COPD Flashcards
Definition of COPD
-Persistent airflow limitation that is usually progressive
-Associated with enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases
-Exacerbations and comorbidities contribute to severity
Why is COPD underrecognized?
-Disease with insidious onset
-Often treated as asthma
-Smokers don’t seek treatment
-Can present late with more advanced disease
Prevalence of COPD
-Prevalence increasing as living longer
-More prevalent in older individuals
-2%/ 1.2 million
Describe the triad of pathological changes in COPD
-Bronchial gland enlargement
-Bronchiolitis
-Emphysema
What is chronic bronchitis?
-Hyperplasia of goblet cells
=Increased inflammatory
=Mucus hypersecretion
-Cough productive of sputum on most days for 3 months over 2 consecutive years
Definition of emphysema
-Condition of the lung characterised by abnormal, permanent enlargement of airspaces distal to the terminal bronchioles, accompanied by destruction of their walls without obvious fibrosis
=Loss of elastic recoil
=Airflow limitation and gas trapping
Types of emphysema
-Centrilobular
=Central part of lobule destroyed
=Upper lobe predominance
=Common type in smokers
=Associated with bullous disease
-Panlobular
=End lobule destroyed
=Lower lobes
=Genetic (alpha-1 antitrypsin deficiency)
Histological changes in emphysema
-Loss of attachments
-Fibrosis inflammation
Exposure risk factors for COPD
-Cigarette smoke
-Occupational dust and chemicals
-Environmental tobacco smoke (ETS)
-Indoor and outdoor air pollution
-Infections (recurrent in children)
-Socio-economic status
Host risk factors for COPD
-Alpha-1 antitrypsin deficiency
-Airway hyper-responsiveness
-Poor lung growth
-Age
Describe Alpha-1 antitrypsin deficiency
-Alpha 1 proteinase deficiency
-1/5000 live births UK
-A1-AT aggregates in liver (liver disease in some cases in childhood)
-Emphysema <50 years of age (often 4th decade)
=Panlobular predominantly basal emphysema
-Smoking is cofactor
-Fam history
Pathogenesis of COPD
-Cigarette smoke (biomass particles/ particulates)
-Host factors/ amplifying mechanisms
=Lung inflammation
=Activation of alveolar macrophages and epithelial cells
=Neutrophil and CD8+ activation
=Small airway narrowing, alveolar destruction
=Oxidative stress (reactive oxygen species)
=Proteinases (destruction of lungs)
=COPD pathology
History taking in COPD
-Onset, variability and progression of symptoms such as:
=Breathlessness — assess severity using the Medical Research Council (MRC) dyspnoea scale.
=Cough and sputum production — ask about haemoptysis and consider other causes.
=Peripheral oedema — consider cor pulmonale.
=Weight loss – consider other causes.
-Exposure to risk factors including:
=Smoking — if the person is a current smoker document pack-years smoked (number of cigarette smoked per day divided by 20 multiplied by number of years smoked).
=Occupational or environmental exposures.
-Impact of symptoms on daily life and occupation:
=Impact of COPD on wellbeing and daily life can be assessed using the COPD Assessment test (CAT)
-Previous exacerbations or hospitalization.
-Past medical history and comorbidities including:
=Anxiety and depression.
=Cardiovascular disease and metabolic syndrome.
=Lung or liver disease.
=Osteoporosis.
=Asthma.
-Family history including:
=Lung or liver disease – consider underlying causes such as alpha-1-antitrypsin deficiency.
-Severity in FEV1% pred
-LTOT
-Previous exacerbations/ hospital admissions +/- NIV
-Any previous discussions/decisions around escalation of
care/resuscitation/anticipatory care planning. Care requirements/ability to manage ADLs/PADLs.
Smoking/vaping status. Usual treatment including any recent steroids/antibiotics
Symptoms of COPD
Suspect COPD in people aged over 35 years with a risk factor (such as smoking, occupational or environmental exposure) and one or more of the following symptoms:
-Breathlessness — typically persistent, progressive over time, and worse on exertion.
-Chronic/recurrent cough (may be intermittent and unproductive)
-Regular sputum production (increase could suggest infective exacerbation)
-Frequent lower respiratory tract infections.
-Wheeze.
