Chronic - COPD Flashcards
What is COPD?
COPD is an umbrella term encompassing the older terms chronic bronchitis and emphysema. Characterised with airflow obstruction which is progressive, not fully reversible and does not change markedly over several months
What is COPD caused by?
- Smoking (MOST COMMON)
- Alpha-1 antitrypsin deficiency
- Industrial exposure e.g. soot
- Air pollution
- Frequent lower respiratory tract infections during childhood
What are the signs of COPD?
- Pursed lip breathing – protective manoeuvre that increases pressure within the airways causing a delay in the closure
- Tachypnoea – increased resp rate to compensate for hypoxia and hypoventilation
- Use of accessory muscles of respiration – leaning forward onto something due to difficulty in moving air in and out of the lungs
- Barrel chest – hyperinflation and air trapping due to incomplete expiration
- Hyper-resonance on percussion
- Reduced intensity of breath sounds
- Reduced air entry
- Wheezing
What investigations are recommended in patients with suspected COPD?
- post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70%
- chest x-ray
- hyperinflation
- bullae: if large, may sometimes mimic a pneumothorax
- flat hemidiaphragm
- also important to exclude lung cancer
- full blood count: exclude secondary polycythaemia, eosinophilia can show asthmatic features
- body mass index (BMI) calculation
What is involved in the general management of COPD?
- >smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
- annual influenza vaccination
- one-off pneumococcal vaccination
- pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)
What bronchodilator therapy can be offered first-line for symptomatic relief in COPD?
a short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is first-line treatment
for patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by whether the patient has ‘asthmatic features/features suggesting steroid responsiveness’
What criteria determine whether a patient with COPD has asthmatic/steroid responsiveness?
- any previous, secure diagnosis of asthma or of atopy
- a high blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
- substantial variation in FEV1 over time (at least 400 ml)
- substantial diurnal variation in peak expiratory flow (at least 20%)
A patient with COPD is still having breathlessness despite treatment with a SABA. They have asthmatic features/features suggesting steroid responsiveness. What is the next step in management?
A patient with COPD is still having breathlessness despite treatment with a SABA. They have no asthmatic features/features suggesting steroid responsiveness. What is the next step in management?
If long trials of short and long-acting bronchodilators are not helping with SOB in COPD, what is the next step?
oral theophylline
Which antibiotic is given as oral prophylactic antibiotic therapy in COPD? When should it ben given?
Repetitive infective exacerbations - prophylactic azithromycin
Have to meet strict criteria:
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
What can be given for chronic productive cough?
mucolytics e.g. carbocysteine
What are the features of cor pulmonale? How is it managed?
- features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2
- use a loop diuretic for oedema, consider long-term oxygen therapy
- ACE-inhibitors, calcium channel blockers and alpha blockers are not recommended by NICE
What factors improve survival in stable COPD?
smoking cessation - the single most important intervention in patients who are still smoking
long term oxygen therapy in patients who fit criteria
lung volume reduction surgery in selected patients
What does a typical flow volume and volume time for spirometry look like in COPD?
What is the MRC dyspnoea scale?
