COPD Flashcards
What 2 processes can COPD involve. Describe them.
chronic bronchitis - neutrophils cause mucous hyper secretion and mucociliary dysfunction
- partially reversible
emphysema - alveolar damage causes impaired gas exchange
- non-reversible
What can cause COPD?
smoking
alpha-1-antitrypsin deficiency
4Cs:
- cadmium (used in smelting)
- coal
- cotton
- cement
What clinical features are seen in COPD?
- chronic cough - often productive
- dyspnoea (starting with exertional)
- wheeze
- in severe cases right sided HF may develop causing peripheral oedema
What investigations should be carried out in someone with suspected COPD?
- post bronchodilator spirometry (to check FEV1/FVC <0.7)
- CXR: hyperinflation, bullae, flat hemidiaphragm
- FBC: to exclude secondary polycythaemia
- due to chronic hypoxaemia
- increases risk of clot
State how the following types of COPD are defined.
- mild (stage 1)
- moderate (stage 2)
- severe (stage 3)
- very severe (stage 4)
- FEV1 >80% predicted
- FEV1 50-79% of predicted
- FEV1 30-49% of predicted
- FEV1 <30%
T/F: peak expiratory flow rate should be measured in COPD
False: limited value as it may underestimate the level of airflow obstruction
What general management should be given to all patients with COPD?
- smoking cessation advice (incl. offering nicotine replacement therapy, varenicline or bupropion)
- annual influenza vaccine
- one-off pneumococcal vaccine
- pulmonary rehabilitation
- Describe the bronchodilator therapy management in COPD
- What are 4 asthmatic / steroid responsiveness features?
- a) What can be given if inhalers do not work or cannot be used?
b) When would this medication have to be altered?
start with SABA or SAMA
if patients remain breathless or have exacerbations add longer acting inhaler
if signs of asthmatic or steroid responsiveness add LABA + ICS
if remain breathless / exacerbations after this add LAMA
if no signs of asthmatic or steroid responsiveness add LABA + LAMA
NOTE: if patient is taking a SAMA and a LAMA is added, change SAMA to SABA
- previous diagnosis of asthma / atopy
- high eosinophil count
- variation of FEV1 over time (>400mls)
- diurnal variation in PEFR (at least 20%)
- a) oral theophylline
b) would have to be reduced if giving macrolide or fluoroquinolone ABx
Symptom management
When should the following be offered:
- mucolytics
- loop diuretics
- antibiotic prophylaxis (azithromycin)
- if productive cough and only continued if symptoms improved
- if cor pulmonale present:
- raised JVP
- peripheral oedema
- systolic parasternal leave
- loud P2 - if patient has persistent exacerbations despite stopping smoking and optimising treatment
also must pass the following:
- CT thorax to exclude bronchiectasis
- sputum culture to exclude atypical infection
- ECG to exclude long QT (as azithromycin can cause prolonged QT)
Long term oxygen therapy
- What patients should be assessed?
- What assessment is carried out?
- When should patients be offered long term oxygen therapy?
- What patients should not be offered long term oxygen therapy?
- FEV1 <30% (consider if <50%)
- cyanosis / sats <92%
- peripheral oedema / raised JVP
- polycythaemia
- 2 arterial blood gases at least 3 weeks apart
- pO2 <7.3 kPa
- pO2 <8.0 kPa
+ pulmonary hypertension, peripheral oedema or polycythaemia
- any patients still smoking
Acute exacerbation of COPD
- What clinical features are seen?
- causes
a) What is the most common bacterial cause and 2 others
b) What is the most common viral cause? - How is it managed?
- worsening of COPD symptoms (cough, dyspnoea, wheeze)
- increase in sputum
- may be hypoxic + confused
- a) most common: haemophilus influenza
+ strep. pneumonia
+ moraxella
b) rhinovirus
- increase bronchodilator therapy
- prednisolone 30mg for 5 days
+ amoxicillin (doxycycline if pen allergic) for 5 days if purulent sputum or clinical signs of pneumonia
+ O2 therapy if required: start at 15L/min and titrate down to see what is tolerated
What should be offered to a patient experiencing frequent COPD exacerbations?
home ABx and prednisolone
- should still contact if having to take to assess severity
- only take ABx if purulent sputum
What is the best thing to do to prevent the progression to COPD?
stop smoking
Smoking cessation
- what treatments can be offered and in what combination?
- Prescribing
a) How much should be prescribed initially?
b) if someone has a failed attempt, when can a repeat prescription be offered?
- nicotine replacement therapy, varenicline, bupropion - these cannot be offered in combination with one another
- a) enough to last until 2 weeks after stop date - reassessment and further management only given to those who demonstrate their quit attempt is continuing
b) only after 6 months
Nicotine Replacement Therapy
- What are the side effects?
- What is offered?
- N+V
- headache
- flu-like symptoms
- patch + another form (e.g. gum, spray, inhaler, lozenge)
