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Medicine year 3 ANNA > COPD > Flashcards

COPD Flashcards

1
Q

What is COPD?

What are the symptoms?

A
  • Progressive disease state characterised by airflow limitation that is not fully reversible.
  • A picture of both emphysema and chronic bronchitis.
  • In COPD air can get in but not out, due to airway obstruction (bronchitis) and reduced alveolar elascticity (emphysema). This leads to hyperexpansion, and development of holes / bullae on CT.
  • FEV1 < 80% of predicted (accounting for pts; age, sex and height)
  • FEV1/FVC (ratio) < 70%
  • Symptoms:
    • progressive shortness of breath,
    • wheeze,
    • cough,
    • sputum production (including haemoptysis)
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2
Q

Name 3 causes of airway obstruction

A
  1. Asthma (reversible)
  2. COPD
  3. Bronciectasis
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3
Q

Name 4 causes of airway restriction

A
  1. Interstitial lung disease
  2. Obesity
  3. Scoliosis
  4. Ideopathic pulmonary fibrosis
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4
Q

What do pulmonary function tests show for obstructive vs restrictive lung disease?

A

Obstructive

  • N/↓ FVC
  • ↓↓ FEV1
  • Ratio FEV:FVC <0.70

Restrictive

  • ↓↓ FVC
  • ↓ FEV1
  • Ratio stays the same
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5
Q

What is the GOLD classification of COPD?

A

Numbers: severity of airflow limitation (spirometric grade 1 to 4)

  1. Mild
  2. Moderate
  3. Severe
  4. Very Severe

Letters: (groups A to D) provides information regarding symptom burden and risk of exacerbation which can be used to guide therapy

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6
Q

What does CURB-65 stand for?

A
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7
Q

What are the genetic and environmental causes of COPD?

A
  • Genetic
    • a1-antitrypsin deficiency
  • Environmental
    • Smoking (+exposure passively)
    • Cannabis
    • Mineral dusts
      • coal
      • cadmium
      • grain and flour
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8
Q

What are the differences between asthma and COPD?

A
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9
Q

What are the inhaled treatments used in COPD?

A
  • SABA = short-acting beta2 agonist – this may be continued at all stages if required
  • SAMA = short-acting muscarinic antagonist
  • LABA = long-acting beta2 agonist
  • LAMA = long-acting muscarinic antagonist
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10
Q

Mucolytics in COPD

When should they be considered?

Give an example

A
  • Should be ‘considered’ in patients with a chronic productive cough and continued if symptoms improve
  • Should not be used to prevent exacerbations
  • Carbocysteine
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11
Q

Give some examples of sympathomimetric agents:

  1. ß2 agonists
  2. Anticholinergics / muscarinic antagonists
A
  1. ß2 agonists
    • Short acting (SABA)
      • e.g. salbutamol, terbutaline
    • Long acting (LABA)
      • e.g. salmeterol, eformoterol
  2. Muscarinic antagonists / “antimuscarinics”
    • ipratropium (SAMA)
    • tiotropium (LAMA)
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12
Q
  1. What does SABA stand for?
  2. When are they used in COPD?
  3. How do they work?
  4. Common side effects / counselling points
  5. Interactions
  6. Give 3 examples.
A
  1. Short acting beta agonists
  2. used to relieve breathlessness
  3. Acts on ß2 receptors in smooth muscle cells, causing relaxation
  4. Activation of flight/flight in b2 receptors elsewhere gives side effects of:
    • tachycardia
    • palpatations
    • anxiety
    • tremor
    • increase glucose in blood
    • !! take care if patient has cardiovascular disease !!
    • Drives K+ into cells (treatment of hyperkalaemia)
    • Counsel patient that this treats the symptoms, not the disease
  5. High dose SABA +
    • Theophylline
    • corticosteroids
    • → can lead to hypokalaemia; monitor K+ levels
  6. salbutamol, terbutaline, albuterol
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13
Q
  1. What does LABA stand for?
  2. When are they used in COPD?
  3. How do they work?
  4. Common side effects / counselling points
  5. Interactions
  6. Give 3 examples.
A
  1. Long acting beta agonists
  2. Second line treatment of COPD w/w.out asthmatic features
  3. Acts on ß2 receptors in smooth muscle cells, causing relaxation
  4. Activation of flight/flight in b2 receptors elsewhere gives side effects of:
    • tachycardia
    • palpatations
    • anxiety
    • tremor
    • increase glucose in blood
    • !! take care if patient has cardiovascular disease !!
    • Drives K+ into cells (treatment of hyperkalaemia)
    • Counsel patient that this treats the symptoms, not the disease
  5. High dose LABA +
    • Theophylline
    • corticosteroids
    • → can lead to hypokalaemia; monitor K+ levels
  6. salmeterol, formeterol, olodaterol
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14
Q
  1. What does SAMA stand for?
  2. When are they used in COPD?
  3. How do they work?
  4. Common side effects / counselling points
  5. Interactions
  6. Give an example
A
  1. Short Acting Muscarinic Antagonists
  2. Used to relieve breathlessness in COPD e.g. brought on by exercise/ exacerbations. 1st line (or SABA)
  3. Activation of muscarinic receptors (w acetylcholine) has a parasympathetic response. SAMAs block this activation, causing a sympathetic response i.e.
    • increase heart rate
    • relax smooth muscle
    • reduce GI secretions
    • pupil dilation in eye
  4. When inhaled there are fewer systemic effects
    • but dry mouth is common (patient can use water/ sugar-free gum)
  5. Low systemic absorption, but cauting in patients with angle-closure glaucoma (can raise intraocular pressure)
  6. ipratropium, brand name “Atrovent”
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15
Q
  1. What does LAMA stand for?
  2. When are they used in COPD?
  3. How do they work?
  4. Common side effects / counselling points
  5. Interactions
  6. Give 2 examples.
A
  1. Long Acting Muscarinic Antagonists
  2. Used to prevent breathlessness and exacerbations, 2nd line if no asthmatic features.
  3. Activation of muscarinic receptors (w acetylcholine) has a parasympathetic response. LAMAs block this activation, causing a sympathetic response i.e.
    • increase heart rate
    • relax smooth muscle
    • reduce GI secretions
    • pupil dilation in eye
  4. When inhaled there are fewer systemic effects
    • but dry mouth is common (patient can use water/ sugar-free gum)
  5. Low systemic absorption, but cauting in patients with angle-closure glaucoma (can raise intraocular pressure)
  6. Tiotropium (Spireva), glycopyrronium (Seebri Neohaler)
  7. Tiotropium bromide is more effective than salmeterol (LABA) in preventing exacerbations for pts with moderate-to-very severe COPD
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16
Q

