Case 10 - COPD Flashcards
1
Q
What is COPD?
A
Airway obstruction due to inflammation of the small airways
2
Q
What 2 diseases is COPD made up of?
A
- Chronic bronchitis
- Emphysema
3
Q
What is chronic bronchitis?
What are the symptoms?
A
- Inflammation of the bronchi
- Cough, chest pain, headache, malaise
- Productive cough at least 3 months each year for 2 consecutive years
4
Q
What is emphysema?
A
- Permanent dilation of the alveoli and lose elasticity
- Difficulty exhaling
- Structural changes of the alveoli
5
Q
What are the exogenous causes of COPD?
A
- Smoking/ passive smoking
- Air pollution
- Occupational exposure: coal miners
- Biomass fuel: industrialised countries
- Recurrent pulmonary infections + TB
6
Q
What are the endogenous causes of COPD?
A
- α1-antitrypsin deficiency
- Antibody deficiency syndrome (IgA deficiency)
- Matrix metalloproteinases
- TNF – α
- Glutathione S transferase
- Primary ciliary dyskinesia
7
Q
How to classify COPD?
A
- GOLD 1: Mild syx: ≥ 80%
- GOLD 2: Moderate syx: 50–79%
- GOLD 3: Severe syx: 30–49%
- GOLD 4: V severe syx: < 30%
8
Q
Below which FEV1/FVC ratio is there airflow limitation in patients?
A
<70%
9
Q
What are the 2 types of emphysema?
A
- Panlobular (panacinar)
- Centrilobular (centriacinar)
10
Q
What are the signs and symptoms of COPD?
A
- Chronic cough with expectoration (clear sputum) in the morning
- Dyspnoea
- Cyanosis
- Barrel chest
- Accessory muscle use
- Peripheral oedema
- Palpable liver edge
- Reduced lung expansion
- No diurnal variation
11
Q
What is present on percussion of chest in COPD?
A
- Hyper-resonant lungs: due to hyperinflation of lungs
- Reduced lung expansion
12
Q
What is present on auscultation of chest in COPD?
A
- Inspiratory wheeze
- Corse crackle
- Silent chest in advanced COPD
- Decreased breath sounds advanced COPD
13
Q
What is the normal oxygen saturations of COPD patients?
A
88%-92%
14
Q
If FEV1 changes are <12% post bronchodilator, what does this mean?
A
- Irreversible bronchoconstriction
- COPD
15
Q
What are the signs of COPD on chest x-ray?
A
- Flattened ribs
- Flattening of diaphragm
- Hyperlucency of lungs – appear blacker
- Narrow cardiac diameter – lungs expanded so push into heart
16
Q
What are the differentials for COPD?
A
- Asthma
- Bronchial carcinoma
- Bronchiectasis
- Congestive heart failure
17
Q
What is bronchiectasis?
How to diagnose it?
A
- Copious purulent sputum and mid inspiration coarse crackles
- HR CT
18
Q
How to conservatively manage COPD?
A
- Smoking cessation
- Nicotine replacement therapy
- Nicotine receptor blockers (varenicline and bupropion)
- Pneumococcal and influenza vaccination
19
Q
What changes in breathing helps in COPD?
A
Pursed lip breathing - Breathe through nose and out slowly through lips
- Increases airway pressure
20
Q
What differential would you consider in an older person presenting with asthma-like symptoms?
A
- Asthma differentials in older people
- Idiopathic pulmonary fibrosis
- Churg-Strauss
21
Q
What differential would you consider in a younger person presenting with COPD-like symptoms?
A
- Alpha 1 antitrypsin deficiency
22
Q
What investigations are conducted with COPD?
A
- CXR
- ABG: respiratory failure
- FBC: polycythaemia
- CT thorax: bullae, bronchial wall thickening
23
Q
What is the treatment algorithm for COPD?
A
- Start SABA/SAMA then use PRN
- LABA
- FEV1 > 50% = add LABA and LAMA
- FEV1 < 50% = add LAMA, LABA, and ICS
- Triple therapy: LABA + LAMA + ICS
24
Q
What are other treatment options for COPD patients?
A
- Theophylline: aminophyillne
- LTOT: PaO2 ≤ 55 mm Hg or SaO2 ≤ 88 % at rest
- Mucolytics: Carbocisteine
25
What surgical options are there for COPD patients?
- Lung volume reduction
- Lung transplant
- Bullae removal
26
What are the features of an acute exacerbation of COPD?
- Increased SOB
- Increased cough and wheeze
- Increase in sputum/puerility (change in colourless sputum of COPD to more yellow/green)
- Hypoxia and related confusion
27
What investigations are done in COPD exacerbation?
- ABG
- CXR (excludes other diagnoses and provides evidence of infection)
- FBC
- U&E
- CRP
- ECG
28
How to treat COPD exacerbation?
