Case 3: Chronic Breathlessness Flashcards
Sympathetic innervation of bronchiolar smooth muscle is mediated by
noradrenaline
Sympathetic innervation of bronchiolar smooth muscle is mediated by noradrenaline acting on beta receptors to cause
bonchodilation
parasymp on lungs
bronchoconstriciton
parasymp receptor and agonist in lungs
acH on muscarinic causes bronchoconstriction
type 1 alveolar cells
simple squamous cells where gas exchange occurs
type 11 alveolar cells
synthesis of surfactant ….10% of cells in alveolar small cuboidal
Pneumocytes
alveolar cells
pulmonary arteries supply
deoxygenated blood from the right ventricle to the alveolar capillary network
Pulmonary veins carry
oxygenated blood from lungs to left atrium
the bronchial arteries supply oxygenated blood from the thoracic aorta to the
lung tissues
the bronchial veins drain deoxygenated blood to the
pulmonary and systemic venous systems
what conditions do you see breathlessness Variation in symptoms at different times of day
Answer(s): Asthma, Asthma/COPD overlap syndrome, Anxiety
Explanation: Diurnal variation in symptoms is a classic feature of asthma
what conditions do you see Night time symptoms breathlessness
Answer(s): Asthma, Asthma/COPD overlap syndrome
Explanation: Nocturnal symptoms are a classic feature of asthma
what conditions do you see symptoms when lying flat breathlessness
cardiac pathology
Explanation: Orthopnoea is a feature of congestive cardiac failure. The doctor could also have asked about paroxysmal nocturnal dyspnoea.
what conditions do you see ankle swelling breathlessness
Answer(s): Cardiac pathology, Pulmonary embolism
Explanation: Bilateral ankle swelling is a sign of cardiac pathology, especially congestive cardiac failure. Unilateral ankle swelling may be an indication of DVT/PE.
what conditions do you see chest pain breathlessness
Answer(s): Cardiac pathology, Pulmonary embolism
Explanation: If the patient answered ‘yes’ to this, you would want to explore this symptom further (for example using a SOCRATES approach) to help determine the likely cause of this pain
what conditions do you see Faintness/lightheadedness breathlessness
Answer(s): Cardiac pathology, Anxiety
Explanation: Cardiac pathology and very classically aortic stenosis can cause breathlessness with lightheadedness. Anxiety may result in lightheadedness or hyperventilation with tingling numbness around the mouth.
what conditions do you see Occupational history breathlessness
Answer(s): Occupational diseases, Asthma, Hypersensitivity pneumonitis
Explanation: There are a number of lung diseases associated with occupational exposure that need to be considered where appropriate. For example, coal miner’s pneumoconiosis, silicosis, beryllisosis, Farmer’s lung (a hypersensitivity pneumonitis). Occupational asthma is a type of asthma caused by exposure to inhaled irritants in the workplace.
what conditions do you see if you have had exposure to asbestos breathlessness
Answer(s): Asbestosis, Malignancy
Explanation: It is well documented that women exposed to asbestos by laundering their husband’s work clothes are at risk of asbestosis and mesothelioma. Asbestos exposure also increases the risk of lung cancer, in particular adenocarcinoma.
what conditions cause breathlessness due to pets
Answer(s): Asthma, Hypersensitivity pneumonitis
Explanation: Asking about pets and exposure to potential asthma-triggering allergens is important in a breathlessness history. Exposure to birds can also cause hypersensitivity pneumonitis in some people.
what condition causes breathlessness due to birds
Answer(s): Hypersensitivity pneumonitis
Explanation: A type of hypersensitivity pneumonitis due secondary to repeated inhalation of avian antigens is seen in bird keepers (sometimes known as ‘Pigeon Fancier’s Lung’).
what conditions causes breathlessness due to smoking
Answer(s): COPD, Malignancy, Cardiac Pathology
Smoking is a risk factor for many respiratory and cardiac pathologies and should always be asked about.
acute and chronic findings of hypersensitivity pneumonitis
Inhaled antigenic organic dusts: Farmer’s lung (moldy hay). Humidifier lung (thermophilic bacteria). Bird-fancier’s lung (avian proteins). Acute and chronic forms. Chronic disease findings: Interlobular and intralobular interstitial thickening. Honeycombing, Traction bronchiectasis. May spare costophrenic angles.
hemoptysis respiratory history
Haemoptysis is always useful to ask about when taking a respiratory history and is associated with a number of pathologies including lung cancer, tuberculosis and pulmonary embolism.
smoking history
Mrs Smith may well have a smoking-related lung disease, therefore it is very important to take a smoking history and to take the opportunity to make every contact count (I.e. have opportunistic conversations about behaviour change). Taking a detailed smoking history entails finding out the following information.
- Are they a current smoker?
- What age did they start smoking?
- Do they smoke cigarettes or roll-ups?
- How many cigarettes a day do they smoke? (If they smoke roll-ups, how much tobacco is used in a week? - half an ounce of tobacco is around 20 cigarettes.)
- Have they ever smoked more or less than they do now?
- Any breaks from smoking?
- Have they ever tried to give up? What was helpful? What were the challenges? Why did they start again?
- Have they tried nicotine replacement therapy before?
- Does anyone else in the house smoke, i.e., are they a passive smoker (living with other people who smoke also makes it more difficult to quit)?
- Is quitting smoking something they would consider now?