How do xanthines work?

Name some examples

A
  • Xanthines inhibit phosphodiesterase (PDE), which increases intracellular cAMP levels, causing bronchodilation (sympathetic NS)
  • Theophylline
  • Aminophylline

NICE only recommends theophylline in COPD after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy

17
Q
  1. When are ICS used in COPD?
  2. How are they prescribed?
  3. Common side effects / counselling points
  4. Interactions
  5. Give 3 examples.
A
  1. Third line, only in patients with asthma-like symptoms suggesting steroid responsiveness.
  2. Usually prescribed with LAMA + LABA
    • ​​e.g. in combined inhaler, Symbicort (salmeterol + fluticasone)
    • Unlike in asthma:
      • ICS do not prevent disease progression in COPD
      • Airway inflammation in COPD is poorly responsive to steroids
  3. Fewer systemic effects inhaled : oral, but:
    • oral thrush
    • sore mouth
    • hoarseness
    • adrenal suppression
    • osteoporosis
    • don’t give to COPD patients at risk of pneumonia
    • advise patients that systemic effects are rare
    • advise to rinse mouth / gargle to reduce risk of thrush
  4. Not usually problem due to low systemic absorption
  5. beclomethasone, budesonide, fluticasone
18
Q

What are the side effects of long term ICS use?

A
  1. Oral thrush
  2. Hoarseness
  3. adrenal suppression
  4. ostoporosis
  5. growth restriction (in children)
19
Q

What should you keep a COPD patient’s O2 sats between and why?

A

SpO2 88-92%

  • COPD patients retain a lot of CO2
  • Thus they rely on their hypoxic drive to maintain their respiratory effort –> Don’t take that away!
20
Q

What are the findings on examination of a COPD patient?

A
  • Tachypnoea
  • Use of accessory muscles of respiration (sternocleidomastoid, scalenes, pec major + minor, serratus anterior, latissimus dorsi and abdominals)
  • Hyperinflation ‘barrel-chest’
  • ↓ cricosternal distance (<3cm)
  • ↓ chest expansion
  • Resonant or hyperresonant percussion note
  • Quiet breath sounds (e.g. over bullae)
  • Wheeze
  • Cyanosis
  • Tar stained fingers
  • Cor pulmonale (oedema + ↑ JVP) – ankle oedema
21
Q
  1. What are the indications for NIV (non-invasive ventilation)?
  2. What are the contraindications?
  3. Who should start NIV?
A
  1. Non-invasive ventilation - key indications
    • COPD with respiratory acidosis pH 7.25-7.35
    • type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea

cardiogenic pulmonary oedema unresponsive to CPAP

* weaning from tracheal intubation
* RR \>25 2. Contraindications:
* Confusion
* pH\<7.25
* Agitation / lack of co-operation
* GCS\<8
* risk of gastric aspiration
* facial trauma
* untreated pneumothorax 3. ST2 +
22
Q

What are the types of NIV?

A
23
Q

Why is NIV preferable to intubation and mechanical ventilation in COPD?

