Case 7 - COPD

Question 1

What are the issues Mr Craven voices in the video?

Answer 1

Breathing problems – breathlessness, finds himself catching his breath more often, e.g. when climbing stairs at home. His wife has noticed. A year ago – was fine running for and catching the bus, and climbing stairs. Now can’t walk as far as he used to in 10 mins, slower pace. A smoker. No breathlessness at rest, SOBOE (shortness of breath on exertion)

No flem, no cough

Question 2

What are the possible differential diagnoses given the information so far (On Mr Craven)?

Answer 2

COPD - smoking history, SOBOE

Lung cancer - smoking history

Asthma

Leaky heart valve - impaired blood flow = less oxygenated blood circulates around the body

Pulmonary fibrosis

Pulmonary embolism

Pneumothorax - air trapped between the lung tissue and the pleura (squishes the lung tissue)

Lower respiratory tract infection

Congestive heart failure

Pulmonary oedema

Vascular defects

Acute cornoary syndrome

Anaemia

Renal or liver failure

Deconditioning - muscle get weaker over time due to lack of use

Obesity

Question 3

What causes SOBOE on a cellular level?

Answer 3

Insiffucient oxygen delivery in times of need (i.e. during exertion)

Question 4

What are some key questions that can be asked to narrow down the differentials?

Answer 4

How long has he noticed his symptoms?

Gradual or sudden onset?

Is there any pain? - some heart conditions, pulmonary embolism, or lung cancer if the tumour is located near the edge of the lung where it irritates the pleura

Does it wake you up at night?

Have you made any changes to your life?

Does it get worse when lying down? - some heart conditions get worse when lying flat, if the left side of the heart does not work as well, the blood pools in the lungs especially when lying down (less so when standing due to gravity)

Is there a fever?

Have you had any leg swelling? - e.g. pitting oedema, if the right side of the heart is not working, blood pools in the system veins, gravity causes swelling in the leg veins

Are there any changes to your urine?

What is his occupation? - e.g. construction worker = asbestos can irritate lungs and cause scarring, working with chemicals e.g. in factories or mines

Do you have a cough / flem with your cough? - heart /systemic conditions less likely, lung cancer, asthma, COPD, infection etc.

Question 5

What are a few things to look for on examination to narrow down the differentials?

Answer 5

Abnormal lung sounds - if the patient had COPD, likely to hear wheezing due to turbulent flow of air (rather than laminar flow, which is normal), pneumonia = crackling due to mucus

Cyanosis check - bluish tinge to mucous membranes in the hands and feet

Barrel chest - when the chest is hyper expanded, contains more air than usual

Tar staining on the fingernails - smoking

Heart - listen for murmurs / leaky valves

Clubbing - finger nail changes e.g. lung cancer

Question 6

Why may smokers may not say they have a cough?

Answer 6

Smoking causes coughing, so if they have been smoking for a long time, they may not notice they have a chronic cough as it is a part of their daily life

Question 7

What are some tests that can be ordered on Mr Craven?

Why? What may be seen on the tests / what could they indicate?

Answer 7

Chest X-ray - signs of heart failure, pulmonary pathology

Blood test - to detect anaemia (full blood count), allergies or any thyroid, liver, kidney or heart failure (look for BNP, B-type natriuretic peptide, levels)

Spirometry - ostructive or restrictive condition

ECG - record your heart’s electrical activity, heart failure, arrhythmia, pulmonary embolism

Echocardiogram - non-invasive ultrasound of heart

Urea and electrolytes, and random blood glucose level - renal failure and diabetes as causes of metabolic acidosis and breathlessness

Question 8

Looking at Mr Craven’s graph, what are his:

a) FVC?
b) FEV₁
c) FEV₁ : FVC ratio?

Answer 8

a) total volume expelled from total inspiration to total expiration - 3.95 L
b) the volume of air expelled after the lungs have been completely filled - 2.3 L
c) 0.58 (normal is generally above 0.8)

Question 9

Look at Mr Craven’s results, is he more likely to have an obstructive or restrictive defect?

Answer 9

Obstructive

Question 10

Define what is meant by the terms obstructive and restrictive defects, and what are some possible causes?

What are some examples of each of them?

