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Finals: Medicine > COPD > Flashcards

COPD Flashcards

1
Q

What does COPD stand for

A

Chronic Obstructive Pulmonary Disease (COPD)

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2
Q

Define the term: chronic obstructive pulmonary disease (COPD)

A

COPD is an umbrella term for group of lung conditions that cause breathing difficulties. It includes chronic bronchitis and emphysema.

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3
Q

chronic obstructive pulmonary disease (COPD) is characterised by what?

A

Persistent airflow limitation that is not fully reversible.

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4
Q

Patients with COPD are susceptible to exacerbations during which there is worsening of their lung function. Exacerbations are often triggered by

A

Infections and these are called infective exacerbations.

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5
Q

COPD is an umbrella term for group of lung conditions.

Name the two lung conditions

A

Chronic bronchitis

Emphysema

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6
Q

Define chronic bronchitis

A

Lung condition in the COPD family

Defined as cough and sputum for at least 3 consecutive months in each of 2 consecutive years.

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7
Q

Chronic bronchitis is defined as a cough and sputum for how long

A

for at least 3 consecutive months in each of 2 consecutive years.

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8
Q

Define emohysema

A

defined histologically as abnormal permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of the alveolar walls and without obvious fibrosis.

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9
Q

What is the most important aetiological factor for COPD

A

Tobacco Smoking

  • Accounting for over 90% of cases.
  • However only 10-20% of heavy smokers develop COPD indicating individual susceptibility.
  • Individual’s risk is directly proportional to their pack years.
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10
Q

Name some of the risk factors associated with COPD

A

COPD is caused by long-term exposure to toxic particles and gases.

Prevalence of COPD is directly related to the prevalence of risk factors.

Risk factors include:

  • Tobacco smoking
  • Genetic - alpha 1 antitrypsin deficiency
  • Occupational exposures such as coal dust exposure
  • Indoor air pollution such as cooking with biomass fuels in poorly ventilated areas.
  • Low socioeconomic status
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11
Q

Define the term “pack year”

A

Pack year is a clinical quantification of tobacco smoking used to measure a person’s exposure to tobacco. This is used to assess their risk of developing pathologies related to cigarette exposure such as COPD.

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12
Q

What is the equation for pack year

A

1 pack year = 20 cigarettes/day/year

A pack year is defined as twenty cigarettes smoked every day for one year.

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13
Q

What is the genetic deficiency associated with COPD

A

Alpha 1 antitrypsin deficiency

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14
Q

What percentage of COPD cases are associated with alpha 1 antitrypsin deficiency

A

1-3%

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15
Q

When should alpha 1 antitrypsin deficiency be suspected

A

Suspected in patients with COPD who are young, non-smokers or have a positive family history.

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16
Q

Where is Alpha-1 antitrypsin produced

A

In the liver

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17
Q

What is the function of Alpha-1 antitrypsin

A

Acts as a protease inhibitor - inhibiting the action of neutrophil elastase

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18
Q

Describe the pathogenesis of how Alpha 1 Antitrypsin deficiency can lead to COPD

A

Alpha 1 Antitrypsin is a protease inhibitor and inhibts the action of neutrophil elastase

Neutrophil elastase acts by damaging bacteria however if left unchecked (as in alpha 1 antitrypsin deficiency) it can cause the breakdown of elastin in the lungs.

Elastase is a protein important to the structural integrity of the alveoli.

Breakdown of the elastase in the lungs causes emphysema leading to COPD

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19
Q

The emphysema related to alpha 1 antitrypsin deficiency is different to that caused by smoking.

How do they differ

A

Differ in location

alpha 1 antitrypsin deficiency - the emphysema is characteristically pan-acinar with a lower zone predominance.

Smoking – the emphysema is characteristically centri-acinar.

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20
Q

What 4 changes in the lungs can chronic bronchitis cause

A
  • Goblet cell hyperplasia
  • Mucus hypersecretion
  • Chronic inflammation and fibrosis
  • Narrowing of small airways
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21
Q

What immune cells infiltrate and are activated as part of the action of emphysema in COPD

A

Neutrophilic and CD8+ infiltration

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22
Q

What immune cells infiltrate and are activated as part of the action of asthma

A

Eosinophil infiltration with CD4+ T lymphocytes.