-Weight loss, anorexia and fatigue — common in severe COPD but other causes must be considered.
-Waking at night with breathlessness.
-Ankle swelling – consider cor pulmonale.
-Chest pain – uncommon in COPD, consider other causes.
-Haemoptysis – uncommon in COPD, consider other causes.
-Reduced exercise tolerance.
-Acute confusion?
-Right sided HF with peripheral oedema
Symptoms of acute exacerbation of COPD
-Commonly reported symptoms include:
=Increased breathlessness.
=Increased cough.
=Increased sputum production and change in sputum colour.
-Other reported symptoms may include:
=Increased wheeze and chest tightness.
=Upper respiratory tract symptoms (for example cold or sore throat).
=Reduced exercise tolerance.
=Ankle swelling.
=Increased fatigue.
=Acute confusion.
Conditions in past medical history
-Asthma
-Allergies
-Sinusitis
-Nasal polyps
-Respiratory infections in childhood
Inspection findings in clinical examination
-Resting RR >20 breaths/minute
-Use of accessory muscles of respiration
-Pursed lip breathing (emphysematous)
-Chest wall abnormalities reflecting pulmonary hyperinflation
=Horizontal ribs, barrel shaped, protruding abdomen
-Flattening of hemi-diaphragm associated with paradoxical indrawing of:
=Lower rib cage on inspiration, reduced cardiac and liver dullness, widening of xiphisternal angle, decreased crico-sternal distance
-Central cyanosis, signs of CO2 retention
-Peripheral oedema
-Weight loss/ loss of muscle tone
-Raised jugular venous pressure and/or peripheral oedema (may indicate cor pulmonale).
-Cachexia
-Flapping tremor
Palpation and percussion findings in clinical examination
-Often unhelpful in COPD
-Decreased cricosternal distance
-Detection of the apex beat may be difficult due to pulmonary overinflation
-Lower sternum resonant percussion (gas trapping)
-Loss of lover dullness
Auscultation findings in clinical examination
-Reduced breath sounds
-Wheezing during quiet breathing (scattered bilateral)
-Respiratory crackles occur vary with coughing but not diagnostic (infection)
4 components of COPD management
- Assess and monitor disease
- Reduce risk factors
- Manage stable COPD
=Education
=Pharmacologic
=Non-pharmacologic - Manage exacerbations
Diagnosis of COPD
-Symptoms
-Exposure to risk factors
-Spirometry
=Post-bronchodilator and baseline FEV1
=FEV1/FVC<0.7 confirms airflow limitation
NICE recommend considering a diagnosis of COPD in patients over 35 years of age who are smokers or ex-smokers and have symptoms such as exertional breathlessness, chronic cough or regular sputum production.
The following investigations are recommended in patients with suspected COPD:
=post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70%
=chest x-ray: hyperinflation, bullae (can mimic pneumothorax), flat hemidiaphragm. Also important to exclude lung cancer
=full blood count: exclude secondary polycythaemia
=body mass index (BMI) calculation
=Spirometry: Measure post-bronchodilator spirometry to confirm the diagnosis of COPD — do not routinely perform reversibility testing as part of diagnostic work up.
Additional investigations for COPD
-Sputum culture – if sputum is purulent and persistent (to identify organisms).
-Serial home peak flow measurements – to exclude asthma if diagnosis is in doubt.
-ABG
-Bloods: FBC, US, CRP, LFT
-ECG and serum natriuretic peptides – if cardiac disease or pulmonary hypertension are suspected.
=Echocardiogram may also be indicated.
-CT thorax – if symptoms seem disproportionate to spirometry measurements; another diagnosis (such as fibrosis or bronchiectasis) is suspected, or an abnormality on chest x-ray requires further investigation.
-Serum alpha-1-antitrypsin.
=Consider alpha-1-antitrypsin deficiency in people with early onset of symptoms, minimal smoking history or a positive family history.
=Referral to a specialist for management and screening of family members is required if alpha-1-antitrypsin deficiency is identified.
Stratification of severity of COPD
-Mild FEV1>80% predicted
-Moderate 50%<FEV1<80% pred
-Severe 30%<FEV1<50% pred
-Very severe FEV1<30% pred
(post-bronchiodilator)