Answer 10

Obstructive = blockage of the airways affecting flow of air e.g. cystic fibrosis, asthma, COPD, chornic bronchitis, tumours, emphysema etc. FEV₁ : FVC ratio less than 0.7 = indicative of this - less than 70% of the total is expelled within the first second suggetsing blockage of the airflow

Restrictive = the chest is unable to expand to their fullest so less air is drawn in as normal e.g. obesity, pulmonary fibrosis (scarred lungs), scoliosis (affects curvature of spine laterally, ribs and lungs are unable to expand in the correct way so less flow into the lungs), neuromuscular conditions (muscular dystrophy), etc. FVC is lower than normal, FEV₁ is normal or proportionally decreased with the FVC, FEV₁ : FVC ratio can be normal or get increased

Question 11

Scoliosis Vs kyphosis

Answer 11

Lateral deviation ‘S’ on the back

‘S’ shaped curvature coming out of the back

Question 12

What does COPD stand for?

What are the disease processes of the COPD? (2 main conditions)

Answer 12

Chronic Obstructive Pulmonary Disease

2 main conditions can cause it - emphysema or bronchitis

Question 13

What is the pathophysiology for both of these 2 conditions? (emphysema and bronchitis)

How are they both obstructive diseases?

Answer 13

Emphysema = damage to the elastin in the alveoli from the elastase enzyme, so the alveoli are unable to expand and recoil, so larger alveoli that cannot recoil reducing the SA:V ration, reducing SA available for gas exchange. Obstructive because alveoli that can recoil form a pressure that allow for the airways to remain open, however, without this elastin, there is less force keeping the airways open

Bronchitis = airway epithelium is irritated by smoke, pollutants etc. leading to inflammation and excess mucus production. Mucus causes the flemmy cough. Scarring and thickenning of tissue = increased mucus production narrowing airways due to blood flow to the area causing swollen walls that narrow the lumen and so affecting breathing. Inflammation, hypertrophy of goblet cells = increased mucus secretion

bronchiectasis - usually caused from bronchitis - airways dilate = scarring = more mucus production

Question 14

What do COPD patients have pathophysiologically?

Answer 14

Some have only bronchitis, others have only emphysema, but most patients normally have a bit of both

Question 15

What are the differences between these 2 x-ray images?

Answer 15

Differences:

Flattened diaphragm

Heart looks smaller - more elongated and narrowed

More white / opaqueness at the bottom = breast tissue

Coming out of the vertebrae at the back = posterior rib, and followed around forms the anterior rib

Question 16

What is meant by the term ‘barrel chest’?

What are bullae? How do they look on the x-ray?

Can cartilage be seen on an x-ray?

Which of the COPD conditions can cause barrel chest?

Answer 16

Hyperexpanded chest - hyperinflation signs that can be seen on an x-ray, more than 7 anterior ribs visible at the midclavicular line, flattened diaphragm, heart may appear smaller and narrowed as the lung tissue has moved down as it so full and pulls down th eheart with it.

Bullae - when the alveoli get so damaged they become a singular unit and become very large so the outside wall is very delicate. Bullae can burst, causing a pneumothorax (as the air leaks into the pleural space). They can be seen on x-rays like bubbles - faint white outline of lung tissue and blacker middles where the air is

Not really, turns up as black - why the ribs are visible from the posterior (where it is bone), and then disappear towards the anterior (where it turns to cartilage)

Emphysema - due to expanded, unrecoiled alveoli

Question 17

How may the GP support Mr Craven with smoking cessation?

Answer 17

Discuss smoking cessation with Mr Craven - whether Mr Craven is ready to stop smoking, right time for him?

Refer Mr Craven to smoking cessation specialist to discuss further options - education, medications (medications to quit or medications to replace nicotine), therapies

Could try nicotine replacement therapy - e.g. gum, sprays, patches, inhalers etc.

Support groups

Question 18

How may the GP support Mr Craven with nutrition to improve?

Answer 18

Fruit and veg to boost immune system

Malnourished = weak muscles = weaker breathing, obese = restrictive defect on top of obstructive

Many COPD patients are malnourished = refer to a dietician, meal prep plans to improve diet

GP may give infographics to patients for them to read to self-improve nutrition

Question 19

How may the GP support Mr Craven with keeping well in the cold?

Answer 19

Flu jabs, anti-pneumococcal jabs, infective exascubation of COPD, pack of antibiotics given to patient to take when they get an infection, keeping warm in the winter etc.

Question 20

What are the 3 main categories of COPD drugs? What are their mechanisms and an example drug of it?

Answer 20

Beta-2-agonist = SNS causes bronchodialtion so agonists that act on those receptors simulates SNS activity to dilate the bronchi

Anti-cholinergics (AKA muscarinic antagonists - chemicals that block muscarinic ACh receptors) = brincho are usually naturally slightly constricted, these dilate the bronchi completely

Steroid inhalers - corticosteroids - reduce inflammation

Short acting (for beta-agonatics and anticholinergics) = rescue therapy - taken when experiencing shortlessness of breath

Long acting (for beta-agonatics and anticholinergics) = maintenance = acts throughout the day

Mucolytic = oral mediation, NOT INHALED - break down sputum so it is easier to cough up

Question 21

What does Mr Craven’s patient profile reveal about him?

