COPD Flashcards
What does COPD stand for
Chronic Obstructive Pulmonary Disease (COPD)
Define the term: chronic obstructive pulmonary disease (COPD)
COPD is an umbrella term for group of lung conditions that cause breathing difficulties. It includes chronic bronchitis and emphysema.
chronic obstructive pulmonary disease (COPD) is characterised by what?
Persistent airflow limitation that is not fully reversible.
Patients with COPD are susceptible to exacerbations during which there is worsening of their lung function. Exacerbations are often triggered by
Infections and these are called infective exacerbations.
COPD is an umbrella term for group of lung conditions.
Name the two lung conditions
Chronic bronchitis
Emphysema
Define chronic bronchitis
Lung condition in the COPD family
Defined as cough and sputum for at least 3 consecutive months in each of 2 consecutive years.
Chronic bronchitis is defined as a cough and sputum for how long
for at least 3 consecutive months in each of 2 consecutive years.
Define emohysema
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.
What is the most important aetiological factor for COPD
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.
Name some of the risk factors associated with COPD
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
Define the term “pack year”
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.
What is the equation for pack year
1 pack year = 20 cigarettes/day/year
A pack year is defined as twenty cigarettes smoked every day for one year.
What is the genetic deficiency associated with COPD
Alpha 1 antitrypsin deficiency
What percentage of COPD cases are associated with alpha 1 antitrypsin deficiency
1-3%
When should alpha 1 antitrypsin deficiency be suspected
Suspected in patients with COPD who are young, non-smokers or have a positive family history.
Where is Alpha-1 antitrypsin produced
In the liver
What is the function of Alpha-1 antitrypsin
Acts as a protease inhibitor - inhibiting the action of neutrophil elastase
Describe the pathogenesis of how Alpha 1 Antitrypsin deficiency can lead to COPD
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
The emphysema related to alpha 1 antitrypsin deficiency is different to that caused by smoking.
How do they differ
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.
What 4 changes in the lungs can chronic bronchitis cause
- Goblet cell hyperplasia
- Mucus hypersecretion
- Chronic inflammation and fibrosis
- Narrowing of small airways
What immune cells infiltrate and are activated as part of the action of emphysema in COPD
Neutrophilic and CD8+ infiltration
What immune cells infiltrate and are activated as part of the action of asthma
Eosinophil infiltration with CD4+ T lymphocytes.
What are the 3 cardinal symptoms of COPD
- Dyspnoea (laboured breathing)
- Chronic cough
- Sputum production
Name some of the symptoms a patient may experience with COPD
- Chronic cough: usually productive
- Sputum production
- Breathlessness: usually on exertion in early stages
- Frequent episodes of bronchitis. Mostly during the winter months.
- Wheeze
Name some of the signs a patient may experience with COPD
- 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.
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
Used to describe patients where emphysema dominates.
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
used to describe patients where chronic bronchitis dominates.
What type of COPD patient is breathless but not cyanotic:
a) Pink puffers
b) Blue bloaters
a) Pink puffers
What type of COPD patient is not breathless but cyanotic:
a) Pink puffers
b) Blue bloaters
b) Blue bloaters
What type of respiratory failure is associated with pink puffer COPD patients
Type 1 respiratory failure
What type of respiratory failure is associated with blue bloaters COPD patients
Type 2 respiratory failure
Why are the pink puffers (COPD patient) are typically thin
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.
Why are pink puffers have a barrel chested
Due to air trapping
Name some of the characteristics of pink puffer of COPD
- Tachypnoea (rapid breathing)
- Severe dyspnea (shortness of breath)
- Hyper-resonance on chest percussion
What will be the radiological features of a pink puffer COPD on chest x ray
Hyperinflation of lungs
Flattened diaphragm
Why are blue bloaters “blue” (COPD patient)
Blue appearance because they are cyanotic
Why are blue bloaters cyanotic
- 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.
Why are blue bloaters “bloaters”
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”
Why should we be cautious about giving blue bloater patients oxygen
- 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.
Name some of the classic features of blue bloaters
Blue appearance - due to cyanotic
Bloated due to fluid retention
Finger clubbing
Recurrent cough
Sputum production
Fill in the blank
Blue bloaters (predominant bronchitis)
Pink puffers (predominant emphysema)
COPD is a syndrome encompassing of two components
Name them
emphysema and chronic bronchitis
Consider the diagnosis of COPD for people who are over 35, and smokers or ex-smokers, with any of following symptoms.
Name these symptoms
- exertional breathlessness
- chronic cough
- regular sputum production
- frequent winter ‘bronchitis’
- wheeze
COPD is diagnostic based on?
CLinical history
Clinical dignosis
What is the first test for diagnosis of COPD and for monitoring disease progress
Spirometry
What pattern is evident on spirometry for COPD
Obstructive pattern i.e. reduced FEV1 and FEV1/FVC ratio.
How can you distinguish between COPD and asthma on spirometry
Post-bronchodilator FEV1/FVC ratio is still low (< 0.7) in COPD
In asthma it is reversed
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
‘church steeple’ form on the flow-volume chart.
