Case 10- COPD Flashcards
Investigations for suspected COPD
Post bronchodilator spirometry- FEV1/FVC less than 70%
TLCO (transfer factor of CO)- decreased for COPD.
sputum culture
FBC- secondary polycythaemia, infection, serum alpha 1 anti trypsin (only if a young person)
CXR
CT Thorax
ECG/ TOE- assess cardiac function (cor pulmonale)
Gives indication of severity of the disease
NB- if an infection: UE, CRP, sputum and blood cultures
MRC dyspnoea scale
1- breathlessness on strenuous exercise
2- breathlessness on walking up hill
3- breathlessness that slows speed of walking on flat
4- stop to catch breath after 100m walking on flat
5- unable to leave house due to breathlessness
When is mechanical ventilation indicated?
Respiratory failure with hypercapnic acidosis
Hypoxaemia
Marked dyspnoea
Respiratory muscle fatigue
Drugs that can cause pulmonary fibrosis
Amiodarone
Cyclophosphamide
Methotrexate
Nitrofurantoin
Sx of COPD
SOB, productive cough, wheeze, use of accessory muscles, signs of cor pulmonale
COPD differentials
Asthma, CCF, bronchiectasis, TB, GORD, ACE-I use, lung cancer, bronchitis
Acute exacerbation of COPD differentials
CCF, acute exacerbation asthma, pneumonia, pleural effusion, pneumothorax, PE, ACS, cardiac arrhythmia
Sx of IPF
Progressive dyspnoea on exertion, non-productive cough, end expiration basilar crackles, weight loss, fatigue, malaise, clubbing, arthralgia
Beta blockers
Careful in COPD/ asthma
NB- steroids not shown to be very helpful
Lung transplant
Rarely possible in young patients if they stop smoking
LAMA
Tiotropium
SAMA
Iprateopium
CXR findings for COPD
Flattened diaphragm
Hyper inflated lungs
Horizontal ribs
Bullae (air spaces- increased black spaces)
Chronic bronchitis
Defined clinically- productive cough for 3 months of 2 years
Emphysema
Defined histologically- large air spaces
Features of acute COPD exacerbation
Increased dyspnoea, cough, wheeze
Increase in sputum- infective cause
Hypoxia, potentially confusion
Most common bacterial organisms that cause infective exacerbations of COPD
H influenzae
S pneumoniae
Moraxella catarrhalis
NB- human rhinovirus is an important cause too
Management of an acute exacerbation of COPD
Increased bronchodilator use via a nebuliser
Prednisolone 30mg for 5 days
Antibiotics if sputum purulent or clinical signs of infection ie. fever/consolidation on Xray (amoxicillin, clarithromycin, doxycycline)
NB- can also have IECOPD in absence on CXR changes/consolidation (consolidation makes its pneumonia)
Alpha 1 antitrypsin features
Young patients (may have history of recurrent infections, smoking etc.)
Lungs- emphysema in lower lobes (upper lobes in COPD)
Liver- cirrhosis and HCC in adults (abnormal LFTs), cholestasis in children
Management of alpha 1 anti trypsin deficiency
No smoking
Supportive- bronchodilator and physiotherapy, monitor for complications, symptom control
Medical- IV alpha 1 anti trypsin protein concentrates (NICE don’t recommend)
Surgery- lung volume reduction surgery, lung/ liver transplantation
Bronchiectasis
Permanent dilation of the airways secondary to chronic infection or inflammation
Causes of bronchiectasis
TB, measles, pneumonia
CF
Obstruction eg. Lung cancer, foreign body
ABPA
Kartageners, youngs syndrome
Imaging signs of bronchiectasis
Tramlines (increased lung markings)
Signet ring sign (CT chest)
Features of bronchiectasis
Chronic, productive cough
Dyspnoea, wheeze
Sputum
Haemoptysis
Recurrent chest infections
On examination; crepitations and expiratory wheeze
FEV1 staging of COPD
Post bronchodilator FEV1/FVC is less than <0.7 for all
Stage 1- mild (>80%)- if no symptoms, COPD can’t be diagnosed
Stage 2- moderate (50-79%)
Stage 3- severe (30-49%)
Stage 4- very severe (<30%)
Assess any of the following for potential LTOT in COPD
Stage 4 very severe (FEV1 less than 30%) (consider for stage 3 severe (FEV1 30-49%))
Cyanosis
Polycythaemia
Peripheral oedema
Raised JVP
Oxygen sats less than 92%
pO2<7.3
NB- Assessment is done by measuring arterial blood gases on 2 occasions at least 3 weeks apart in patients with stable COPD on optimal management.
