what is spirometry?
a series of breathing tests a patient must do to help diagnose and monitor lung conditions
how is spirometry carried out?
use a bronchodilator to widen airways
breathe into a spirometer
two measurements made: the volume of air you can breathe out in one second AND the total volume of air you can breathe out
which two measurements are made in spirometry?
the total volume of air that is breathed out and the volume of air breather out in one second
why is a chest x-ray done to diagnose COPD?
to look for problems in the lungs that are characteristic of COPD
why are blood tests done to diagnose COPD?
to see if the symptoms have an alternative cause, besides COPD such as anaemia (low iron), polycythaemia (high concentration of erythrocytes) or alpha-1 antitrypsin deficiency
why are peak flow tests done to diagnose COPD?
measures how fast you blow air out of your lung = to rule out asthma
why is a phlegm sample done to diagnose COPD?
to check for any chest infections
how is COPD treated?
- no cure but treatment slows progression of disease
- stopping smoking
- inhalers and tablets
- pulmonary rehabilitation
- surgery/lung transplant
why is smoking cessation effective treatment for COPD?
- cigarette smoke causes damage to the airways/alveoli in COPD in the first place
- to prevent further worsening/exacerbation of the symptoms, smoking must stop
why are inhalers and tablets effective treatment for COPD?
enable bronchodilation to ease breathlessness
what is pulmonary rehabilitation?
pulmonary rehabilitation is a specialised programme of exercise and education which improves the amount of exercise you can do before you go out of breath
what are the types of inhalers for COPD?
short-acting bronchodilators
long-acting bronchodilators
steroid inhalers
how do short-acting bronchodilators work?
when you feel breathless, up to a maximum of 4 times a day
two types: beta-2 agonist (salbutamol, terbutaline) OR antimuscarinic (ipatropium)
used for exacerbations
how do long-acting bronchodilators work?
each dose lasts 12 hours so only needs to be taken 1-2 times a day
two types: beta-2 agonist (salmeterol, fometerol, idacaterol) and antimuscarinic (tiotropium, glycopyronium, aclidinium)
when should long-acting bronchodilators be used?
each dose lasts 12 hours so only needs to be taken 1-2 times a day
what are steroid inhalers?
contain corticosteroid medicine which reduces inflammation of the airways
when are steroid inhalers used?
if long-acting inhalers are not effective and patient still gets breathless and if patient has frequent flare-ups/exacerbations
what are theophylline tablets?
bronchodilator but the mechanism of action is unclear BUT reduces inflammation of the airways and relaxes muscles lining airways
what are possible side effects of taking theophylline tablets?
palpitations
insomnia
headaches
sickness
when are steroid tablets given?
a 5 day course of treatment for a particularly bad flare up
why are steroid tablets not given for long-term use to treat COPD?
can cause unwanted side effects such as weight gain, mood swings and osteoporosis
when are antibiotics prescribed in COPD?
if there are indications of a chest infection e.g xray or green sputum
what is a key sign of a chest infection in a patient with COPD?
colour of the phelgm changes and phelgm becomes thicker (consistency)
what does pulmonary rehabilitation involve?
physical exercise
education about your condition
dietary advice
psychological support
how does nebulised medicine help a patient with COPD?
turns liquid medicine into a fine mist and so large dose of medicine can be taken in on go via a mask
what is roflumilast?
tablet used to treat flare-ups that reduces inflammation in the airways
when is roflumilast prescribed?
when a patient has has two severe exacerbations over the last 12 months, despite already using inhalers
what are the side effects of roflumilast?
sickness
weight loss
headache
what is long-term oxygen therapy?
when blood oxygen saturation is low, oxygen therapy can be given to normalise levels through nasal mask or tubes
taken for 16 hours a day - can be taken at home
what is strictly not allowed when giving a patient long-term oxygen therapy?
smoking cigarettes as increased oxygen level is highly flammable = could cause explosion
what is non-invasive ventilation and when is it used?
mask attached to face which supports lungs and assists breathing, usually given to ease an exacerbation
what is a lung transplant?
removal of damaged lungs and replacement with healthy lungs from donor
what is a comorbidity?
the simultaneous presence of two or more diseases in a patient
what are some comorbidities for COPD?
hypertension diabetes mellitus osteoporosis anxiety cardiac disease hyperlipidaemia
why is COPD particularly bad in patients during the winter?
collection of bacteria in the lung flare up when patient has a cold so particularly bad exacerbations in winter
what is opacification on an x-ray?
when fluid/material builds up in the lung parenchyma and appears whiter/more opaque than the normal, healthy lung surroundings
what is a pleural effusion?
buildup of excess fluid between the layers of the pleura
is an infective exacerbation of COPD reversible?
most cases can return back to normal pre-exacerbation levels however a small proportion of cases cannot due to irreversible destruction of the airways
what is an exacerbation?
acute change in symptoms of patient’s baseline - could be ue to infective or non-infective cause
which test is essential for patients that present with shortness of breath?
chest x ray
What is an ABG?