What is the FEV1
Forced Expiratory Volume in 1 second (FEV1) is the volume of air exhaled in the first second during forced exhalation after maximal inspiration.
What is the FVC
Forced vital capacity (FVC) is the total amount of air exhaled
Severity of the airflow obstruction in COPD can be graded using the what measurement
Predicted FEV1
COPD is graded based on predicted FEV1
What is the predicted FEV1 for mild COPD (Stage 1)
> 80% of predicted
COPD is graded based on predicted FEV1
What is the predicted FEV1 for moderate COPD (Stage 2)
50-79% of predicted
COPD is graded based on predicted FEV1
What is the predicted FEV1 for severe COPD (Stage 3)
30-49% of predicted
COPD is graded based on predicted FEV1
What is the predicted FEV1 for very severe COPD (Stage 4)
<30% of predicted
COPD is graded based on predicted FEV1
Fill in the blank of the FEV1 which is associated with each COPD stage
Name some of the investigations for COPD
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
Name a potential complication of COPD
Cor pulmonale
-
Signs of cor pulmonale
- Peripheral oedema
- Left parasternal heave: caused by right ventricular hypertrophy
- Raised JVP
- Hepatomegaly
Name some of the signs of carbon dixoide renteion
- Drowsy
- Asterixis (flapping tremor; tremor of the hand when the wrist is extended)
- Confusion
Name some of the signs of cor pulmonale
- Peripheral oedema
- Left parasternal heave: caused by right ventricular hypertrophy
- Raised JVP
- Hepatomegaly
Why are patients with COPD have pitting oedema
- Pitting oedema as a consequence of salt and water retention caused by renal hypoxia and hypercapnia.
COPD is a progressive chronic condition. What does the management of COPD focuses on
The management of COPD focuses on improving symptoms such as breathlessness and reducing the frequency and severity of exacerbations.
Name some of the conservation management for COPD
Education
Smoking cessation
Vaccination - offered seasonal influenza vaccine and pneumococcal vaccine
Pulmonary rehabilitation
Describe the management of acute exacerbations of COPD
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
What additional therapy may be considered in severe exacerbations of COPD
Intravenous theophylline
If you give IV theophylline, what must be required in addition to this
Requires cardiac monitoring
Describe the medical management of the chronic management of COPD
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
What type of inhalers is used in COPD to provide immediate symptom relief as part of their long term management
Short-acting bronchodilator either a SABA or SAMA.
We are able to quality of patients risk of exacerbations in COPD.
What are the 4 components that make up this
- Patient symptoms (CAT assessment)
- Breathlessness (Dyspnoea Scale)
- Severity of airflow limitation (Gold scale)
- Number of exacerbations in the last year
What is the grading system used in assessment of the impact of breathlessness in COPD
Dyspnoea Scale
Grade 1-5 (5 being the worse)
In patients in Group A COPD (few symptoms and low risk of exacerbations)
What is the first line therapy
short- or long-acting bronchodilator
LAMAs and LABAs are preferred over SAMAs and SABAs
Which inhaler has a greater effect on exacerbation reduction in COPD
a) LAMA
b) LABA
LAMAs have a greater effect on exacerbation reduction than LABAs.
What inhaler needs to be discontinued if a LAMA is prescribed
SAMA
In patients in Group B COPD (more symptoms and low risk of exacerbations)
What is the first line therapy
long-acting bronchodilator, either a LAMA or LABA
In patients in Group C COPD (few symptoms and high risk of exacerbations)
What is the first line therapy
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.
In patients in Group D COPD (more symptoms and high risk of exacerbations)
What is the first line therapy
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
When should ICS/LABA combination be considered in group D COPD patients
if the patient’s blood eosinophil count is ≥300 cells/microlitre or the patient has a history of asthma.
What is an adverse effect of ICS
ICS increases the risk of developing pneumonia in some patients.
Group A COPD patients have:
a) Few or more symptoms
b) Low or high risk of exacerbations
Few symptoms
Low risk of exacerbations
Group B COPD patients have:
a) Few or more symptoms
b) Low or high risk of exacerbations
More symptoms
Low risk of exacerbations
Group C COPD patients have:
a) Few or more symptoms
b) Low or high risk of exacerbations
Few symptoms
High risk of exacerbations
Group D COPD patients have:
a) Few or more symptoms
b) Low or high risk of exacerbations
More symptoms
High risk of exacerbations
What additional therapy could be used in patients who often produce thick sputum on a frequent basis
(COPD)
Mucolytic agents
does not improve lung function or quality of life
What surgical interventions may be considered in the management of COPD
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
In additional to inhalers, what is another therapy that may be useful in the long term management of COPD
Particularly in late disease
Long term oxygen therapy (LTOT)
LTOT is required for at least 15 hours a day for a benefit to be seen.
What percussion note will most likely be seen in COPD patients
Patients with COPD:
a) What type of mask should oxygen be admitted through
b) What oxygen stats should they be targeting for
a) Venturi mask for more accurate oxygen level
b) Oxy sat 88-92
Which single intervention is most likely to improve the COPD patients prognosis?
Smoking cessation – improves prognosis and prevents worsening of symptoms