Answer 21

A huge fan of Glasgow Rangers

Had a chest infection recently - took amoxicillin

Grew up in Glasgow, both parents were smokers

Enjoys fly fishing

Works as a British gas plumber

30 pack-year smoking history

Took his wife to the cinema for their anniversary

Question 22

What are the 4 main causes of breathlessness?

Answer 22

1. Lung conditions
2. Heart conditions
3. Anxiety
4. Being unfit

Question 23

How do lung conditions cause breathlessness?

What lung conditions cause long-term (chronic) breathlessness?

What lung conditions cause short-term (acute) breathlessness?

Answer 23

Airways = inflammed and narrowed, or filled with phlegm - harder for air to move in and out; or loss of elasticity - reduced expansion and recoil with air filling

COPD, asthma, lung cancer, pulmonary fibrosis, bronchiectasis (airways scarred and inflammed with mucus), asbestos irritation

COPD/asthma flare up, pulmonary embolism, pneumothorax, pneumonia, TB, build up of fluid in the lungs

Question 24

How do heart conditions cause breathlessness?

What heart conditions cause acute breathlessness?

What heart conditions cause chronic breathlessness?

When does breathlessness caused by heart conditions worsen?

Answer 24

Heart failure - issues with the rhythm, valves or cardiac muscle of the heart; or inability to increase cardiac output during exercise

Heart attack, abnormal heart rhythm

leaky valve - cause fluid to pool (esp. when laying flat)

During the night / when asleep

Question 25

What is anxiety characterised by? Why?

What are panic attacks? What are the symptoms of panic acttacks?

Answer 25

Shortness of breath, tight feeling in the chest, tense muscles, faster breathing - body’s ‘fight or flight’ situation to a stressful situation

Body’s normal response is exaggerated, you get a rapid build-up of physical responses. Body releases hormones to increase breathing and heart rate, body tried to take in more oxygen - pounding heart, feel faint, sick, sweaty, shaky limbs, disconnected from your body

Question 26

Why can being unfit cause breathlessness?

What are the issues associated with being underweight or overweight that cause breathlessness?

What condition can people severely overweight develop and what is it characterised by?

Answer 26

Unfit = weaker muscles = weaker respiratory muscles = weaker breaths

Underweight = less muscle mass, weaker respiratory muscles

Overweight = esp. BMI over 25, more effort to breathe and move around with excess weight that needs to be lifted off the chest and abdomen when breathing (limits lung expansion - restrictive)

Obesity hypoventilation syndrome - poor breathing leads to lower O₂ levels and higher CO₂ levels in the blood

Question 27

What are some other reasons to long-term breathlessness?

Answer 27

Smoking

Kidney disease

Conditions that affect the muscles - muscular dystrophy, motor neurone disease

Postural conditions - scoliosis, kyphosis

Thyroid disease

Anaemia - fewer RBCs to carry O₂

Question 28

When going to see the doctor, how should you prepare to discuss the issue of breathlessness?

What are the 3 points that should be raised?

Answer 28

Think of how to describe it - going to the doctors may be a short journey, where you spend most of your time sitting, so you may not actually be breathless during the appointment

Bring along someone to help describe the issue

what you used to be able to do that you can’t do any more

what people of your age around you do that you think you should be able to do

what your personal goals are for your day-to-day activity

Question 29

What is the MRC breathlessness scale?

Why is the MRC scale good, and used by professionals often?

Answer 29

Proposed by the Medical Research Council - scale of 1-5 (look at image)

Takes out the subjective component - does not focus on how it makes the patient feel. It is instead objective, describes what it stops the patient doing

Question 30

What might a doctor ask in response to a patient raising concerns about breathlessness?

Answer 30

Gradual or sudden onset?

Occupation?

Pain?

When it gets worse?

Extent of breathlessness?

Smoking history? Exercise?

Family history and own medical history - heart, lung or thyroid disease or anaemia?

Mental health - fear, anxious, hopelessness, depressed?

What you are currently doing to cope?

Question 31

What examinations might a doctor carry out in response to breathlessness concerns?

Answer 31

No. of breaths per minute
Listen to your chest
Feel how your chest moves as you breathe
Heart rate and rhythm
Blood pressure and temperature
Height, Weight, Waist and BMI
Examine head/neck and armpits for swollen lymph glands
Look at eyes, nails, skin and joints
Blood oxygen levels

Question 32

What is the sequence of events that should take place if there is suspected COPD or asthma?

