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Year 3 > Case 10 - COPD > Flashcards

Case 10 - COPD Flashcards

1
Q

What is COPD?

A

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

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2
Q

How does smoking lead to COPD?

A

Toxic products of smoke > activate macrophages and dendritic cells > activates T cells (emphysema), fibroblasts (bronchiolitis) and proteases (mucus hypersecretion)

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3
Q

What are the genetic causes of COPD?

A

Genetic:

  • Alpha-1-antitrypsin deficiency
  • Matrix metalloproteinases
  • TNF-alpha
  • Glutathione S transferase
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4
Q

How is COPD graded?

A

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%
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5
Q

What are differentials for COPD?

What questions should you ask to exclude these?

A 
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?
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6
Q

What questions should you ask in a smoking history?

A 
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?
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7
Q

What are blue bloaters and pink puffers?

A

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

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8
Q

What is the triad of COPD symptoms?

A

SOB
Chronic cough
Daily sputum production

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9
Q

What are symptoms of COPD?

A

SOBOE
Cough - productive of white frothy sputum
Wheeze
Winter exacerbations

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10
Q

What are signs of COPD?

A 
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
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11
Q

What would clubbing or lymphadenopathy in COPD suggest?

A

Cancer, these are not usual in COPD

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12
Q

How can we categorise patients’ COPD symptoms?

A

Can categorise dyspnoea using MRC 1-5 score

Then using spirometry, BMI, exacerbation frequency and MRC can put patient into a phenotype

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13
Q

What would spirometry show in COPD?

A

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

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14
Q

What does CXR show in COPD?

A 
May not show anything
May see:
-Hyperinflation of lungs
-Flattened hemi-diaphragms
-Blunting of costophrenic angles
-Reduced upper lobe markings
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15
Q

What would CT show in COPD?

A

Can see the emphysematous bullae and bronchial wall thickening

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16
Q

What are the complications of COPD?

A 
Exacerbation
Cor pulmonale
Pneumonia
Pneumothorax
Cachexia
Peripheral neuropathy
17
Q

What are the symptoms and causes of exacerbations of COPD?

A 
Increased SOB
Increased sputum production (green/yellow)
Coryzal symptoms
Increased cough
Sputum purulence
Ankle swelling

Often due to S.pneumoniae, pseudomonas or H.Influenzae

18
Q

What is cor pulmonale?

A 
RHF due to COPD
Hypoxia > pulmonary artery vasoconstriction
Increased pulmonary artery pressure
Leads to increased RV contraction
RVH
RVF
19
Q

What is the treatment order for COPD?

A

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

20
Q

SABA types and SEs

A

Salbutamol (ventolin)
Terbutaline (bricanyl)

Tremor
Tachycardias
Arrhythmias
Myocardial ischaemia

21
Q

LABA types and SEs

A

Salmeterol (serevent)
Formeterol (oxis)

Tremor
Tachycardias
Arrhythmias
Myocardial ischaemia

22
Q

Steroid types and SEs

A

Beclamethosone (becotide)
Budenoside (pulmicort)

Increased oral thrush
Increased risk of pneumonia due to immune suppression
Dry mouth/hoarse voice
Adrenal suppression

23
Q

Anti-muscarinics types and SEs

A

Tiotropium (LAMA)
Ipratropium (SAMA)

Dry mouth
Nausea
Headache

24
Q

Theophylline SEs

A

Tachycardia
Toxicity
Anaphylaxis

25
Q

Oxygen indications in COPD

A

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

26
Q

What investigations would be done for COPD exacerbation?

A 
ECG
CXR
FBC, U and E, CRP
Sputum and blood cultures
ABG
27
Q

What is initial management of COPD exacerbation?

A

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

28
Q

How do you manage T2RF in COPD exacerbation?

A 
Nebs
O2
IV steroids
CXR
Re-do ABG, then consider BIPAP/NIV
29
Q

What are signs of hypercapnia?

A 
Drowsiness
Dilated pupils
Bounding pulse
Hand flap
Confusion
Reduction in consciousness
30
Q

Indications for BIPAP?

A

Indicated in those who have acidosis despite oxygen, moderate-severe breathlessness and RR > 25

31
Q

What are the types of oxygen a patient could be put on?

A

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

32
Q

Indications for CPAP

A

For those with T1RF, sleep apnoea, HF and pulmonary oedema

Evens out the ventilation/perfusion mismatch

33
Q

How do WBC cause COPD?

A

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

34
Q

How does COPD lead to hyperinflation?

A

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

35
Q

What are the environmental causes of COPD?

A

Environmental:

  • Smoking
  • Cannabis
  • Biofuels
  • Mineral dusts
36
Q

What is BIPAP?

A

Provides airflow alternating between two pressures to match end expiatory and inspiration pressures
Forces the patient to breathe - gives added push

37
Q

Contraindications for BIPAP?

A

Shouldn’t be used for anyone with low consciousness and those who don’t have the ability to maintain their own airways

Year 3 (23 decks)

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