Chronic Obstructive Pulmonary Disease Flashcards
What medication did he recently take for his chest infection?
Amoxicillin
What is his smoking history?
30 pack-year
What symptoms and signs does Mr Craven present with?
‘Catching his breath a bit over the last few months’
Finds climbing the stairs and running for more difficult
Slower pace when walking
What does the GP suggest?
Breathing test using spirometer
Set up meeting with stop smoking counsellor
What does the GP say is the best way to stop smoking?
Combination of medication and specialist support
What are the 4 main causes of breathlessness?
Lung conditions
Heart conditions
Anxiety
Being unfit
How can lung conditions cause breathlessness?
Cause airways to become inflamed and narrowed
Fill the airways with phlegm so it harder for air to move in and out of the lungs
Make the lungs stiff and less elastic so its harder for them to expand and fill with air
Give examples of lung conditions that can causes long-term breathlessness?
COPD Asthma Interstitial Lung disease (inc. pulmonary fibrosis) Bronchiectasis Industrial/Occupational e.g. asbestosis Lung cancer
What lung conditions cause acute breathlessness?
Asthma/COPD flare up Pulmonary embolism Pneumonia Tuberculosis Pneumothorax Collapsed lung Build up of fluid in lung or lining of lungs
How can chronic breathlessness be caused by heart conditions?
Problems with: Rhythm Valves Cardiac muscles Heart is unable to increase its pumping strength in response to exercise
When might heart failure due to breathlessness worsen?
Worse at night or when asleep
Which heart conditions can cause acute breathlessness?
Heart attack
Abnormal heart rhythm
(palpitations)
How can anxiety cause breathlessness?
Normal body response by your body to what you think is a stressful situation
Your body prepares for action
As you get more anxious you may start to breather faster and tense your breathing muscles
What is a panic attack?
When your body’s normal response is exaggerated
Rapid build up of physical responses
Body tries to take in more oxygen so heart beats faster and muscles tense
What are the symptoms of a panic attack?
Have a pounding heart Feel faint Sweat Feel sick Have shaky limbs Feel you're not connected to your body
Why might being unfit cause breathlessness?
Muscles get weaker
Weaker muscles need more oxygen to work
How can being an unhealthy weight make us feel breathless?
Underweight: Breathing muscles will be weaker
Overweight: More effort to breathe and move around
Having more weight in chest or abdomen restricts how much you lungs can move
What BMI value will mean you are more susceptible to breathlessness?
25
What can people who are severely overweight develop?
Obesity hypoventilation syndrome
Want is obesity hypoventilation syndrome?
Poor breathing leads to lower oxygen levels and high CO2 levels in their blood
What are the other reasons of chronic breathlessness?
Smoking
Conditions that affect how your muscles work
e.g. muscular dystrophy, MG and motor neurone disease
Postural conditions that alter the shape of your spine e.g. scoliosis and kyphosis
Anaemia
Kidney disease
Thyroid disease
What should someone experiencing breathlessness do when they go to see their doctor?
Think about how they’ll describe their breathlessness
Bring someone who can help
What is the MRC breathlessness scale?
Scale health professionals use to measure breathlessness
Shows what it stops you from doing
What does grade 1 on the MRC scale represent?
Not troubled by breathlessness except on strenuous exercise
What does grade 2 on the MRC scale represent?
Short pf breath when hurrying on the level or walking up a slight hill
What does grade 3 on the MRC scale represent?
Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace
What does grade 5 on the MRC scale represent?
Too breathless to leave the house, or breathless when undressing
What is important to tell your doctor?
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
What tests might a GP carry out?
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
What may a GP refer a patient with breathlessness for?
Chest X-Ray Spirometry ECG Echocardiogram Blood tests
What could blood tests detect?
Anaemia
Allergies
Thyroid/ Liver/ Kidney/ Heart problems
What would you look for on chest radiography?
Signs of heart failure
Pulmonary pathology
What would you look for on a ECG?
Heart failure
Arrhythmia
Pulmonary embolism
What would you look for when performing a spirometry test?
Signs of obstructive airway disease
Restrictive pattern associated with interstitial lung disease
What would a U+E and a blood glucose test show?
Renal failure and diabetes as causes of metabolic acidosis and breathlessness
What could a thyroid function test detect?
Thyroid disease as a cause of breathlessness
How can you assess heart failure?
B-type natriuretic peptide test
What factors are characteristic of asthma?
