Chronic Obstructive Pulmonary Disorder (COPD) Flashcards
Define COPD
Chronic, slowly progressive airflow obstruction with little to no reversibility or variability due to lung tissue damage, heavily associated with smoking
What are the causes of COPD?
Smoking
Alpha 1 Antitrypsin Deficiency
Jobs involving dust, vapours, fumes
Air pollution
Chronic asthma
Describe the presentation of COPD
Dyspnoea/Orthopnoea
- Progressive and persistent
Cough
- Clear sputum, persistent
Chest Tightness
Wheeze
Reduced chest expansion
Recurrent chest infection
Hyperinflated chest
Coraco-sternal distance <3cm
Resonant or hyper-resonant
Cyanosis
Tachypnoea
Use of accessory muscles
- SCM, intercostals, abdominal muscles
What tests are used in the investigation/diagnosis of COPD?
ECG
- Extended P waves due to atrial strain right sided heart failure
Sputum Culture
- Infective causes of exacerbation
ABG
- Evidence of type 2 respiratory distress
- Acidosis
CXR
- Hyperinflated chest (flattened hemidiaphragm, thin heart and increased number of visible anterior ribs)
- Bullae
Alpha 1 Antitrypsin Test
FBC
- Polycythaemia
Pulmonary Function Tests/Spirometry
- Obstructive pattern
Transfer factor for CO
- Decreased in COPD, can give an indication about the severity of the disease
What is the pharmacological management of stable COPD?
Short Acting Beta 2 Agonist (SABA)
Short Acting Muscarinic Antagonist (SAMA)
Long Acting Beta 2 Agonist (LABA)
Long Acting Muscarinic Antagonists (LAMA)
Inhaled Corticosteroids (ICS)
Long term oxygen therapy
Give an example of a SABA
Salbutamol
Terbutaline
Give an example of a SAMA
Ipatropium bromide
Give an example of an ICS
Beclometasone dipropionate
Give an example of a LAMA
Tiotropium
Give an example of a LABA
Salmetorol
Give an example of a LTRA
Montelukast
Theophylline
Aminothylline
What is the management of acute exacerbation of COPD? (emergency treatment)
High flow oxygen
Salbutamol nebulised 5mg/4h
IV 200mg Hydrocortisone
Intubation and ventillation in severe cases
What is the non-pharmacological managemet of COPD?
Smoking cessation
Pulmonary rehabilitation
- Recomended early in diagnosis when patients begin to feel breathless
Vaccinations
- Annual influenza
- Once off pneumococcal
What are complications of long-term steroid use?
Immunosuppression
Bruising
>Abdominal fat
HTN
Osteoporosis
What is alpha-1-antitrypsin deficiency?
Lack of a1-antitrypsin, an enzyme made in the liver, that controls the breakdown of other enzymes in the body
What mode of inheritence is alpha-1-antitrypsin deficiency?
Autosomal recessive
How is alpha-1-antitrypsin deficiency managed?
Smoking cessation
Supportive
- Bronchodilators
- Physiotherapy
IV alpha1-antitrypsin protein concentrates
Surgery
- Lung volume reduction surgery
- Lung transplantation
What is a complication of alpha-1-antitrypsin deficiency?
Hepatocellular carcinoma
Why does COPD cause secondary polycythemia?
Secondary polycythemia most often develops as a response to chronic hypoxemia, which triggers increased production of erythopoietin by the kidneys
What is the diagnostic test for COPD?
Spirometry, showing an obstructive pattern with little to no reversibility
What organisms cause infective exacerbations of COPD?
Haemophilus influenzae
Streptococcus pneumoniae
Moraxella Catarrhalis
Rhinovirus
What is the most common organism causing infective exacerbations of COPD?
Haemophilus influenzae
Give features that suggest a patient’s COPD would be steroid responsive
Previous diagnosis of asthma or atopy
>Eosinophil
Variation of FEV1
Variation of peak expiratory flow
Describe the COPD management ladder in steroid responsive patients
SABA/SAMA, stays throughout ladder
LABA and ICS
LABA, LAMA, ICS triple therapy
Specialist referral
Describe the COPD management ladder in a non steroid responsive patient
SABA/SAMA stays throughout ladder
LABA + LAMA
LABA LAMA + ICS triple therapy 3 month trial and reverted back if it does not work
Specialist referral
When should long term oxygen therapy be offered?
If ABG show PaO2 < 7.3kpa on two occassions measured 3 weeks apart
Or to those with a pO2 of 7.3 - 8 kPa and one of the following
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension
What interventions improve survival in COPD?
Smoking cessation
Long term oxygen therapy
What antibiotic is used for infection prophylaxis in COPD?
Azithromycin
Doxyclycline if long QT syndrome
What has to be monitored with azithromycin use?
ECG
- Can cause long QT syndrome
LFTs
What factors would prompt the assessment of a patient for long term oxygen therapy?
FEV1 <30-49%
Cyanosis
Polycythaemia
Peripheral oedema
>JVP
O2 <92% on room air
Do not offer LTOT to people who continue to smoke despite being offered smoking cessation advice and treatment, and referral to specialist stop smoking services
What feature of COPD can mimic a pneumothorax?
Large bullae
What should be given in patients with frequent exacerbations of COPD?
Home supply of prednisolone and azithromycin
What is a complication of oxygen administration in COPD patients?
Over administration of oxygen
These patients lose their hypoxic drive for respiration, therefore retain CO2 and subsequently hypoventilate leading to respiratory arrest/type 2 respiratory failure
What is the O2 sat goals in COPD patients?
88-92% target until blood gases available
94-98% if CO2 is normal on ABG
Describe an obstructive spriometry pattern
decreased FEV1
normal/decreased FVC
decreased FEV1/FVC
What is FEV1?
Forced expiratory volume
The amount of air a person can forcefully exhale in one second
What is FVC?
Forced vital capacity
The amout of air a person can forcefully exhale after taking a deep breath
What is the FVC/FEV1 ratio in COPD?
Less than 0.7
Meaning that being able to blow air out is limited by the damage to their airways causing airway obstruction
What should be offered to pregant woman who smoke?
Nicotine replacement therapy should be offered, varenicline and bupropion are contraindicated
What is stage 1/mild airflow obstruction?
FEV1 over 80% of predicted
What is stage 2/moderate airway obstruction?
FEV1 50-79% of predicted
What is stage 3/severe airway obstruction?
FEV1 30-49% of predicted
What is stage 4/very severe airway obstruction?
FEV1 less than 30% of predicted
What oxygen should be used to treat any critically ill patient?
High flow/15l via non re-breather mask EVEN IN CO2 RETAINERS/COPD
