Chronic Obstructive Pulmonary Disease (COPD) Flashcards
What is chronic obstructive pulmonary disease (COPD)?
It is defined as an irreversible condition in which there is a gradual deterioration of air flow through the lungs, due to damaged lung tissue
What is the COPD triad?
Emphysema
Chronic bronchitis
Small airway fibrosis
What is emphysema?
It is defined as a condition in which inner walls of the alveoli weaken and rupture, creating enlarged air spaces
What is chronic bronchitis?
It is defined as a cough with sputum production for at least three months in two consecutive years
What are the four risk factors for COPD?
Smoking
Middle Aged > 35 Years Old
Alpha-1 Antitrypsin (AAT) Deficiency
Air Pollution
What is the most common risk factor for COPD?
Smoking
How does smoking cause COPD?
It inactivates alpha-1 antitrypsin , which causes emphysema
What is the inheritance of AAT deficiency?
Autosomal dominant
What is AAT deficiency? Explain how it is a risk factor of COPD
AAT is a protease inhibitor, which functions to prevent neutrophil elastase from breaking down alveolar structures
Therefore, AAT deficiency results in increased destruction of alveolar structure - precipitating emphysema development
Does AAT deficiency result in early or late onset COPD?
Early onset < 45 yrs old
What other organ tends to be affected by AAT deficiency?
Liver, resulting in cirrhosis
What are the six clinical features of COPD?
Progressive Dyspnoea
Chronic Productive Cough
Wheeze
Recurrent LRTIs
Peripheral Oedema
Tachypnoea
Describe the sputum associated with COPD
Colourless
However, may be green during infection
Why is peripheral oedema a clinical feature of severe COPD?
In severe COPD, cor pulmonale (right sided heart failure) can develop which leads to peripheral oedema
Which clinical feature is used to differentiate between COPD and heart failure?
Heart failure = orthopnea
What scoring system can be used to assess the severity of dyspnoea?
Medical Research Council (MRC) Dyspnoea Scale
What scoring system can be used to assess the impact of COPD on a patients wellbeing and daily life?
COPD Assessment Test (CAT) Score
What six investigations are used to diagnose COPD?
Spirometry
Blood Tests
Arterial Blood Gas (ABG)
Sputum Culture
Chest X-Ray (CXR)
ECG Scan
What is spirometry?
It measures the volume and flow of air during exhalation and inhalation
What three metrics can be obtained with spirometry?
Forced Expiratory Volume 1 (FEV1)
Forced Vital Capacity (FVC)
FEV1 : FVC
What is FEV1?
It is defined as the volume that has been exhaled at the end of the first second of forced expiration
What is FVC?
It is defined as the volume that has been exhaled after a maximal expiration, following a full inspiration
What spirometry result indicates COPD? Why does this make sense?
FEV1 : FVC < 70%
COPD is an obstructive lung disease
What does a FEV1 : FVC < 70% result indicate?
This means that the overall lung capacity is not as bad as the patient’s ability to quickly blow air out of their lungs
How can we use spirometry to differentiate between COPD and asthma? Why does this make sense?
We test the reversibility of airflow obstruction
This is due to the fact that COPD results in irreversible airflow obstruction, however asthma is reversible
How can we use spirometry to test airflow obstruction reversibility?
We administer bronchodilators or corticosteroids
What post-bronchodilator spirometry test result indicates COPD?
FEV : FVC < 70%
What spirometry results indicates stage one (mild) COPD?
Predicted FEV1 > 80%
Post-Bronchodilator FEV:FVC < 0.7
What spirometry result indicates stage two (moderate) COPD?
Predicted FEV1 = 50% – 79%
Post-Bronchodilator FEV:FVC < 0.7
What spirometry result indicates stage three (severe) COPD?
Predicted FEV1 = 30% - 49%
Post-Bronchodilator FEV:FVC < 0.7
What spirometry result indicates stage four (very severe) COPD?
Predicted FEV1 = < 30%
Post-Bronchodilator FEV:FVC < 0.7
What two investigations are used to diagnose COPD?
Clinical presentation
Spirometry
What are the three clinical criteria for a diagnosis of COPD?
> 35 years old
The patient presents with COPD clinical features
The patient presents with a COPD risk factor
What spirometry results indicate a diagnosis of COPD?
Spirometry = FEV : FVC < 70%
Post-bronchodilator spirometry = FEV : FVC < 70%
What two blood tests indicate a diagnosis of COPD?
Decreased Serum Alpha-1 Antitrypsin Levels
Decreased Transfer Factor for Carbon Monoxide (TLCO) Levels
What blood test can be used to differentiate between COPD and asthma? How?