How can these be differentiated?

Answer 32

1. Assess airway obstruction using a spirometry test -
2. Distinguish COPD from asthma using - smoking history (COPD>asthma), age (COPD>35 generally), chronic cough (COPD>asthma), breathlessness (COPD = progressive, asthma = variable), night time wakening with breathlessness (asthma>COPD)
3. Further distinguishers - response rate to bronchodilators (asthma>COPD), if FEV₁ : FVC ratio returns to normal with drugs (asthma>COPD)

Question 33

Before a confirmed diagnosis of COPD, what else must be done?

Answer 33

1. Chest radiography to excluse any other serious lung pathology (e.g. lung cancer), and full blood count (to excluse e.g. anaemia)

Question 34

What is the sequence of events that should take place for suspected heart failure?

Answer 34

ECG

BNP levels - for those without previous history of MI

Specialist referral (seen within the next 2 weeks) - previous history of MI

Question 35

What is the sequence of events that should take place for suspected bronchiectasis?

Answer 35

Chest radiography to exclude other causes

Refer to respiratory specialist to confirm diagnosis via CT scans

Question 36

What is the sequence of events that should take place if suspected pleural effusion?

Answer 36

Build up of fluid between the pleura (membranes outside the lungs)

Chest radiography to confirm diagnosis

Question 37

What is the sequence of events that should take place if suspected lung cancer?

Answer 37

Urgent chest x-ray in people aged over 40 (within 2 weeks)

Question 38

What is the main cause of preventable illness and premature death in the UK?

What are some withdrawal symptoms associated with smoking cessation?

Answer 38

Smoking

Nicotine cravings, irritability, depression, restlessness, poor concentration, light-headedness, sleep disturbances, and increased appetite

Question 39

What is recommended to be the most effective approach?

Where should patients wishing to stop smoking be referred to?

Answer 39

Abrupt quiting
Combination of drug treatment and behavioural support

local NHS stop smoking services
if they decline, then refer them to a suitable healthcare professional

Question 40

What are the 3 treatment options to help stop smoking?

What are the most effective options?

What can be used if the most effective treatments options are not appropriate?

Answer 40

Nicotine replacement therapy, Varenicline (Champix) and Bupropion hydrochloride

Varenicline OR combination of long-acting NRT (transdermal patch) and short-acting NRT (lozenges, gum, sublingual tablets, inhalator, nasal spray and oral spray)

Bupropion hydrochloride or single therapy NRT

Question 41

What should be considered when deciding which drugs to prescribe?

Answer 41

Smoker’s adherence
Preference
Previous experience of smoking-cessation aids
Contra-indications
Side effects
Pregnancy/ Breastfeeding

Question 42

How are transdermal patches (long-acting NRT) applied?

When are short acting nicotine preparations used?

How may smokers who are unwillingly to stop use NRT?

Answer 42

placed for 16 hours, removed overnight - if they experience cravings on waking a 24 hour patch can be used

Whenever the urge to smoke occurs or to prevent cravings

‘Harm reduction approach’
Smoking reduction
Temporary abstinence
Improves chance of stopping smoking in the long term

Question 43

How do e-cigarettes work?

How does smoking affect pregnancy?

Answer 43

Deliver nicotine without the toxins found in tobacco smoke
Cannot be prescribed

Harmful effects of exposure to second-hand smoke for both mother and baby
Ongoing support should be offered during and following pregnancy
NRT should only be used in pregnant females if non-drug treatment options have failed

Question 44

What is found in smoke that may cause an increase in dose in other drugs the patient is taking?

Answer 44

Polycyclic aromatic hydrocarbons found in tobacco smoke increase the metabolism by inducing hepatic enzymes of some drugs

Question 45

What forms of NRT are available?

How long does NRT treatment last? How should NRT treatment be used?

Who can use NRTs?

What are the possible side effects of NRTs?

Answer 45

Skin patches, chewing gum, inhalators, tablets, oral strips and lozenges, nasal and mouth spray

Typically 8-12 weeks, gradually reduce the dose, eventually stop

Over 12s (although under 18s shouldn’t use lozenges without medical advice) pregnant women, breastfeeding women can all use NRTs

Skin irritation, irritation of nose, throat or eyes, difficulty sleeping, upset stomach, dizziness, headaches

Question 46

Where can one get Vareniciline and how is Varenicline taken?

Who cannot take Varenicline?

What are the side effects of Varenicline?