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23
Q

What are the 3 cardinal symptoms of COPD

A
  1. Dyspnoea (laboured breathing)
  2. Chronic cough
  3. Sputum production
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24
Q

Name some of the symptoms a patient may experience with COPD

A
  • Chronic cough: usually productive
  • Sputum production
  • Breathlessness: usually on exertion in early stages
  • Frequent episodes of bronchitis. Mostly during the winter months.
  • Wheeze
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25
Q

Name some of the signs a patient may experience with COPD

A
  • Dyspnoea (laboured breathing)
  • Other physical signs are seldom obvious until the disease is advanced.
  • Pursed lip breathing - prevents alveolar collapse by increasing the positive end expiratory pressure
  • Wheeze
  • Coarse crackles may accompany infection
  • Loss of cardiac dullness: due to hyper-expansion of lungs from emphysema
  • Downward displacement of liver: due to hyper-expansion of lungs from emphysema
  • Signs of carbon dioxide retention
    • Drowsy
    • Asterixis (flapping tremor; tremor of the hand when the wrist is extended)
    • Confusion
  • Signs of cor pulmonale
    • Peripheral oedema
    • Left parasternal heave: caused by right ventricular hypertrophy
    • Raised JVP
    • Hepatomegaly
  • Pitting oedema as a consequence of salt and water retention caused by renal hypoxia and hypercapnia.
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26
Q

There are two classic phgenotypes of a patient with COPD. Pink puffers and blue bloaters

Pink puffers is used to describe what kind of patient

A

Used to describe patients where emphysema dominates.

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27
Q

There are two classic phgenotypes of a patient with COPD. Pink puffers and blue bloaters

Blue bloaters is used to describe what kind of patient

A

used to describe patients where chronic bronchitis dominates.

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28
Q

What type of COPD patient is breathless but not cyanotic:

a) Pink puffers
b) Blue bloaters

A

a) Pink puffers

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29
Q

What type of COPD patient is not breathless but cyanotic:

a) Pink puffers
b) Blue bloaters

A

b) Blue bloaters

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30
Q

What type of respiratory failure is associated with pink puffer COPD patients

A

Type 1 respiratory failure

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31
Q

What type of respiratory failure is associated with blue bloaters COPD patients

A

Type 2 respiratory failure

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32
Q

Why are the pink puffers (COPD patient) are typically thin

A

Patients are typically thin because they use so much energy because they have a high respiratory drive and because they are using the accessory muscles.

They have a high respiratory drive i.e. they have a high breathing effort.

Often using their accessory muscles and pursed lip breathing to help draw oxygen in.

Often patients are hunched-over with their arms resting stabilising their upper arms to allow the muscles e.g. sternocleidomastoid, pectoralis major, and trapezius, to work purely as accessory muscles for respiration.

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33
Q

Why are pink puffers have a barrel chested

A

Due to air trapping

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34
Q

Name some of the characteristics of pink puffer of COPD

A
  • Tachypnoea (rapid breathing)
  • Severe dyspnea (shortness of breath)
  • Hyper-resonance on chest percussion
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35
Q

What will be the radiological features of a pink puffer COPD on chest x ray

A

Hyperinflation of lungs

Flattened diaphragm

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36
Q

Why are blue bloaters “blue” (COPD patient)

A

Blue appearance because they are cyanotic

37
Q

Why are blue bloaters cyanotic

A
  • Result of hypoxia i.e. low oxygen in the blood.
  • The chronic obstruction to the airway means less oxygen is able to get in and less carbon dioxide is able to get out.
  • The airways are obstructed by mucus hypersecretion and accumulation.
38
Q

Why are blue bloaters “bloaters”

A

Due to fluid retention

  • Less blood is getting to the left side of the heart (as a consequence of hypoxemic vasoconstriction (reduced ventilation to compensate for the V/Q mismatch).
  • This causes a reduction in left ventricular output.
  • As a consequence, there is a decreased circulatory volume.
  • Decrease circulatory volume results in the activation of the RAAS system causes more fluid retention – causing the “bloating”
39
Q

Why should we be cautious about giving blue bloater patients oxygen

A
  • Patients are insensitive to the high CO2 levels and come to depend on hypoxemia to drive ventilation.
  • Attempts to abolish hypoxaemia by administering oxygen can make the situation much worse by decreasing respiratory drive in these patients who depend on hypoxia to drive their ventilation.
40
Q

Name some of the classic features of blue bloaters

A

Blue appearance - due to cyanotic

Bloated due to fluid retention

Finger clubbing

Recurrent cough

Sputum production

41
Q

Fill in the blank

Blue bloaters (predominant bronchitis)

Pink puffers (predominant emphysema)

A
42
Q

COPD is a syndrome encompassing of two components

Name them

A

emphysema and chronic bronchitis

43
Q

Consider the diagnosis of COPD for people who are over 35, and smokers or ex-smokers, with any of following symptoms.

