COPD Flashcards
What is the definition of COPD?
How does it differ from asthma?
It is a common and largely preventable lung condition
It is characterised by persistent respiratory symptoms and airflow obstruction (progressive, not fully reversible)
This is different to asthma, as in asthma the airflow obstruction is reversible
It is a treatable condition, but it is not curable
What are the 3 most typical symptoms of COPD?
- cough
- breathlessness
- sputum production
What were the previous terms used to describe COPD?
emphysema & chronic bronchitis
Why does COPD happen?
- inflammation starts and recruits immune cells, particularly macrophages
- this inflammatory cycle becomes uncontrolled and results in an excess of proteases + reactive oxygen species
- parenchyma supporting the alveoli is broken down, along with elastin
- the alveoli can no longer spring shut on expiration, resulting in reduced expiration
- the airways are full of mucus and not held open by parenchyma so collapse upon expiration
- destruction of alveolar walls impairs gas exchange
What is always required for diagnosis of COPD?
How can it be confirmed to be an obstructive lung condition?
spirometry is always required for diagnosis
FEV1 / FVC < 0.7
What are the potential risk factors for chronic inflammation that drives COPD?
- mainly noxious particles / gases (i.e. tobacco smoke, air pollution, occupational exposure)
- recurrent infections
- alpha-1-antitrypsin deficiency
- asthma
- age
chronic inflammation results in airway and parenchymal damage
What is significant about chronic inflammation in the lungs?
- chronic inflammation in the lungs leads to airway and parenchymal damage
- this produces airflow obstruction
How is COPD diagnosed?
- diagnosis is based on clinical features + spirometry
- COPD is suspected when patient >35 + risk factor + one or more clinical symptoms
What clinical symptoms may you see when making a diagnosis of COPD?
- dyspnoea
- recurrent / persistent cough
- regular sputum
- recurrent infections
- wheeze
What is the nature of the dyspnoea in COPD?
- unlike asthma, it is PERSISTENT breathlessness
- it is progressive
- it is exercise-induced
- it presents with “air hunger”, chest heaviness & gasping
What is the nature of the cough in COPD?
Why is a concurrent wheeze checked for?
- the cough is chronic
- it is productive in 30% of patients
- sputum is produced, but NOT always coughed up
- presence of a concurrent wheeze helps to exclude pulmonary oedema
What examination signs may be seen in a patient with COPD?
- cyanosis
- raised JVP and/or peripheral oedema (indicates cor pulmonale)
- cachexia
- hyperinflation of the chest
- use of accessory muscles / pursed lip breathing
- wheeze and/or crackles on auscultation
Examination is often normal, but ^ signs may be present
What are more non-specific symptoms that may also be present in a COPD patient?
- weight loss
- fatigue
- anorexia
- nocturnal dyspnoea
- ankle swelling
- reduced exercise tolerance
these may be as a result of the sequelae that come on after COPD
In general, why do people get COPD?
What can accelerate the degenerative changes?
It is a disease caused by declining lung function
Lung function declines with age
It can be accelerated by a lower baseline lung function
Or by inflammatory damage to the lungs
Why might someone have a lower baseline lung function?
- childhood respiratory disease (asthma) or infection
- malnourishment or other cause of poor development
Why might someone have inflammatory damage to the lungs?
- SMOKING
- respiratory infections / chronic bronchitis
- susceptibility to inflammation (family Hx) or environmental exposures
- lack of anti-inflammatories (a1-antitrypsin deficiency)
What spirometry results are needed for a diagnosis?
What else is important to consider?
post-bronchodilator FEV1 / FVC < 0.7
consider other causes in patients who have a ratio of < 0.7, particularly if they have atypical symptoms
When taking a COPD history, what symptoms are important to exclude?
- haemoptysis
- hoarseness of the voice
- episodic rather than continuous disease
- pink frothy sputum
- night sweats
- appetite loss
What other differentials should be considered when a patient presents with COPD-like symptoms?
- heart failure
- lung cancer
- interstitial lung disease
- asthma
- anaemia
- TB
- cystic fibrosis
What peripheral signs might be present on examination?
- increased respiratory effort - tripod position, flared nostrils, use of accessory muscles
- hypercapnia (CO2 retention) - flap + bounding pulse
What chest signs may be present in a patient with COPD?
- WHEEZE
- tachypnoea with prolonged expiration
- barrel chest - loss of percussion over heart + liver
- cor pulmonale (RV heave, peripheral oedema + raised JVP)
- Hoover’s sign
What is cor pulmonale?
right heart failure, secondary to lung disease
Why does cor pulmonale occur?
- chronic hypoxia causes progressive pulmonary hypertension
- this leads to right ventricular hypertrophy and impaired RV function
What signs / symptoms may be seen in a patient with cor pulmonale?
- hepatomegaly
- parasternal heave
- peripheral oedema
- raised JVP
- loud pulmonary second heart sound (2nd ICS)
What are the 3 first line investigations for COPD?
