Case 10 - COPD Flashcards
What is COPD?
Multifactorial disease made up of asthma, emphysema, bronchitis (production of sputum for more than 3 months of the year) etc.
Progressive airway obstruction that is not reversible
How does smoking lead to COPD?
Toxic products of smoke > activate macrophages and dendritic cells > activates T cells (emphysema), fibroblasts (bronchiolitis) and proteases (mucus hypersecretion)
What are the genetic causes of COPD?
Genetic:
- Alpha-1-antitrypsin deficiency
- Matrix metalloproteinases
- TNF-alpha
- Glutathione S transferase
How is COPD graded?
GOLD staging and NICE staging
GOLD I (Mild) - FEV1 >80% GOLD II (Moderate) FEV 50-79% GOLD III (Severe) FEV1 30-49% GOLD IV (V Severe) FEV1<30%
What are differentials for COPD?
What questions should you ask to exclude these?
PE Asthma Angina Lung fibrosis Restrictive lung disease
Any similar episodes? PND? Orthopnea? Peripheral oedema? Any chest pain? Light-headedness? Ever owned a bird? Asbestos exposure? Smoking history?
What questions should you ask in a smoking history?
Have you ever smoked? When did you start? When did you stop? Do you still smoke? Cigarettes/roll-ups? How many a day? Ever more or less? Ever tried to quit? Ever taken a break? Anyone else in the house smoke?
What are blue bloaters and pink puffers?
T2RF - blue bloaters. Tend to be larger patients with increased fluid retention and breathing effort due to gas trapping
T1RF - pink puffers. Tend to be cachexic patients who have underlying pathology
What is the triad of COPD symptoms?
SOB
Chronic cough
Daily sputum production
What are symptoms of COPD?
SOBOE
Cough - productive of white frothy sputum
Wheeze
Winter exacerbations
What are signs of COPD?
Hyperinflation of chest Expiratory wheeze Reduced breath sounds Cachexia Decreased cricosternal distance Tar staining of fingers Increased RR Paradoxical lower chest movements Tracheal tug Indrawing of intercostals Palpable liver edge
What would clubbing or lymphadenopathy in COPD suggest?
Cancer, these are not usual in COPD
How can we categorise patients’ COPD symptoms?
Can categorise dyspnoea using MRC 1-5 score
Then using spirometry, BMI, exacerbation frequency and MRC can put patient into a phenotype
What would spirometry show in COPD?
Obstructive, non-reversible picture
FEV1:FVC ratio will be <70% and FEV1 will be reduced more than FVC
However, patients can still feel healthy with very low FEV1, so not a good symptomatic indicator
What does CXR show in COPD?
May not show anything May see: -Hyperinflation of lungs -Flattened hemi-diaphragms -Blunting of costophrenic angles -Reduced upper lobe markings
What would CT show in COPD?
Can see the emphysematous bullae and bronchial wall thickening
What are the complications of COPD?
Exacerbation Cor pulmonale Pneumonia Pneumothorax Cachexia Peripheral neuropathy
What are the symptoms and causes of exacerbations of COPD?
Increased SOB Increased sputum production (green/yellow) Coryzal symptoms Increased cough Sputum purulence Ankle swelling
Often due to S.pneumoniae, pseudomonas or H.Influenzae
What is cor pulmonale?
RHF due to COPD Hypoxia > pulmonary artery vasoconstriction Increased pulmonary artery pressure Leads to increased RV contraction RVH RVF
What is the treatment order for COPD?
1) SABA
2) SABA and LABA/LAMA
3) SABA and LABA/LAMA and ICS in those with FEV1:FVC <50% or frequent exacerbators
4) SABA and LABA and LAMA and ICS
5) Oral theophylline/high dose bronchodilators/pulmonary rehab
SABA types and SEs
Salbutamol (ventolin)
Terbutaline (bricanyl)
Tremor
Tachycardias
Arrhythmias
Myocardial ischaemia
LABA types and SEs
Salmeterol (serevent)
Formeterol (oxis)
Tremor
Tachycardias
Arrhythmias
Myocardial ischaemia
Steroid types and SEs
Beclamethosone (becotide)
Budenoside (pulmicort)
Increased oral thrush
Increased risk of pneumonia due to immune suppression
Dry mouth/hoarse voice
Adrenal suppression
Anti-muscarinics types and SEs
Tiotropium (LAMA)
Ipratropium (SAMA)
Dry mouth
Nausea
Headache
Theophylline SEs
Tachycardia
Toxicity
Anaphylaxis
Oxygen indications in COPD
Only prescribed if there is proven improvement in symptoms following administration
LTOT indicated for those with oxygen<7.3kPa when well
Or for those 7.3-8 with comorbidities ie. pulmonary HTN, ankle swelling, nocturnal hypoxaemia and secondary polycythaemia
Should be used for over 15 hours a day
What investigations would be done for COPD exacerbation?
ECG CXR FBC, U and E, CRP Sputum and blood cultures ABG
What is initial management of COPD exacerbation?
Salbutamol 5mg nebs
Ipratropium 500 mcg nebs
O2 in venturi > for those at risk of T2RF aim for 88-92%
IV hydrocortisone 100mg
Broad spectrum antibiotics (amoxicillin and clarithromycin)
ABG
If in T1RF, continue and consider CPAP
How do you manage T2RF in COPD exacerbation?
Nebs O2 IV steroids CXR Re-do ABG, then consider BIPAP/NIV
What are signs of hypercapnia?
Drowsiness Dilated pupils Bounding pulse Hand flap Confusion Reduction in consciousness
Indications for BIPAP?
Indicated in those who have acidosis despite oxygen, moderate-severe breathlessness and RR > 25
What are the types of oxygen a patient could be put on?
Venturi - specific amount of airflow - when there’s targeted sats
Nasal cannula - cannot provide high flow oxygen, and not a specific amount is delivered. Eat and drink as normal
Non-rebreathe mask - good for the acute patient but non-specific amount of oxygen
Indications for CPAP
For those with T1RF, sleep apnoea, HF and pulmonary oedema
Evens out the ventilation/perfusion mismatch
How do WBC cause COPD?
Increased number of lymphocytes in the lung tissue mediate the lung disease:
Goblet cell hyperplasia - cough and sputum
Airway narrow - SOB and wheeze
Alveolar destruction - SOB
How does COPD lead to hyperinflation?
Usually the pressures forces air out to the atmosphere
In COPD there may be airway damage and stricturing, meaning there is a pinch point > air is trapped in the alveoli > hyperinflation
COPD patients have to perform pursed lips breathing to inflate the lungs against a pressure
The worse obstruction gets, the higher the cancer risk
What are the environmental causes of COPD?
Environmental:
- Smoking
- Cannabis
- Biofuels
- Mineral dusts
What is BIPAP?
Provides airflow alternating between two pressures to match end expiatory and inspiration pressures
Forces the patient to breathe - gives added push
Contraindications for BIPAP?
Shouldn’t be used for anyone with low consciousness and those who don’t have the ability to maintain their own airways