- Salbutamol and ipratropium via nebuliser
- Oxygen: Do not give 100% as it stops hypoxic drive
- Steroids: IV hydrocortisone and oral prednisolone (continued for 1-2 weeks after)
- Antibiotics (usually amoxicillin, doxycycline, or clarithromycin –
- If nebulisers and steroids don’t help, add theophylline + NIV
29
What is the pathophysiology of cor pulmonale?
Hypoxia -> pulmonary arterial vasoconstriction -> pulmonary hypertension -> RV hypertrophy -> RV failure
30
Which lung volume increases in COPD?
Residual volume and total lung capacity
31
What is the FEV1/FVC for restrictive disease?
| What changes are there in residual volume and lung capacity?
- >70%
| - Reduced residual volume and lower total lung capacity
32
What is a pack year?
Number of cigarettes smoked a day/ 20 (in a pack) X number of years smoked for
33
What is type 1 respiratory failure?
Decreased pO2
| Normal pH
34
What is type 2 respiratory failure (hypercapnia)?
- Decreased pO2
- Increased pCO2 >7 kPa
- Lower pH
35
What are the clinical features of hypercapnia?
- Dilated pupils
- Bounding pulse
- Hand flap
- Myoclonus
- Confusion
- Drowsiness
- Coma
36
What are the names of salbutamol inhalers?
Ventolin, airomir, salamol easi-breathe (blue inhalers)
37
What is the name of terbutaline inhaler?
Bricanyl
38
What is the name of salmeterol inhaler?
Serevent
39
What is the name of formoterol inhaler?
Oxis
40
What is the name of ipotropium bromide (SAMA) inhaler?
Atrovent
41
What is the name of tiotropium (LAMA) inhaler?
Spiriva
42
How is theophylline administered?
Modified release tablet
43
What are the names of inhaled glucocorticoids?
- Beclomethasone: becotide
- Fluticasone: Flixotide
- Budesonide: Pulmicort
44
What is the MRC dyspnoea scale?
- 0: only strenuous exercise
- 1: Level ground/walking up a slight hill
- 2: Walks slower than people of same age from dyspnoea, or has to stop for breath when walking at own pace on level ground
- 3: Stops for breath after walking 100, or after a few minutes on level ground
- 4: Too breathless to leave house
45
What are the causes of
| metabolic acidosis?
```
- Increased acid production:
= Diabetic ketoacidosis
= Lactic acidosis
= Aspirin overdose
- Decreased acid excretion or loss of HCO3-:
= GI loss of HCO3- :diarrhoea, ileostomy, colostomy
= Renal tubular acidosis (retaining H+)
- Addisions disease (retaining H+)
```
46
What are the causes of metabolic alkalosis?
- Gastrointestinal loss of H+ ions: vomiting/diarrhoea
- Renal loss of H+ ions – loop and thiazide diuretics / heart failure / nephrotic syndrome / cirrhosis / Conn’s syndrome
- Iatrogenic – addition of alkali
47
What are the causes of respiratory acidosis?
- Pneumonia
- Guillain Barre syndrome
- Asthma
- COPD
- Latrogenic (excessive mechanical ventilation)
48
What are the causes of respiratory alkalosis?
- Anxiety – often referred to as a panic attack
- Pain – causing an increased respiratory rate
- Hypoxia – resulting in increased alveolar ventilation in an attempt to compensate
- Pulmonary embolism
- Pneumothorax
- Latrogenic (excessive mechanical ventilation)
49
What is respiratory alkalosis?
Hyperventilation leading to more CO2 being exhaled.
50
- What % of oxygen does a venturi mask deliver?
| - What is it used in?
- Delivers 24-60% oxygen
| - COPD and when correct oxygen saturation are essential
51
- What % of oxygen does a non rebreathe mask deliver?
- What is the flow rate?
- How does it work?
- When is it used?
- What is the ideal saturation?
- Delivers 85-90% oxygen
- 15L flow rate
- Bag on mask with valves stopping almost all rebreathing of expired air
- Used for acutely unwell patients
- 94-98%
52
- What is CPAP used for?
Acute pulmonary oedema, sleep apnoea, HF, pneumonia
53
- What are the indications for NIV/BiPAP?
- pH <7.35, pCO2 >6.5 despite controlled oxygen therapy
- Moderate to severe breathlessness with accessory muscle use
- Respiratory rate >25/min
- Used in exacerbations of COPD (without pneumonia) and ARDS
54
What are the contraindications for NIV/BiPAP?
- pH <7.25
- Confusion
- Recent upper GI surgery
- Vomiting
- Fixed airway obstruction
- Life threatening hypoxemia
- Haemodynamically unstable
55
- How long is LTOT used for?
- What should the PaO2 be kept above?
- What are the indications?
- 15 hours a day
- 8 kPa
- Cyanosis
- Polycythaemia
- Peripheral oedema
- Raised JVP
- Oxygen saturations of 92% or less breathing air