- CXR
- Bloods (exclude anaemia)
- BMI
CXR + bloods help to exclude other potential causes
What are the NICE guidelines for when to perform spirometry?
- at diagnosis
- to reconsider the diagnosis in people who respond well to treatment
- to monitor disease progression
What are the 5 different ways in which COPD severity can be measured?
- spirometry (FEV1)
- Medical Research Council dyspnoea scale (MRC)
- exercise tolerance
- number of exacerbations / hospital attendances
- symptom burden - the CAT (COPD assessment test)
What is the Medical Research Council (MRC) dyspnoea scale?
- dyspnoea is graded from 1 to 5, depending on severity of symptoms
How is COPD staged using FEV1?
Stage I - mild:
* FEV1 > 80% predicted
Stage II - moderate:
* FEV1 50-79% predicted
Stage III - severe:
* FEV1 30-49% predicted
Stage IV - very severe:
* FEV1 < 30% prediced
* or < 50% with resp failure
What is involved in the CAT (COPD Assessment Test)?
- it involves 8 questions about symptom burden that are each scored from 0 to 5
What are the 6 key features that can help to differentiate asthma from COPD?
- COPD is typically seen in smokers
- COPD is usually seen in patients > 35
- COPD produces a chronic productive cough
- Breathlessness is progressive and persistent
- night time waking with SOB / diurnal variation in symptoms are features of asthma
How does longitudinal observation help to differentiate between COPD and asthma?
- this involves monitoring symptoms, using peak flow or spirometry
- serial peak flow readings showing >20% variation mean asthma is more likely
- a return of normal FEV1 and normal FEV1 / FVC with treatment = NOT COPD
What medications may be used to differentiate asthma from COPD?
- a large (400mls) response to bronchodilators
- or steroids (30mg prednisolone for 2 weeks)
means asthma is more likely
After a confirmed diagnosis, what are the 2 realms of treatment offered?
- it is important to first cover all of the fundamentals of COPD care
- only after all of these options are offered, inhaled therapies are started
- a SABA and SAMA to use as needed are offered
What is involved in the fundamentals of COPD care?
How often should this be reviewed?
- offer treatment and support to stop smoking
- offer influenza + pneumococcal vaccines
- offer pulmonary rehabilitation if indicated
- co-develop a personalised self-management plan (e.g. recognising triggers)
- optimise treatment for comordibities that could be worsening COPD sx
When should inhaled therapies be offered in COPD?
- after implementation / offering of all of the fundamentals
- if inhaled therapies are needed to relieve breathlessness + exercise limitation
- patient trained to use inhaler + can demonstrate acceptable technique
If a patient is taking a LABA + LAMA but are still symptomatic, what is the next step?
- 3-month trial of LABA + LAMA + ICS for day-to-day symptoms that adversely affect QoL
- if this does not work, then revert back to LABA + LAMA
- if they are still limited by SOB, explore further tx options
What should be done if someone is taking LABA + LAMA but is still having severe exacerbations?
- if they are having 1 severe or 2 moderate exacerbations in a year
- consider LABA + LAMA + ICS
- if they are still having frequent exacerbations, explore further tx options
If someone with COPD has asthmatic features / features of steroid responsiveness, how is tx different?
- LABA + ICS is offered instead of LABA + LAMA
- if they are still symptomatic / having exacerbations, consider LABA + LAMA + ICS
If someone presents with COPD symptoms, but there CAT < 10 and they have few sx, what might be trialled?
a SABA may be trialled and response assessed after 4 weeks
What further resources might be offered to patients if they have an exacerbation?
- all patients and their care plans should be reviewed following an exacerbation
- most patients should be offered a rescue pack of steroids / abx to keep at home
- all patients should be given safety net advice to seek help if their symptoms don’t rapidly improve
What are the common features of an acute exacerbation of COPD?
- increased dyspnoea
- increased sputum production
- cough
- wheeze
- fever
- increased RR or HR > 20% baseline
What are the features of a severe COPD exacerbation?
- cyanosis
- low sats / raised RR
- marked dyspnoea at rest / minimal activity
- pursed lip breathing
- use of accessory muscles
- drowsiness / confusion
- reduction in ability to cope with ADLs
When does someone with a severe COPD exacerbation need hospital admission?
- severe dyspnoea
- haemodynamic instability
- struggling to cope at home
- confusion
- low O2 sats / cyanosis
- failure to respond to treatment
What is involved in the home treatment for an acute COPD exacerbation?
- increase frequency of short-acting bronchodilators
- consider a nebuliser if patient likely to be fatigued
- consider oral steroids (prednisolone 30mg for 5 days)
- consider oral abx (amoxicillin first line, then doxycycline / clarithromycin)
What are other things that need to be put in place / considered for home treatment of an exacerbation?
- ensure safety net advice / monitoring is in place
- if patient is at high risk of tx failure, consider broad spectrum abx (co-amoxiclav)
What might be done if a patient on home management for an exacerbation is not improving?
- consider sputum sample / revisit diagnosis if no improvement in 2-3 days
- if symptoms are persistent, consider further investigation and/or referral
