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Medicine 1 - Clinical > COPD > Flashcards

COPD Flashcards

1
Q

What does COPD stand for?

A

Chronic obstructive pulmonary disease

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2
Q

What is COPD?

A

Non-reversible, long term deterioration in air flow through the lungs caused by damage to lung tissue.

Emphysema + Chronic bronchitis

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3
Q

What causes COPD?

A

Smoking

Alpha 1 antitrypsin deficiency - early onset <4.5 y/o

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4
Q

What are risk factors of COPD?

A

Older age
Female
Lower socio-economic status
Asthma/airway hypersensitivity

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5
Q

What does damage to lung tissue in COPD cause?

A

An obstruction to the flow of air through the airways making it more difficult to ventilate the lungs and making them prone to developing infections.

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6
Q

Presentation

A

Chronic productive cough for at least 3 months in at least 2 consecutive years
without other identifiable cause

Purulent sputum production

Hypoxia

Hypercapnia

Exertional dyspnoea

Cyanosis (‘Blue bloaters’)

Peripheral oedema secondary to cor pulmonale

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7
Q

What does COPD not cause?

A

Clubbing
Haemoptysis
Chest pain

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8
Q

What can chronic hypoxia cause and how?

A

Right ventricular hypertrophy

Pulmonary arteriolar vasoconstriction -> increased pulmonary hypertension

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9
Q

What happens in severe COPD?

A

Hypoxic drive -> body relies on central chemoreceptors

Cor pulmonale

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10
Q

MRC scale to assess breathlessness

A

Grade 1 – Breathless on strenuous exercise

Grade 2 – Breathless on walking up hill

Grade 3 – Breathless that slows walking on the flat

Grade 4 – Stop to catch their breath after walking 100 meters on the flat

Grade 5 – Unable to leave the house due to breathlessness

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11
Q

When can COPD be diagnosed?

A

If ALL criteria met:

  • Typical symptoms
  • > 35 y.o
  • No asthma clinical features

AND

Airflow obstruction confirmed by post-bronchodilator spirometry (no reversibility shown with bronchodilators, excluding asthma)

Spirometry - <0.7

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12
Q

What spirometry results are needed for diagnosis ?

A

Obstructive picture
FEV1/FVC ratio <0.7

FEV1 decreased
FVC normal or decreased
Decreased ratio

No dramatic result to reversibility testing with beta-2-agonists

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13
Q

Severity of airway obstruction using FEV1

A

Stage 1: FEV1 >80% of predicted
Stage 2: FEV1 50-79% of predicted
Stage 3: FEV1 30-49% of predicted
Stage 4: FEV1 <30% of predicted

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14
Q

Blood work results

A

FBC (raised PCV; polycythaemia)

ABG (reduced PaO2 +/- raised PaCO2 or type 2 respiratory failure)

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15
Q

ECG results

A

P-pulmonale (right atrial hypertrophy) and right ventricular hypertrophy, if there is cor pulmonale

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16
Q

CXR results

A

Hyperinflated chest (>6 anterior ribs)

Bullae

Decreased peripheral vascular markings

Flattened hemidiaphragms

Suspended small heart

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17
Q

Non-pharmacological management

A

Smoking cessation

Vaccination (flu yearly + pneumococcal every 5 years)

Pulmonary rehab

Nutritional assessment

Psychological support

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18
Q

Long term management

Step One

A

Short acting bronchodilators:

beta-2 agonists (salbutamol or terbutaline) or short acting antimuscarinics (ipratropium bromide).

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19
Q

Long term management

Step Two

Non-asthmatic

A

Long acting beta agonist (LABA) plus a long acting muscarinic antagonist (LAMA):

“Anoro Ellipta”
“Ultibro Breezhaler”
“DuaKlir Genuair”

20
Q

Long term management

Step Two

Asthmatic

A

(LABA) plus (ICS):

“Fostair“
“Symbicort”
“Seretide”

If these don’t work then they can step up to a combination of a LABA, LAMA and ICS.

“Trimbo”
“Trelegy”
“Ellipta”

21
Q

Severe case management

A

Nebulisers (salbutamol and/or ipratropium)

Oral theophylline

Oral mucolytic therapy to break down sputum (e.g. carbocisteine)

Long term prophylactic antibiotics (e.g. azithromycin)

Long term oxygen therapy at home

22
Q

When is long term oxygen therapy used?

A

Severe COPD that is causing problems such as chronic hypoxia, polycythaemia, cyanosis or heart failure secondary to pulmonary hypertension (cor pulmonale).

It can’t be used if they smoke as oxygen plus cigarettes is a significant fire hazard.

23
Q

Exacerbation of COPD

A

Acute worsening of symptoms such as cough, shortness of breath, sputum production and wheeze.

It is usually triggered by a viral or bacterial infection.