In consultations where smoking is important, but time is very short, we recommend the approach of ‘Ask, Advise, Act.’ For more information and a short e-learning package see the National Centre for Smoking Cessation and Training’s ‘Very Brief Advice on Smoking’.
what causes hyper inflated chest and conditions you see it in
Hyperinflated lungs can be caused by blockages in the air passages or by air sacs that are less elastic, which interferes with the expulsion of air from the lungs. Hyperinflated lungs are often seen in people with chronic obstructive pulmonary disease (COPD) — a disorder that includes emphysema.
polyphonic expiratory wheeze
Polyphonic wheezing consists of multiple musical notes starting and ending at the same time and is typically produced by the dynamic compression of the large, more central airways. Polyphonic wheeze is confined to the expiratory phase only.
Asthma vs COPD
Asthma usually involves acute (temporary) increases in airway resistance whereas COPDs are associated with chronic (long-lasting) increases in airway resistance
findings in COPD CXR
hyperinflation, flattened diaphragm, enlarged retrosternal space, dec. pulmonary vascular markings
LFT and COPD
Lung function tests (spirometry) are the only investigations that can definitively diagnose COPD, and can also determine whether there is any element of reversibility and enable classification of severity of COPD. It might alternatively reveal another diagnosis such as asthma or restrictive lung disease.
D-dimer test
is a global marker of coagulation activation and measures fibrin degradation products produced from fibrinolysis (clot breakdown). The test is used for the diagnosis of DVT when the patient has few clinical signs and stratifies patients into a high-risk category for reoccurrence. Useful as an adjunct to noninvasive testing, a negative D-dimer test can exclude a DVT without an ultrasound.
hallmark symptoms of COPD
Shortness of breath
Chronic cough
Sputum production
Other features include:
Winter exacerbations
Wheeze
extra signs of COPD
Tar-staining (fingers) – in developed countries, COPD is caused almost entirely by smoking but may also first present after an individual has stopped smoking
Chest hyperexpansion – a typical ‘barrel-shaped’ chest develops over time due to air trapping
Pursed lip breathing – this enables a patient to reduce their respiratory rate by increasing their period of expiration; it creates resistance to expiratory airflow and development of a positive expiratory pressure in the airways, reducing airway collapse and aiding ventilation
Accessory muscle use (neck/shoulder) – air trapping and hyperinflation impede effective chest expansion by the diaphragm and intercostal muscles, so the patient uses accessory muscles including the sternocleidomastoid, scalene, trapezius and abdominal muscles to aid ventilation
Peripheral oedema (ankles) – indicates right-sided heart failure due to cor pumonale
Palpable liver – may be due to hyperinflation of the lungs or congestive heart failure
Auscultation – you may hear reduced breath sounds, reduced heart sounds, tachypnoea and wheeze; during an exacerbation there may also be crepitations
Chest wall movement – reduced lateral (‘bucket handle’) chest expansion and increased vertical (‘pump handle’) chest expansion
alpha-1 antitrypsin deficiency
Panacinar emphysema
Intrahepatic accumulation of AAT molecules leading to cirrhosis
PAS stain +
COPD inflammation
Inhalation of noxious particles
Mediators released cause damage to lung tissue.
Airways inflamed
Parenchyma destroyed
goblet cell hyperplasia
causes sputum. COPD, also ariway narrowing and alveolar destruction - breathlessness and wheeze
gold standard for diagnosing COPD
Spirometry is the gold standard investigation for diagnosing COPD and grading severity of COPD. Spirometry machines measure the volume and flow rate of inspiration and expiration, and can therefore be used to diagnose obstructive and restrictive lung diseases. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) developed a classification system for severity of COPD disease based on spirometry. NICE guidelines were updated in 2018 to mirror this classification system.
mild >80%
moderate 50-80%
severe 30-50%
very severe <30%
cardinal feature of COPD
airway obstruction
COPD FEV1/FVC
<70%
why does Premature airway collapse happen in copd
structure damaged - airway not mantained
COPD staging
GOLD Criteria
FEV1/FVC of less than 70%
Then FEV1 of:
I (mild)- more than 80
II (mod)- 50-79
III (severe)- 30-50
IV (very severe)- less than 30
Obstructive flow volume loop in spirometry
short and wide loop
Restrictive flow volume loop
skinny and tall
COPD normal progression
Progressive decline in lung function
Progressive dyspnoea and disability
Right ventricular failure (‘cor pulmonale’)
Exacerbations become more frequent and contribute to morbidity and disability
cor pulmonale
right ventricular hypertrophy and heart failure due to pulmonary hypertension
fundamentals of COPD care
no smoking
vaccinations
physio
personalized plan
comorbities treat
COPD care
inhaled therapy oral add on
surgical therapy
oxygen
smoking cessation drugs
Drugs that blunt cravings for nicotine, including buproprion and varenicline
buproprion moa
inhibits reuptake of NE and dopamine
nicotinic antagonist
varenicline moa
partial agonist and antagonist at a4B2 nicotinic ACh receptors in the brain
inhaled therapies for COPD
SABA beta two receptors - bronchodilation
name some SABAs given to COPD patients
Albuterol
Levalbuterol
Pirbuterol
name a SAMA given to COPD patients
Ipratropium - Short acting muscarinic antagonist
what do we give for COPD treatment for those with no ashmatic features
LABA and LAMA
LABAs given to COPD patients
Salmeterol
Formoterol
LAMAs given to COPD patients
Tiotropium
Aclidinium
Umeclidinium
Glycopyrrolate
what do we give COPD patients with asthmatic features
LABA and ICS
name some ICS inhalers
beclamethasone, fluticason, budesonide
Step 3 COPD Treatment
LABA + LAMA + ICS
oral add ons COPD
theophylline, mucolytic