A large response to bronchodilators
Significant diurnal or day-day variability of serial peak flow measurements
What should you do for patients with COPD?
arrange chest radiography to exclude other serious lung pathology (such as lung cancer) and check the full blood count to identify anaemia or polycythaemia
What is SOBOE?
Shortness of breath on exertion
What are the possible respiratory differential diagnosis for Mr Craven?
Asthma COPD Pulmonary fibrosis Lung cancer Pulmonary embolism Pneumothorax Lower respiratory tract infection
What are the possible cardiovascular/systemic differential diagnosis for Mr Craven?
Congestive heart failure Pulmonary oedema Valvular defects Acute coronary syndrome Anaemia Renal or liver failure Deconditioning
What questions would you ask to hone this differential?
Chest pain? Does it wake you up at night? Does it get worse whilst lying flat? Any lifestyle changes? Occupation? Cough?
What examinations would you perform to hone this differential?
Check for lung/breath sounds (Lamina or Turbulent flow/ Crackling) Cyanosis Barrel chest: hyper-expanded Pitting Oedema Tar staining on fingernails Heart sounds: leaky valves/murmurs
What happens if the LHS of the heart isn’t functioning?
Pooling of blood/fluid in the lungs
What happens if the RHS of the heart isn’t functioning?
Oedema in the legs
What investigations would you carry out?
ECG
CXR
Spirometry
Blood tests
What is FVC?
Forced vital capacity
Total volume of air expelled after inhalation
What is FEV1?
Forced expiratory volume
Volume expelled after inhalation on 1 second
Give examples of restrictive diseases
Obesity TB Scoliosis Neuromuscular weakness e.g. MG Pulmonary fibrosis
Give examples of obstructive diseases
COPD Asthma Cystic fibrosis Emphysema Chronic Bronchitis
What characterises a obstructive disease?
FEV1/FVC ratio of less that 0.7
Only expel less than 70% of your total volume in 1 second
Narrowing of airways
What characterises a restrictive disease?
FEV1/FVC ratio higher or normal
FVC is lower by FEV1 the same
Something preventing your lungs from expanding fully
What does COPD encompass?
Bronchitis
Emphysema
What is the pathophysiology for Bronchitis?
Inflammation and irritation Caused by smoking, asbestos etc. Hypertrophy of goblet cells Increased mucus production Airway narrowing- increase blood flow, inflammatory mediators therefore wall thickens, lumen narrows Inhibits action of cilia
What is the pathophysiology of emphysema?
Damage to the walls of the alveoli via elastase enzyme Reduces surface area for gas exchange Alveoli unable to recoil Air becomes trapped
How does emphysema cause an obstructive disorder?
Less pressure and force keeping the airways open and they collapse in on themselves
Damage of the alveoli (surrounding tissue) causes this
What abnormalities are seen on Mr. Craven’s X-ray?
Diaphragm is flattened
Smaller/Elongated heart
Barrel chest
What are the signs of hyperinflation?
More the 7 anterior ribs visible at the mid-clavicular line
Flattening of the diaphragm
Heart may appear small and narrow
Bullae
What causes hyperinflation?
Emphysema
What are bullae?
When alveoli become a singular unit
Very big
Delicate outer wall
Can burst causing pneumothorax
Air filled spaces with thin walls, bordered only by remnants of alveolar septae
Shown as black areas on CXR
What are steps that someone can take to stop smoking?
Nicotine replacement therapy e.g. patches, sprays, lozenges etc.
Smoking cessation therapist
Education about the harmful affects of smoking
Why is nutrition important in COPD?
Boost immune system to prevent infection
Deal with practical issues e.g unable to eat while coughing
If malnourished, muscles are weaker affecting breathing
If obese, difficulty in expanding the chest
How can improvements in nutrition be made?
Referral to dietician
Patient resources
Why is important to keep well in the cold?
Increased risk of infection during the winter
Flu jab
Pneumoccocal vaccine
Infective exacerbate of COPD- rescue packs with steroids and antibiotics
What are the three main categories of inhaled medications?
Inhaled corticosteroids
Anti-cholinergics
Beta agonists
What is the mechanism of beta agonists?
Bronchodilation
Sympathetic nervous system stimulation
What is the mechanism of anticholinergics?
Prevent bronchoconstirciton
Act against parasympathetic nervous system
What is the mechanism of corticosteroids?