Arterial blood gas
What are the effects of a COPD exacerbation?
- decreased lung function
- decreased physical activity
- worsened mental health
- decreased QoL
- further COPD exacerbations
- mortality
What does this CXR show?
COPD
What does this CXR show?
Infective exacerbation of COPD
What does this CXR show?
Lung tumor
What does this CXR show?
Pleural effusion
What is low blood pH called?
Acidaemia
What is high blood pH called?
Alkalaemia
What can cause acidaemia?
- respiratory acidosis (high PCO2)
- metabolic acidosis (low HCO3)
What can cause alkalaemia?
- respiratory alkalosis (low PCO2)
- metabolic alkalosis (high HCO3)
What is hypoxia?
low blood oxygen
What is hypercapnia?
high blood CO2
What is type 1 respiratory failure?
- hypoxia without hypercapnia
- impaired oxygenation of the blood
- PaO2 < 8kPa
What can cause type 1 respiratory failure?
pulmonary oedema, pneumonia, COPD, asthma, acute respiratory distress syndrome, chronic pulmonary fibrosis, pneumothorax, pulmonary embolism, pulmonary hypertension.
What is type 2 respiratory failure?
- hypoxia with hypercapnia
- impaired exertion of CO2 from the lungs
- Pa CO2 >6.5 kPa
What can cause type 2 respiratory failure?
commonly caused by COPD but may also be caused by chest-wall deformities, respiratory muscle weakness and Central nervous system depression
How do kidneys compensate for respiratory acidosis caused by hypoventilation?
- metabolic compensation
- secretion of H+
- reabsorption of HCO3
- increase in plasma pH
How do the lungs compensate for metabolic acidosis caused by renal failure?
- respiratory compensation
- hyperventilation
- decrease in pCO2
- increase in plasma pH
What is the compensatory mechanism of respiratory acidosis?
metabolic alkalosis
What is the compensatory mechanism of metabolic acidosis?
respiratory alkalosis
What is the compensatory mechanism for respiratory alkalosis?
metabolic acidosis
What is the compensatory mechanism for metabolic alkalosis?
respiratory acidosis
Where does vasoconstriction occur in the lungs of someone with COPD and why?
In the tissue with hypoxia, diverts blood to healthy tissue
How does vasoconstriction in the lungs lead to longterm problems?
- increases resistance
- increases pressure
- leads to pulmonary hypertension
What happens to the heart due to consistent pulmonary hypertension?
- hypertrophy of the heart
- right sided ventricular failure
What is the consequence of right ventricular failure in COPD?
pressure will build up in the venous system
What is a CPAP machine?
- Continuous positive air pressure
- Delivers a constant flow of air through the tubing and mask
- Only helps with inhalation
- Keeps your airways patent and make sure they don’t close
What is a BiPAP machine?
- Bi-level Positive Airway Pressure
- Delivers differing air pressure depending on inspiration and expiration
- During inspiration the pressure in the thorax is lower
- During expiration, the pressure in the thorax is higher
- Reduces the work of breathing by decreasing expiratory pressure –> allows CO2 to be expelled much easier
What are the indications for BiPAP use?
- COPD with respiratory acidosis (pH < 7.35)
- type 2 respiratory failure
- weaning from tracheal intubation
What are the indications for CPAP use?
- Hypoxia in the context of chest wall trauma despite adequate anaesthesia and high flow oxygen
- Cardiogenic pulmonary oedema
- Pneumonia: as an interim measure before invasive ventilation or as a ceiling of treatment
- OSA – Obstructive Sleep Apnoea
What signs indicate that antibiotics should be prescribed?
- Becoming more breathless
- Coughing more
- change in sputum colour (brown, green or yellow) and/or consistency of phlegm
- X-ray abnormality (white spots – infiltrates)
How are antibiotics administered in hospital?
intravenously as reaches tissue at faster rate than oral
Which antibiotics might be used to treat an infective exacerbation of COPD?
amoxicillin, erythromycin
