CBL - COPD Flashcards
Describe the type of patient and their presentation that would make you consider a diagnosis of COPD [7]
- people who are >35yrs, smokers or ex-smokers with the following symptoms:
- exertional breathlessness
- chronic cough
- regular sputum production
- frequent winter “bronchitis”
- wheeze
How do you calculate smoking pack years? [1]
1 pack year = 20 cigarettes/day for 1 year
What features would you see in a full lung function test in a patient with COPD? [3]
- elevated (↑) TLC (total lung capacity) indicating hyperinflation (i.e. TLC >120% predicted)
- raised (↑) RV and RV/TLC ratio indicating airtrapping
- reduced (↓) transfer factor due to emphysema
What features would you see on CXR in a patient with COPD? [5]
- overinflation
- low and flattened diaphragms
- bullae
- pruned blood vessels with large proximal vessels
- relatively little blood visible in peripheral lungs
Define bullae [1]
thin-walled air-filled space within the lung, typically arising in emphysema
What are you looking for in a FBC when investigating a patient with suspected COPD? [2]
look for polycythaemia (raised Hb and PCV) if has chronic hypoxemia
When would you suspect the cause of COPD being due to alpha-1 antitrypsin deficiency? [3]
- early onset
- miminal smoking history
- family history
What are the common pathogens that can be found in a sputum sample in a patient with COPD? [2]
- haemophilus influenzae
- streptococcus pneumoniae
What is type 1 respiratory failure? [1]
- Hypoxic without hypercapnia and with an arterial partial pressure of oxygen (PaO2) of <8 kPa (<60 mmHg)
- i.e. low oxygen (↓O2) and normal or low carbon dioxide (-/↓ CO2)
What is type 2 respiratory failure? [1]
- Hypercapnia and hypoxia with an arterial partial pressure of carbon dioxide (PaCO2) of >6.5 kPa (>50 mmHg)
- i.e. low oxygen (↓O2) and high carbon dioxide (↑CO2)
Define COPD [1]
term used to cover a group of clinical syndromes (chronic bronchitis and emphysema) associated with airflow obstruction and destruction of the lung parenchyma
Define chronic bronchitis [1]
the production of sputum on most days for at least 3 months in at least 2 years (when other causes of chronic cough have been excluded)
Define emphysema [1]
abnormal, permanent enlargement of the airspaces distal to the terminal bronchioles
Describe the pathological changes associated with COPD [5]
inflammatory changes initiated by exposure to noxious particles or gases underlies most of the pathological lesions
- larger airways > 4mm in diameter
- hypersecretion of mucus
- hyperplasia of mucus glands in larger airways
- chronic inflammatory infiltrate - T lymphocytes (CD8), macrophages, neutrophils
- scarring and thickening of airways
Describe the features of small airways disease [4]
- early process in the development of COPD
- airways 2 - 3 mm in diameter, “ bronchiolitis”
- goblet cell hyperplasia
- narrowing of the bronchioles due to mucus plugging, inflammation and fibrosis
What inhaled therapies are given for breathlessness and exercise limitation in a patient with COPD? [2]
- short-acting beta agonist (SABA) or
- short-acting muscarinic antagonist (SAMA) as required
What inhaled therapies are given for exacerbations or persistent breathlessness in a patient with COPD with FEV1 ≥50%? [3]
- LABA (long-acting beta agonist)
- LAMA (long-acting muscarinic antagonist) & discontinue SAMA
- SABAs (as required)
What inhaled therapies are given for exacerbations or persistent breathlessness in a patient with COPD with FEV1 <50%? [3]
- combination inhaler:
- long-acting beta agonist (LABA) + inhaled corticosteroids (ICS)
- long-acting muscarinic antagonist (LAMA) & discontinue SAMA
- SABAs (as required)
What inhaled therapies are given for persistent exacerbations or persistent breathlessness in a patient with COPD? [4]
- combination inhaler:
- long-acting muscarinic antagonist (LAMA) +
- long-acting beta agonist (LABA) +
- inhaled corticosteroid (ICS)
- SABAs (as required)
Give 2 examples of a SABA [2]
short-acting beta agonist = salbutamol, terbutaline
Give an example of a SAMA [1]
short-acting muscarinic antagonist = ipratropium
Give an example of a LABA [1]
long-acting beta agonist = salmeterol
Give an example of a LAMA [1]
long-acting muscarinic antagonist = tiotropium
What oral therapies can be given to patients with COPD and when are they used? [3]
- Oral corticosteroids
- used in short courses for exacerbations of COPD
- Mucolytics
- e.g. carbocysteine
- Helps in sputum expectoration
- Oral theophyllines
In an exacerbation of COPD, what SpO2 levels should you aim for to avoid patients developing hypercapnia? [1]
88-92%
What are the signs of a pink puffer and what does it indicate? [5]
- high respiratory drive
- ↓PaO2
- ↓PaCO2
- desaturates on exercise
- indicates Type 1 respiratory failure
What are the clinical features seen on examination of a pink puffer? [5]
- pursed lip breathing
- uses accessory muscles
- wheeze
- indrawing of intercostals
- tachypnoea
What are the signs of a blue bloater and what does it indicate? [7]
- loss of central sensitivity to CO2
- reliance on hypoxic drive to stimulate breathing
- low respiratory drive
- ↓PaO2
- ↑PaCO2
- right heart failure (oedema)
- indicates Type 2 respiratory failure
What are the clinical features seen on examination of a blue bloater? [9]
- confusion
- drowisness
- cyanosis
- wheeze
- hypoventilation
- warm peripheries
- bounding pulse
- flapping tremor
- peripheral oedema
Define an exacerbation of COPD and what are the commonly reported symptoms of an exacerbation? [5]
- sustained worsening of the patient’s symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset.
- Commonly reported symptoms:
- worsening breathlessness,
- cough,
- increased sputum production
- change in sputum colour
How do you manage an exacerbation of COPD in a hospital setting? [7]
- Assess severity:
- symptoms
- ABG
- CXR
- Controlled oxygen therapy:
- 24-28 % oxygen,
- aim to maintain SpO2 88-92%
- repeat ABGs at 1 hour
- Bronchodilators:
- nebulised salbutamol 2.5-5mg
- ipratropium bromide 0.5mg qds (and PRN)
- consider IV aminophylline if not improving
- Corticosteroids:
- prednisolone 30-40 mg od
- Antibiotics:
- if signs of bacterial infection (purulent sputum, increased sputum volume, ↑WCC, ↑CRP)
- Non-invasive ventilation (NV):
- for acidotic type Il respiratory failure
- Other:
- consider DVT prophylaxis (LMWH),
- monitor fluid balance and nutrition,
- manage co-morbidities
Define pleural effusion [1]
fluid in the pleural space
What are the clinical signs of a pleural effusion? [3]
- decreased breath sounds,
- stony dull to percussion,
- decreased tactile or vocal fremitus
What are the clinical features of a pleural effusion on CXR? [4]
- need >500ml of fluid to be present to see on CXR
- uniformly white appearance
- blunting of the costophrenic and cardiophrenic angles.
- a meniscus at the upper edge
When you take a pleural aspirate, what should you send the samples for? [4]
- send samples for:
- biochemistry,
- pH,
- cytology
- microbiology
What are the 2 categories of pleural aspirate, what are the fluid protein levels of each and what are the typical causes of each type? [10]
- Exudate
- fluid protein usually >30 g/l
- e.g. in…
- pneumonia,
- malignancy,
- TB
- Transudate
- fluid protein <30 g/l (usually <20 g/l)
- e.g. in…
- heart failure,
- liver failure,
- nephrotic syndrome