Answer 46

Only on prescription, 1-2 tablets a day, starting a week or two before starting to quit and treatment usually lasting 12 weeks

Children under 18, pregnant/Breastfeeding women, people with severe kidney problems

Feeling and being sick, difficulty sleeping (insomnia),, sometimes with vivid dreams, dry mouth, constipation or diarrhoea, headaches, drowsiness, dizziness

Question 47

Where can one get Bupropion hydrochloride and how is it taken?

Who cannot take Bupropion hydrochloride?

What are the side effects of Bupropion hydrochloride?

Answer 47

1-2 tablets a day, start 1-2 weeks before quitting, usually lasts 7-9 weeks with treatment

Cannot be taken by people with epilepsy/bipolar disorder/ eating disorders

dry mouth, difficulty sleeping (insomnia), headaches, feeling and being sick, constipation, difficulty concentrating, dizziness

Question 48

What are the fundamentals of COPD care?

Answer 48

Offer treatment and support
Offer pneumococcal and flu vaccines
Offer pulmonary rehab
Co-develop a self-management plan
Optimise treatment for co-morbidities

Question 49

When are inhaled therapies needed? What are the 2 most common inhaled therapies?

Answer 49

To relieve breathlessness and exercise limitation; or other therapies were not successful - SABA and SAMA

Question 50

What is a pMDI?

What is the inhaler technique?

Why is it important to get the technique right?

Answer 50

Pressurised metered dose inhaler (AKA a ‘puffer’)

For a new inhaler / an inhaler that hasn’t been used for 5 days, take off the cap, shake and do test sprays into the surrounding air. Check dose counter is not empty. Stand / sit straight, tilt head up (helps medicine reach lungs). Breathe out, wrap lips around mouth piece, breathe in slowly while pressing the pump. Hold breath (10 seconds max). Remove inhaler. Breathe out. Wait 30 seonds - 1 min for next puff (if prescribed 2nd puff). Replace cap. If inhaler contains steroids, rinse mouth.

Correct technique = more effective = better management of symptoms

Question 51

What is a spacer? Why is it used?

What is the ‘tidal breathing’ technique?

Answer 51

Used alongside the inhaler, usually when the person cannot hold their breath for more than 5 seconds (E.g. during an asthma attack). Requires the ‘tidal breathing’ technique

Can be used to reduce side effects and alleviate symptoms - gets medicine into lungs more effectively = lower medication dosage

–

Hold inhaler upright, take off cap, shake well

Place inhaler into the hole at the back fo the spacer

Sit or stand up straight, tilt chin up

Wrap lips around spacer mouth piece, tight seal, breathe in and out 5 times whilst pressing cannister ont he inhaler once

Remove spacer and inhaler - if prescribed a 2nd puff, repeat after 30 secs - 1 min

Detach spacer and inhaler, replace caps, rinse mouth if inhaler contains steroids (rinsing = reduced side effects)

Question 52

What is an SMI?

How is an unused inhaler primed?

How many times does the inhaler need to be primed?

Answer 52

Respimat inhaler

Hold your inhaler upright, with the cap closed. Twist the base in the direction of the arrows until it clicks. Push up the catch on the side of the inhaler and open the cap. Point the inhaler towards the floor away from you and press the big grey button. Close the cap. If you do not see a white cloud, repeat this sequence until you see a cloud

If not used in 1 week: Once
If not used in 3 weeks: 3 times

Question 53

How is the SMI used?

Answer 53

Prime the inhaler

Twist until clicks and open cap

Check dose counter (not empty)
Hold horizontally
Sit or stand up straight
Tilt chin up
Breathe out gently and slowly
Make tight seal with lips
Breathe in steadily and press grey button

Hold breath for at least 10 seconds

Exhale away from the inhaler

Replace cap, rinse mouth if inhaler medication conatins steroids

Question 54

What is a turbohaler inhaler?

What is the technique to use a turboinhaler?

Answer 54

A type of DPI (dry powder device inhaler)

Prime - Twist off cover and hold upright, turn base one way and then the other until a click is heard. Repeat this sequence once more

Hold upright
Sit or stand up straight
Tilt chin up
Breathe out gently and slowly
Make tight seal with lips
Breathe in steadily and press grey button
Hold breathfor at least 10 seconds

Question 55

How do you choose the right device (pMDI, DPI or SMI) for the patient?

Answer 55

1. Assess patient’s inspiratory ability - can they breathe quick and deep (2-3s); can they breath slow and steady (4-5s)? –> If they can only do quick and deep = DPI; if they can do both = any of them; if they ca only do slow and steady = pMDI or SMI
2. Engage patient in inhaler technique - choose device they are able to use most effectively