24
Q

Investigations needed in exacerbation

A

Chest xray to look for pneumonia or other pathology

ECG to look for arrhythmia or evidence of heart strain (heart failure)

FBC to look for infection (raised white cells)

U&E to check electrolytes which can be affected by infection and medications

Sputum culture if significant infection is present

Blood cultures if septic

25
Q

Target oxygen saturations in COPD

Retaining CO2

A

88-92% titrated by venturi mask

26
Q

Target oxygen saturations in COPD

Not retaining CO2 and bicarbonate is normal

A

If not retaining CO2 and their bicarbonate is normal (meaning they do not normally retain CO2) then give oxygen to aim for oxygen saturations > 94%

27
Q

Exacerbation treatment:

At home

A

Prednisolone 30mg once daily for 7-14 days

Regular inhalers or home nebulisers

Antibiotics if there is evidence of infection

28
Q

Exacerbation treatment:

Hospital

A

Nebulised bronchodilators (e.g. salbutamol 5mg/4h and ipratropium 500mcg/6h)

Steroids (e.g. 200mg
hydrocortisone or 30-40mg oral prednisolone)

O2 - 88-92% NOT higher

Antibiotics if evidence of infection

Physiotherapy can help clear sputum

Assess for evidence of respiratory failure

29
Q

What antibiotics can be given in the event of COPD exacerbation?

A

Amoxicillin
Doxycycline
Co-trimoxazole
Clarithromycin

30
Q

When is oxygen used for treatment?

A

PaO2 < 7.3 kPa

PaO2 7.3-8kPa + second organ dysfunction

31
Q

Palliative treatment

A

Morphine

DNACPR

32
Q

When should a patient with a COPD exacerbation be admitted into hospital?

A

Tachypnoea

Low O2 <90-92%

Hypotension

33
Q

What bacteria can cause acute exacerbation?

A

Strep. pneumoniae

H. influenzae

Moraxella catarrhalis

34
Q

Symptoms of exacerbation in secondary care

A

Confusion
Tripod position
Severe SOB
Flapping tremor
Drowsy
Fever
Wheeze

35
Q

GOLD scale

A

GOLD A 0–1 exacerbations per year + fewer symptoms

GOLD B 0–1 exacerbations per year + more symptoms

GOLD C 2 or more exacerbations per year + fewer symptoms

GOLD D 2 or more exacerbations per year + more symptoms

36
Q

Who qualifies for pulmonary rehabilitation?

A

All patients who are classified as GOLD B or higher should be offered pulmonary rehabilitation.

This consists of a structured programme of exercise and education.

There is consistent evidence that these programmes reduce dyspnoea, fatigue and manage the emotional aspect of the diagnosis, leading to an overall improvement in quality of life.

37
Q

Oxygen given in hospital

A

Initially, 15L of oxygen via non-rebreathe mask should be given until their pCO2 is established as hypoxia will cause death quicker than hypercapnia.

If a patient is found to be a chronic retainer then you should aim for saturations of 88-92% by titrating the oxygen supply down.

38
Q

Diagnostic tool for COPD

A

Spirometry

39
Q

How do you stage COPD?

A

To stage the COPD - you look at FEV1 of the spirometry

40
Q

COPD and surgery

A

COPD can cause difficulties with intubation in surgery

41
Q

Treatment for exacerbation of COPD in hospital

A

The first line management for an IECOPD is:

Salbutamol and ipratropium nebulisers - these help open up the airways so that patients can breathe better.

Corticosteroids - This helps reduce the inflammation in the lungs. Either oral prednisolone or IV hydrocortisone can be given - both are equally effective

Antibiotics - There are clear signs of infection in the scenario, therefore we need to give antibiotics to help the patient clear it.

This patient should also have a 7-14 day course of oral steroids if there is no contraindication, for example prednisolone 30mg OD.

42
Q

A 70-year old gentleman presents to the A&E Department with worsening COPD and is given 60% oxygen via a green Venturi mask.

About half an hour later he has become drowsy and slightly confused. He also complains of a slight headache.

On auscultation, you note there is less wheeze than before. You note that his O2 sats have improved to 98%.

What is the most appropriate next management step?

A

This patient has started to become more drowsy, confused and developed a headache about half an hour after being started on 60% oxygen.

In the context of a COPD patient, this must be treated as hypercapnia.

The oxygen supply should be reduced immediately.

43
Q

When is oral theophylline used?

A

after a trial of short-acting bronchodilators and long-acting bronchodilators, or in patients who are unable to use inhaled therapy.

44
Q

What makes someone with COPD eligible for surgery?

A

Predominant upper lobe emphysema is a factor that would make her eligible for lung reduction surgery, as well as FEV1<50% predicted, PaCO2 <7 and Transfer capacity of the lung for carbon monoxide (TlCO) >20%.

45
Q

Clinical findings on examination

A

Crico-sternal distance <3cm, hyper-resonant percussion note and use of accessory muscles for respiration

46
Q

Mary was diagnosed with chronic obstructive pulmonary disease (COPD) secondary to long-standing smoking.

Which summarises the arterial blood gas sample, assuming full compensation has taken place?

A

Normal pH; Elevated CO2; Elevated HCO3-

47
Q

If you have a PaO2 of 7.3-8, what conditions need to be present to qualify for long term oxygen therapy?

A

Peripheral oedema, pulmonary hypertension, nocturnal hypoxaemia, or secondary polycythaemia.

The normal Hb level for males is 14 to 18 g/dl; that for females is 12 to 16 g/dl

Medicine 1 - Clinical (41 decks)

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