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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?

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
What are the symptoms of an exacerbation of COPD?
* 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
What are the most common CAP causing-organisms in COPD?
1. Haemophilus influenzae (most common cause) 2. Streptococcus pneumoniae 3. Moraxella catarrhalis
27
What are the non-pharmaceutical treatments for COPD?
* ***_STOP SMOKING!_*** * **Vaccination** * **​**Flu * Streptococcus pneumoniae * **Oxygen** * **Physiotherapy** * **Pulmonary rehab** * **End of life care** * **Bullectomy** * **Lung reduction surgery**
28
How does cor pulmonale develop?
29
What are the most common HAP-causing organisms?
1. Psuedomonas 2. Staph 3. Streptococcus
30
How do the different GOLD ABCD classifications alter therapy?
31
Give some generic names for: 1. ICS 2. LABA 3. LAMA 4. Combination inhaler
1. ICS: Clenil, QVAR, pulmicort, Flixotide 2. LABA: Serevent 3. LAMA: Spiriva 4. Combination inhaler: Seretide, Symbicort, Fostair
32
What is p-pulmonale? What does it look like on ECG?
* 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
How do you treat an exacerbation of COPD?
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
What are the clinical features of hypercapnia?
* Dilated pupils * Bounding pulse * Hand flap * Myoclonus * Confusion * Drowsiness * Coma
35
When should you assess for long term oxygen therapy? When should LTOT not be offered?
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
What is interstitial lung disease?
* 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
What are the **complications** of COPD?
**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
When should you give long term o2 therapy?
**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
What do the flow volume loops look like for normal / obstructive / restrictive lung disease?

Medicine year 3 ANNA (30 decks)

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