TLCO
In COPD, TLCO levels are decreased, whereas in asthma they are increased
What additional blood test is conducted in COPD patients? Why?
FBC
To identify the development of secondary polycythaemia complications
What three ABG results indicate a diagnosis of COPD? Why does this make sense?
PaCO2 > 6
Bicarbonate > 30
pH < 7.35
These are signs of CO2 retention and respiratory acidosis
In what two ways are sputum cultures used to diagnose COPD?
They are used to identify chronic infections, such as pseudomonas
It enables targeted antibiotic therapy during COPD exacerbations
What are the four signs of COPD on CXRs?
Hyperinflation
Flattened Diaphragm
Hyperlucent Lungs
Bullae
How do we identify hyperinflation on CXRs?
The appearance of > 6 anterior ribs in the mid-clavicular line
OR
The appearance of > 10 posterior ribs in the mid-clavicular line
What is a bulla on CXR?
It is defined as an air space in the lung measuring > 1 cm in diameter in the distended state
What is another way in which CXRs are used to diagnose COPD?
They can be used to exclude lung cancer
How are ECG scans used to diagnose COPD?
They are used to identify the development of cor pulmonale complications
What are the two signs of cor pulmonale on ECG scans?
Peaked P waves
Right axis deviation
In what four ways do we conservatively manage COPD?
Smoking Cessation
Pulmonary Rehabilitation
Annual Influenza Vaccination
One Off Pneumococcal Vaccination
What is the most effective intervention to prevent progression of COPD disease?
Smoking cessation
What is step one of COPD pharmacological management?
It involves administration of a short acting bronchodilator
What are two subclassifications of short acting bronchodilators?
Short-Acting Beta2 Agonists (SABA)
OR
Short-Acting Muscarinic Antagonists (SAMA)
Name two SABAs examples
Salbutamol
Terbutaline
Name an example of SAMA
Ipratropium Bromide
What do we need to determine if step one of COPD pharmacological management fails?
Whether the patient has asthmatic/steroid responsiveness features
What are the four criteria used to determine whether an individual has asthmatic/steroid responsiveness features?
Previous Asthma/Atopic Disease
Increased Eosinophil Count
FEV1 Variation > 400ml
Diurnal PEF Variation > 20%
What is step two of COPD pharmacological management (in individuals with no asthmatic/steroid responsiveness features)?
Combined Long Acting Bronchodilator
What is contained within combined long acting bronchodilators?
Long-acting beta2 agonist (LABA)
Long-acting muscarinic antagonist (LAMA)
Name three examples of combined long acting bronchodilators
Anoro ellipta
Ultibro breezhaler
DuaKlir genuair
What is step two of COPD pharmacological management (in individuals with asthmatic/steroid responsiveness features)?
Combined LABA & ICS
Name three examples of combined LABA & ICS
Fostair
Symbicort
Seretide
In step two of COPD pharmacological management, what do we need to remember about step one?
All patients who were administered SAMA as their first line, need to be switched to SABA
What is step three of COPD pharmacological management?
It involves administration of triple therapy combination inhalers
What is contained in triple therapy combination inhalers?
LABA
LAMA
ICS
Name two examples of triple therapy combination inhalers
Trimbo
Trelergy ellipta
What three oral pharmacological options can be used to manage COPD?
Oral Theophylline
Oral Prophylactic Antibiotics
Oral Mucolytics
When is oral theophylline considered as a management option for COPD?
It is a fourth line management option, which should only be considered after trials of short/long acting bronchodilators or in those who are unable to administer inhaled therapy
What oral prophylactic antibody can be used to manage COPD?
Azithromycin
What are the three criteria for oral prophylactic antibiotic administration in COPD patients?
Non-Smokers
Optimised Standard Treatment
Recurrent Exacerbations
What oral mucolytic can be administered to manage COPD?
Carbocysteine
When do we consider oral mucolytics to manage COPD?
In those with a chronic productive cough
In which six circumstances do we conduct assessment for LTOT administration?
FEV1 < 30%
Cyanosis
Polycthaemia
Peripheral oedema
Raised JVP
O2 saturations < 92%
How do we assess whether patients should be administered LTOT?
ABG on two occasions, at least three weeks apart in patients with stable COPD on optimal management
What ABG result indicates the administration of LTOT?
In cases where patients have a pO2 < 7.3
OR
In cases where patients have a pO2 1.3 - 8, with one of the following complications; secondary polycythaemia, peripheral oedema, pulmonary hypertension
When is LTOT contraindicated? Why?
Smokers
Due to a risk of explosion/burns
What are the five complications of COPD?