Name these symptoms

A
  • exertional breathlessness
  • chronic cough
  • regular sputum production
  • frequent winter ‘bronchitis’
  • wheeze
44
Q

COPD is diagnostic based on?

A

CLinical history

Clinical dignosis

45
Q

What is the first test for diagnosis of COPD and for monitoring disease progress

A

Spirometry

46
Q

What pattern is evident on spirometry for COPD

A

Obstructive pattern i.e. reduced FEV1 and FEV1/FVC ratio.

47
Q

How can you distinguish between COPD and asthma on spirometry

A

Post-bronchodilator FEV1/FVC ratio is still low (< 0.7) in COPD

In asthma it is reversed

48
Q

Flow volume charts can also be used in COPD.

What is the name of the pattern that will be seen on the flow volume charts for COPD

A

‘church steeple’ form on the flow-volume chart.

49
Q

What is the FEV1

A

Forced Expiratory Volume in 1 second (FEV1) is the volume of air exhaled in the first second during forced exhalation after maximal inspiration.

50
Q

What is the FVC

A

Forced vital capacity (FVC) is the total amount of air exhaled

51
Q

Severity of the airflow obstruction in COPD can be graded using the what measurement

A

Predicted FEV1

52
Q

COPD is graded based on predicted FEV1

What is the predicted FEV1 for mild COPD (Stage 1)

A

> 80% of predicted

53
Q

COPD is graded based on predicted FEV1

What is the predicted FEV1 for moderate COPD (Stage 2)

A

50-79% of predicted

54
Q

COPD is graded based on predicted FEV1

What is the predicted FEV1 for severe COPD (Stage 3)

A

30-49% of predicted

55
Q

COPD is graded based on predicted FEV1

What is the predicted FEV1 for very severe COPD (Stage 4)

A

<30% of predicted

56
Q

COPD is graded based on predicted FEV1

Fill in the blank of the FEV1 which is associated with each COPD stage

A
57
Q

Name some of the investigations for COPD

A

Spirometry - showing an obstructive pattern. Stages the COPD based on predicted FEV1

CXR - exclude other diangosis. Show overinflation in emphsema

High resolution CT

Pulse oximetry - screen for hypoxia

ABG

FBC

Serum alpha 1 antitrypsin - if deficiency will have low levels

ECG

58
Q

Name a potential complication of COPD

A

Cor pulmonale

  • Signs of cor pulmonale
    • Peripheral oedema
    • Left parasternal heave: caused by right ventricular hypertrophy
    • Raised JVP
    • Hepatomegaly
59
Q

Name some of the signs of carbon dixoide renteion

A
  • Drowsy
  • Asterixis (flapping tremor; tremor of the hand when the wrist is extended)
  • Confusion
60
Q

Name some of the signs of cor pulmonale

A
  • Peripheral oedema
  • Left parasternal heave: caused by right ventricular hypertrophy
  • Raised JVP
  • Hepatomegaly
61
Q

Why are patients with COPD have pitting oedema

A
  • Pitting oedema as a consequence of salt and water retention caused by renal hypoxia and hypercapnia.
62
Q

COPD is a progressive chronic condition. What does the management of COPD focuses on

A

The management of COPD focuses on improving symptoms such as breathlessness and reducing the frequency and severity of exacerbations.

63
Q

Name some of the conservation management for COPD

A

Education

Smoking cessation

Vaccination - offered seasonal influenza vaccine and pneumococcal vaccine

Pulmonary rehabilitation

64
Q

Describe the management of acute exacerbations of COPD

A

Oxygen - used cautiously. If evidence of CO2 retention then sat of 88-92%

Bronchodilators - usually given as nebulisers.

  • Beta agonist e.g. salbutamol - can be given back to back until stabilised - then given QDS
  • Muscarinic antagonist e.g. Ipratropium - can be given STAT with salbutamol then 2-4 per day

Corticosteroids - e.g. prednisolone 30mg OD

Antibiotics - typically doxycycline or co-amoxiclav

65
Q

What additional therapy may be considered in severe exacerbations of COPD

A

Intravenous theophylline

66
Q

If you give IV theophylline, what must be required in addition to this

A

Requires cardiac monitoring

67
Q

Describe the medical management of the chronic management of COPD

A

Inhaled therapies form the cornerstone of management in COPD.