A
  • COPD pts will require prolonged ventilation.
  • Mechanical ventilation will result in tracheostomy and subsequent decrease in muscle mass.
  • Unlikely to return to previous level of functionality
24
Q

What does this x-ray show?

A
  • Hyperinflation
  • Flat Diaphragms
  • Small cardiac size
  • All suggestive of Emphysema
25
Q

What are the symptoms of an exacerbation of COPD?

A
  • increase in dyspnoea, cough, wheeze
  • there may be an increase in sputum suggestive of an infective cause
  • patients may be hypoxic and in some cases have acute confusion
26
Q

What are the most common CAP causing-organisms in COPD?

A
  1. Haemophilus influenzae (most common cause)
  2. Streptococcus pneumoniae
  3. Moraxella catarrhalis
27
Q

What are the non-pharmaceutical treatments for COPD?

A
  • STOP SMOKING!
  • Vaccination
    • ​Flu
    • Streptococcus pneumoniae
  • Oxygen
  • Physiotherapy
  • Pulmonary rehab
  • End of life care
  • Bullectomy
  • Lung reduction surgery
28
Q

How does cor pulmonale develop?

A
29
Q

What are the most common HAP-causing organisms?

A
  1. Psuedomonas
  2. Staph
  3. Streptococcus
30
Q

How do the different GOLD ABCD classifications alter therapy?

A
31
Q

Give some generic names for:

  1. ICS
  2. LABA
  3. LAMA
  4. Combination inhaler
A
  1. ICS: Clenil, QVAR, pulmicort, Flixotide
  2. LABA: Serevent
  3. LAMA: Spiriva
  4. Combination inhaler: Seretide, Symbicort, Fostair
32
Q

What is p-pulmonale? What does it look like on ECG?

A
  • The description of the p - waves on an ECG of someone with cor pulmonale
  • The p waves are “peaked” at greater than 2.5mm amplitude in lead II.
  • Represents right atrial enlargement.
33
Q

How do you treat an exacerbation of COPD?

A
  1. Nebulised SABA / SAMA
    • 2.5 to 5 mg nebulised every 20 minutes for up to 2 hours or until clinical improvement, followed by 4-6 hourly dosing; (100 micrograms/dose inhaler) 100-200 micrograms (1-2 puffs) every 20 minutes for up to 2 hours or until clinical improvement, followed by 4-6 hourly dosing
  2. Prednisolone
    • 30-60 mg orally once daily for 5 days
  3. Oxygen (check with ABGs for CO2 retention)
  4. Airway clearance e.g. non-oscillating positive expiratory pressure
  5. Antibiotics
    • piperacillin/tazobactam: Dose consists of 3 g of piperacillin and 0.375 g of tazobactam
    • AND azithromycin
  6. Non-invasive Positive Airway ventilation
34
Q

What are the clinical features of hypercapnia?

A
  • Dilated pupils
  • Bounding pulse
  • Hand flap
  • Myoclonus
  • Confusion
  • Drowsiness
  • Coma
35
Q

When should you assess for long term oxygen therapy?

When should LTOT not be offered?

A
  1. Assess patients if any of the following:
    • very severe airflow obstruction (FEV1 < 30% predicted). Assessment should be ‘considered’ for patients with severe airflow obstruction (FEV1 30-49% predicted)
    • cyanosis
    • polycythaemia
    • peripheral oedema
    • raised jugular venous pressure
    • oxygen saturations less than or equal to 92% on room air
  2. 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.
36
Q

What is interstitial lung disease?

A
  • An umbrella term for a large group of disorders that cause fibrosis of the lungs.
  • The scarring causes stiffness in the lungs which makes it difficult to breathe.
  • Some example of ILDs include:
    • Idiopathic Pulmonary Fibrosis
    • Hypersensitivity Pneumonitis
    • Sarcoidosis
    • Asbestosis
37
Q

What are the complications of COPD?

A

Complications:

  • Acute exacerbation ± infection
  • Polycythemia (↑ hematocrit – % volume of RBCs in blood)
  • Respiratory failure (T1/T2)
  • Cor pulmonale (oedema + ↑ JVP)
  • Pneumothorax (rupture bullae)
  • Lung carcinoma
38
Q

When should you give long term o2 therapy?

A

Long-term Oxygen Therapy (LTOT):

  • If PaO2 is maintained >8.0 kPa for 15h a day à 3 year survival ↑ by 50% (argument for LTOT)
  • LTOT should be given for;
    • Clinically stable non-smokers with PaO­2 < 7.3kPa (values stable on 2 occasions > 3wks apart)
    • If PaO2 is 7.3-8.0kPa + pulmonary hypertension (e.g. right ventricular hypertrophy, loud S2) or polycythemia, or peripheral oedema, or nocturnal hypoxia
    • Terminally ill patients
39
Q

What do the flow volume loops look like for normal / obstructive / restrictive lung disease?

A

Medicine year 3 ANNA (30 decks)

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