Reduce inflammation
What is the main cause of preventable illness and premature death in the UK?
Smoking tobacco
What can smoking cessation be associated with?
Temporary withdrawal symptoms
Caused by nicotine dependence
What are symptoms of withdrawal?
Nicotine cravings Irritability Depression Restlessness Poor concentration Light-headedness Sleep disturbances Increased appetite
What is recommended to be the most effective approach?
Abrupt quiting
Combination of drug treatment and behavioural support
Where should patients wishing to stop smoking be referred to?
local NHS stop smoking serviced
if the decline to attend a suitable healthcare professional
What is NRT?
Nicotine replacement therapy
What drugs are used in NRT?
Varenicline (Champix)
Bupropion hydrochloride
What is taken in to consideration when choosing which drug?
Smoker's adherence Preference Previous experience of smoking-cessation aids Contra-indications Side effects Pregnancy/ Breastfeeding
What are he most effective options?
Varenicline OR
combination of long-acting NRT (transdermal patch) and short-acting NRT (lozenges, gum, sublingual tablets, inhalator, nasal spray and oral spray)
What can be used if the most effective treatments options are not appropriate?
Bupropion hydrochloride
Single therapy NRT
How are patches applied?
Transdermal
16 hours
Removed overnight
If they experience cravings on waking a 24 hour patch can be used
When are short acting nicotine preparations used?
Whenever the urge to smoke occurs or to prevent cravings
How may smokers who are unwillingly to stop use NRT?
‘Harm reduction approach’
Smoking reduction
Temporary abstinence
Improves chance of stopping smoking in the long term
How do e-cigarettes work?
Deliver nicotine without the toxins found in tobacco smoke
Cannot be prescribed
How does smoking affect pregnancy?
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
What may cause an increase in dose in other drugs?
Polycyclic aromatic hydrocarbons found in tobacco smoke increase the metabolism of some drugs
What forms of NRT therapy are available?
Skin patches Chewing gum Inhalators Tablets, oral strips and lozenges Nasal and mouth spray
How long does NRT treatment last?
Typically 8-12 weeks
Gradually reduce the dose
Eventually stop
Who can use NRTs?
Over 12s
Under 18s shouldn’t use lozenges without medical advice
Pregnant women
Breastfeeding women
What are the possible side effects of NRTs?
Skin irritation Irritation of nose, throat or eyes Difficulty sleeping Upset stomach Dizziness Headaches
How is Varenicline taken?
1-2 tablets a day
A week or two before starting to quit
Who cannot take Varenicline?
Children under 18
Pregnant/Breastfeeding women
People with severe kidney problems
What are the side effects of Varenicline?
feeling and being sick difficulty sleeping (insomnia), sometimes with vivid dreams dry mouth constipation or diarrhoea headaches drowsiness dizziness
How is bupropion taken?
1-2 tablets a day
1-2 weeks before quitting
7-9 weeks with treatment
Cannot be taken by people with epilepsy/bipolar disorder/ eating disorders
What are the side effects of bupropion?
dry mouth difficulty sleeping (insomnia) headaches feeling and being sick constipation difficulty concentrating dizziness
What are the fundamentals of COPD care?
Offer treatment and support Offer pneumococcal and flu vaccines Offer pulmonary rehab Co-develop a self-management plan Optimise treatment for co-morbidities
When are inhaled therapies needed?
Relieve breathlessness
Exercise limitation
Other therapies were not successful
What is a pMDI?
Pressurised metered dose inhaler
What is a spacer?
Can be used to reduce side effects and alleviate symptoms
Lesser dose
How long should you wait between puffs?
30 seconds - 1 minute
How should you use a Respimat (SMI) inhaler?
Prime the inhaler Twist until clicks and open cap 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 press for at least 10 seconds
How many times do you need to prime your inhaler?
If not used in 1 week: Once
If not used in 3 weeks: 3 times
What should you do if you have used an inhaler that contains steroids?
Rinse your mouth with water
What is a turbohaler inhaler?
Dry powder device
DPI
How do you prime a turbohaler?
Twist off cover and hold upright
Turn base one way and then the other until a click is heard
How do you use a turbohaler?
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 press for at least 10 seconds
How do you use a turbohaler?
Hold upright Sit or stand up straight Tilt chin up Breathe out gently and slowly Make tight seal with lips Breathe in quickly and press grey button Hold press for at least 10 seconds
