Case 2 - COPD Flashcards
Other than smoking, other causes of COPD?
- Inhaled illicit drugs
- Pollution
- Smoke exposure - coal/wood burning stove
- Chronic bronchitis
- Genetic - alpha 1 antitrysin deficiency
What is COPD?
- Airflow obstruction
- Progressive
- Not fully reversible
- predominantly caused by smoking
Pathophyisology of COPD
- Ephysema and chronic bronchitis =
- Mucous gland hyperplasia
- Loss cilia function
- Emphysema - alveolar wall destruction causing enlarged air spaces distal to terminal bronchiole
- Chronic inflammtion - macrophages and neutrophils –> fibrosis of small airways
Management of COPD outpatient
COPD care bundle:
* Smoking cessation
* Pulmonary rehabilitation
* Bronchodilators
* Antimuscarinics
* Steroids
* Mucolytics
* Diet
* LTOT - if suitable
* Lung volume reduction surgery - if appropriate
Who manages someones COPD?
MDT approach
3 things used to manage COPD which improve mortality
- Smoking cessation
- LTOT
- Lung volume reduction surgery
Why do we use LTOT for COPD?
- Extended hypoxia –> renal and cardiac damage
- Prevent this using LTOT
Criteria for LTOT
- pO2 consistently below 7.3kPa OR below 8kPa with polycythaemia, peripheral oedema or pulmonary HTN
- No CO2 retention
- O2 needs balanced with loss of independence and loss activity
NOT a treatment for breathlessness, treat hypoxia instead
What does pulmonary rehabilitation aim to do?
- Stop cycle of inactivty
- When breathless people do not exercise =
- You do less = muscles weaken
- = get more breathless
- = feel depressed and avoid activity even more
What does pulmonary rehab stop?
- Inactivity
- Social isolation
What does pulmonary rehabilitation involve?
6-12 week programme of supervised, unsupervised exercise, nutritional advice, disease education and peer support
Two types of COPD exacerbation
Infective - change in sputum volume/colour, fever, raised WCC +/- CRP
Non-infective
Overall manageemnt of COPD exacerbation
ABCDE
* Oxygen - sats aim for 94-98% unless evidence of acute or previous T2RF - then change to 88-92%
* NEBs - salbutamol and ipratropium
* Steroids
* Abx if raised CRP/WCC or purulent sputum
* CXR
What to consider if T2RF and pH 7.25-7.35?
NIV - eg BiPAP
What medication to consider if steroids and NEBs and O2 not helping exacerbation?
- IV aminopylline? - not a lot of evidence for this
What to consider if pH on ABG is <7.25?
ITU referral - invasive ventilation may be needed
Dose of steroid in COPD exacerbation
30mg oral prednisolone (is 40 in asthma)
What must we get before commencing NIV?
CXR - check if any untreated pneumothorax - contraindication for NIV
Contraindications for NIV
- Untreated pneumothorax
- Impaired consciousness (GCS <8)
- Upper airway secretions
- Facial injury
- Long term hypoxia
- Vomit
- If agitated
What is lung volume reduction surgery?
- Used when localised emphysema to lobe - heterogenous emphysema
- Removal of part of lung to make overall lung better
- Use CT scan to determine if suitable
Why is smoking cessation encouraged in COPD?
SLOWS rate of decline of FEV1
At any age you give up
LTOT minimum amount of time per day for benefits
16 hrs per day
Stepway management of COPD
- SABA or SAMA
- LABA + ICS- if suggest will be steroid responsive - if still nothing –> LAMA, LABA and ICS
- If no steroid responsiveness try LABA and LAMA
