COPD Flashcards
What does COPD stand for?
Chronic obstructive pulmonary disease
What is COPD?
Non-reversible, long term deterioration in air flow through the lungs caused by damage to lung tissue.
Emphysema + Chronic bronchitis
What causes COPD?
Smoking
Alpha 1 antitrypsin deficiency - early onset <4.5 y/o
What are risk factors of COPD?
Older age
Female
Lower socio-economic status
Asthma/airway hypersensitivity
What does damage to lung tissue in COPD cause?
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.
Presentation
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
What does COPD not cause?
Clubbing
Haemoptysis
Chest pain
What can chronic hypoxia cause and how?
Right ventricular hypertrophy
Pulmonary arteriolar vasoconstriction -> increased pulmonary hypertension
What happens in severe COPD?
Hypoxic drive -> body relies on central chemoreceptors
Cor pulmonale
MRC scale to assess breathlessness
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
When can COPD be diagnosed?
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
What spirometry results are needed for diagnosis ?
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
Severity of airway obstruction using FEV1
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
Blood work results
FBC (raised PCV; polycythaemia)
ABG (reduced PaO2 +/- raised PaCO2 or type 2 respiratory failure)
ECG results
P-pulmonale (right atrial hypertrophy) and right ventricular hypertrophy, if there is cor pulmonale
CXR results
Hyperinflated chest (>6 anterior ribs)
Bullae
Decreased peripheral vascular markings
Flattened hemidiaphragms
Suspended small heart
Non-pharmacological management
Smoking cessation
Vaccination (flu yearly + pneumococcal every 5 years)
Pulmonary rehab
Nutritional assessment
Psychological support
Long term management
Step One
Short acting bronchodilators:
beta-2 agonists (salbutamol or terbutaline) or short acting antimuscarinics (ipratropium bromide).
Long term management
Step Two
Non-asthmatic
Long acting beta agonist (LABA) plus a long acting muscarinic antagonist (LAMA):
“Anoro Ellipta”
“Ultibro Breezhaler”
“DuaKlir Genuair”
Long term management
Step Two
Asthmatic
(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”
Severe case management
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
When is long term oxygen therapy used?
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.
Exacerbation of COPD
Acute worsening of symptoms such as cough, shortness of breath, sputum production and wheeze.
It is usually triggered by a viral or bacterial infection.
Investigations needed in exacerbation
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
Target oxygen saturations in COPD
Retaining CO2
88-92% titrated by venturi mask
Target oxygen saturations in COPD
Not retaining CO2 and bicarbonate is normal
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%
Exacerbation treatment:
At home
Prednisolone 30mg once daily for 7-14 days
Regular inhalers or home nebulisers
Antibiotics if there is evidence of infection
Exacerbation treatment:
Hospital
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
What antibiotics can be given in the event of COPD exacerbation?
Amoxicillin
Doxycycline
Co-trimoxazole
Clarithromycin
When is oxygen used for treatment?
PaO2 < 7.3 kPa
PaO2 7.3-8kPa + second organ dysfunction
Palliative treatment
Morphine
DNACPR
When should a patient with a COPD exacerbation be admitted into hospital?
Tachypnoea
Low O2 <90-92%
Hypotension
What bacteria can cause acute exacerbation?
Strep. pneumoniae
H. influenzae
Moraxella catarrhalis
Symptoms of exacerbation in secondary care
Confusion
Tripod position
Severe SOB
Flapping tremor
Drowsy
Fever
Wheeze
GOLD scale
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
Who qualifies for pulmonary rehabilitation?
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.
Oxygen given in hospital
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.
Diagnostic tool for COPD
Spirometry
How do you stage COPD?
To stage the COPD - you look at FEV1 of the spirometry
COPD and surgery
COPD can cause difficulties with intubation in surgery
Treatment for exacerbation of COPD in hospital
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.
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?
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.
When is oral theophylline used?
after a trial of short-acting bronchodilators and long-acting bronchodilators, or in patients who are unable to use inhaled therapy.
What makes someone with COPD eligible for surgery?
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%.
Clinical findings on examination
Crico-sternal distance <3cm, hyper-resonant percussion note and use of accessory muscles for respiration
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?
Normal pH; Elevated CO2; Elevated HCO3-
If you have a PaO2 of 7.3-8, what conditions need to be present to qualify for long term oxygen therapy?
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