Hypercapnic Respiratory Failure
Cor Pulmonale
Bronchiectasis
Secondary Polycythaemia
Osteoporosis
What is cor pulmonale?
It is right-sided heart failure due to chronic pulmonary hypertension
What type of pleural effusion is associated with cor pulmonale - exudate or transudate?
Transudate
When does cor pulmonale tend to arise in COPD?
End stage COPD
What complication of COPD is associated with increased TLCO levels?
Secondary polycythaemia
What is a COPD exacerbation?
It is defined as an acute deterioration of clinical features
What is the most common trigger of COPD exacerbations?
Respiratory tract infection
What are the four common infective agents that trigger COPD exacerbations?
Haemophilus influenzae
Streptococcus pneumoniae
Moraxella catarrhalis
RSV
What is the most common infective agent to trigger COPD exacerbations?
Haemophilus influenzae
What five investigations are used to diagnose a COPD exacerbation?
Blood Tests
Arterial Blood Gas (ABG)
Sputum Culture
Chest X-Ray (CXR)
ECG Scan
What are the three blood tests used to diagnose a COPD exacerbation?
Full Blood Count (Increased WCC Levels)
Blood Culture (Infective Agent)
Urea & Electrolytes (Deranged Results)
What three ABG results indicate a diagnosis of COPD exacerbation? Why does this make sense?
PaCO2 > 6
Bicarbonate > 30
pH < 7.35
These are signs of CO2 retention and respiratory acidosis
In what other way are ABGs used to diagnose a COPD exacerbation?
It is used to identify the development of respiratory failure complications
What are the two signs of type one respiratory failure on ABG?
Normal pCO2 levels
Decreased pO2 levels
How can we remember type one respiratory features on ABG?
Only ONE result is affected
What are the two signs of type two respiratory failure on ABG?
Decreased pCO2 levels
Decreased pO2 levels
How can we remember type two respiratory features on ABG?
TWO results are affected
How are sputum cultures used to diagnose COPD exacerbations?
It can be used to identify infections and enable targeted antibiotic therapy
How are CXRs used to diagnose COPD exacerbations?
They can be used to identify infections
How are ECG scans used to diagnose COPD exacerbations?
They are used to identify cor pulmonale complications
When is oxygen therapy used to manage COPD exacerbations?
When oxygen saturation levels are below 88%
What oxygen mask is used to deliver oxygen to COPD patients?
Venturi mask
What is a venturi mask?
They are masks used to deliver a specific percentage of oxygen
What oxygen saturation level is aimed for in COPD CO2 retainers?
88% - 92%
Why do we aim for lower oxygen saturation levels in COPD CO2 retainers?
CO2 retainers respiratory drive is dependent upon CO2 levels
Therefore if we administer these patients too much oxygen, there is decreased stimulation of their respiratory drive - leading to a decreased respiratory rate and increased retention of CO2
How can we identify CO2 retainers?
ABG - normal bicarbonate levels but increased pCO2 levels
What oxygen saturation level is aimed for in COPD non-CO2 retainers?
> 94%
When is non-invasive ventilation indicated for management of COPD exacerbations?
Respiratory acidosis persists despite immediate maximum standard medical treatment
PaCO2 > 6
pH < 7.35, > 7.26
What non-invasive ventilation is used to manage COPD exacerbations?
Bi-level positive airway pressure
What are the three pharmacological management options for COPD exacerbations in a primary care setting?
Short-Acting Bronchodilators
Prednisolone
Antibiotics
How do we review short acting bronchodilator administration during COPD exacerbations?
We administer them at an increased frequency
In some cases, individuals are administered a nebuliser
What prednisolone dose is administered to treat COPD exacerbations?
30mg once daily for a course of 5 - 14 days
What three antibiotics are administered to treat COPD exacerbations?
Amoxicillin
Clarithromycin
Doxycycline
When do we consider antibiotic administration in COPD exacerbations?
When individuals present with purulent sputum or clincial signs of pneumonia
What are the five pharmacological management options for COPD exacerbations in a secondary care setting?
Nebulised Bronchodilators
IV Bronchodilators
Steroids
Antibiotics
Analeptics
What two nebulised bronchodilators are administered to manage COPD exacerbations? At what dose?
Salbutamol 5mg/4h
Ipratropium bromide 500mcg/6h
What IV bronchodilator is administered to manage COPD exacerbations?
Aminophylline
When do we administer IV bronchodilators to manage COPD exacerbations?
In severe cases that don’t respond to nebulised bronchodilators
What is the function of analeptics?
To stimulate the CNS
What analeptic is administered to manage COPD exacerbations?
Doxapram
When do we administer analeptics to manage COPD exacerbations?
In severe cases that don’t respond to oxygen therapy