All patients diagnosed with COPD should be prescribed a short-acting bronchodilator for immediate symptom relief either a SABA or SAMA.

SABA and SAMA improve lung function and breathlessness and quality of life.

Stepwise therapy according to patient’s group class based on their risk of exacerbations

68
Q

What type of inhalers is used in COPD to provide immediate symptom relief as part of their long term management

A

Short-acting bronchodilator either a SABA or SAMA.

69
Q

We are able to quality of patients risk of exacerbations in COPD.

What are the 4 components that make up this

A
  • Patient symptoms (CAT assessment)
  • Breathlessness (Dyspnoea Scale)
  • Severity of airflow limitation (Gold scale)
  • Number of exacerbations in the last year
70
Q

What is the grading system used in assessment of the impact of breathlessness in COPD

A

Dyspnoea Scale

Grade 1-5 (5 being the worse)

71
Q

In patients in Group A COPD (few symptoms and low risk of exacerbations)

What is the first line therapy

A

short- or long-acting bronchodilator

LAMAs and LABAs are preferred over SAMAs and SABAs

72
Q

Which inhaler has a greater effect on exacerbation reduction in COPD

a) LAMA
b) LABA

A

LAMAs have a greater effect on exacerbation reduction than LABAs.

73
Q

What inhaler needs to be discontinued if a LAMA is prescribed

A

SAMA

74
Q

In patients in Group B COPD (more symptoms and low risk of exacerbations)

What is the first line therapy

A

long-acting bronchodilator, either a LAMA or LABA

75
Q

In patients in Group C COPD (few symptoms and high risk of exacerbations)

What is the first line therapy

A

1st line – LAMA

LAMAs have a greater effect on exacerbation reduction than LABAs in patients with moderate to very severe COPD

If symptoms persist or have recurrent exacerbations can go onto LABA/LAMA or LABA/ICS.

76
Q

In patients in Group D COPD (more symptoms and high risk of exacerbations)

What is the first line therapy

A

1st line: LAMA or LABA/LAMA or LABA/ICS

LAMA is the first choice for most patients.

LABA/LAMA combination should be considered if the patient is highly symptomatic

77
Q

When should ICS/LABA combination be considered in group D COPD patients

A

if the patient’s blood eosinophil count is ≥300 cells/microlitre or the patient has a history of asthma.

78
Q

What is an adverse effect of ICS

A

ICS increases the risk of developing pneumonia in some patients.

79
Q

Group A COPD patients have:

a) Few or more symptoms
b) Low or high risk of exacerbations

A

Few symptoms

Low risk of exacerbations

80
Q

Group B COPD patients have:

a) Few or more symptoms
b) Low or high risk of exacerbations

A

More symptoms

Low risk of exacerbations

81
Q

Group C COPD patients have:

a) Few or more symptoms
b) Low or high risk of exacerbations

A

Few symptoms

High risk of exacerbations

82
Q

Group D COPD patients have:

a) Few or more symptoms
b) Low or high risk of exacerbations

A

More symptoms

High risk of exacerbations

83
Q

What additional therapy could be used in patients who often produce thick sputum on a frequent basis

(COPD)

A

Mucolytic agents

does not improve lung function or quality of life

84
Q

What surgical interventions may be considered in the management of COPD

A

Lung volume reduction surgery

Bullectomy: may be considered when large bullae compress surrounding normal lung tissue.

Lung transplantation: may benefit selected patient with advanced disease

85
Q

In additional to inhalers, what is another therapy that may be useful in the long term management of COPD

Particularly in late disease

A

Long term oxygen therapy (LTOT)

LTOT is required for at least 15 hours a day for a benefit to be seen.

86
Q

What percussion note will most likely be seen in COPD patients

A
87
Q

Patients with COPD:

a) What type of mask should oxygen be admitted through
b) What oxygen stats should they be targeting for

A

a) Venturi mask for more accurate oxygen level
b) Oxy sat 88-92

88
Q

Which single intervention is most likely to improve the COPD patients prognosis?

A

Smoking cessation – improves prognosis and prevents worsening of symptoms

Finals: Medicine (91 decks)

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