General supportive management of COPD
Smoking cessation advice
Annual influenza vaccination
One off pneumococcal
Pulmonary rehabilitation (MRC grade 3)
Medical management of COPD
- SABA or SAMA
- Asthmatic/steroid responsive features- LABA+ICS, then triple therapy LAMA LABA + ICS (SAMA or SABA)
- No asthmatic/ steroid responsive features- LABA+LAMA (Switch SAMA to a SABA)
Asthma/steroid responsiveness features
Previous diagnoses of asthma or atopy, high blood eosinophils, FEV1 variation, diurnal variation of PEFR (20%)
Prophylactic antibiotic therapy in COPD
azithromycin prophylaxis is recommended in select patients
patients should not smoke, have optimised standard treatments and continue to have exacerbations
other prerequisites include a CT thorax (to exclude bronchiectasis) and sputum culture (to exclude atypical infections and tuberculosis)
LFTs and an ECG to exclude QT prolongation should also be done as azithromycin can prolong the QT interval
Investigations for IPF
Spirometry- restrictive picture (FEV1 normal/decreased, FVC decreased, FEV1/FVC normal or increased), reduced TLCO
Bloods- FBC UE LFT (infection?)
Imaging- bilateral interstitial shadowing on CXR, but CT scan is investigation of choice
ANA positive in 30 cases
Management of IPF
Refer to respiratory physician
Supportive management- smoking, substances, exercise, support with work diet etc.
Supplementary oxygen and if possible a lung transplant
Pirfenidone nintedanib may help (say “antifibrotics”)
Nicotine replacement therapy
N and v headache and flu like symptoms
Offer 2 forms if high dependency
Varenicline
Nicotine receptor agonist
1 week before stopping
12 weeks total
Nausea, headache, insomnia, abnormal dreams
Not in pregnancy, breast feeding, depression, self harm
Burporpion
Nicotine agonist and a norepinephrine and dopamine reputable inhibitor
1-2 weeks before stopping
Risk of seizure (b for bad)
Contraindicated in epilepsy, pregnancy breast feeding, eating disorder
Pregnancy and smoking cessation
CBT
NRT- remove patches before bed
CO2 and COPD
Acute retainers- low pH with a raised pCO2
Chronic retainers- raised bicarbonate. Over time kidneys have increased bicarbonate levels to balance acidic CO2 and maintain a normal pH.
Polycythaemia and COPD
When a patient has been referred to hospital;
If new- refer to respiratory
If long standing or already been seen by respiratory- repeat FBC in 2 months as outpatient (target 0.54)
Acute bronchitis
Cough- white clear productive sputum
Exclude pneumonia with a CXR
ESR below 100- conservative
ESR- above 100, systemically unwell, or co morbidities- doxycycline 5 days
Investigations for alpha 1 antitrypsin
Low serum-alpha 1-antitrypsin (screening test of choice)
Liver biopsy shows cirrhosis and acid-Schiff-positive staining globules (this stain highlights the mutant alpha-1-antitrypsin proteins) in hepatocytes
Genetic testing for the A1AT gene
High resolution CT thorax diagnoses bronchiectasis and emphysema
Management of bronchiectasis
Conservative- immunisations, exercise, postural drainage
Medical- ABX for exacerbations, long-term/prophylactic in severe cases, bronchodilators in selected cases
Surgery- surgery in selected cases
When to offer LTOT COPD in COPD
pO2 <7.3 or
pO2 7.3-8 and one of the following;
Secondary polycythaemia
Peripheral oedema
Pulmonary HTN
NB- don’t offer to people if they continue to smoke
NB- Assessment is done by measuring arterial blood gases on 2 occasions at least 3 weeks apart in patients with stable COPD on optimal management.
Non invasive ventilation
BiPAP or CPAP- involves forcing air into lungs (in between basic oxygen and intubation)
BiPAP- type 2 respiratory failure eg. COPD
CPAP- where airway is prone to collapse (Obstructive sleep apnoea, Congestive cardiac failure, Acute pulmonary oedema)
NB- BTS suggest NIV works best in COPD with respiratory acidosis pH 7.25-7.35, but it can be used in more acidotic patients (closer monitoring/HDU)
Immediate management of critically ill CO2 patient with very low sats
Reservoir mask at 15 litres/min
(hypoxia kills)
glycopyrronium
LAMA
