COPD Flashcards
What does COPD stand for?
Chronic Obstructive Pulmonary Disease
What is COPD?
A lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible.
What is the GOLD definition of COPD?
COPD is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.
What is the biggest risk factor for COPD in high/middle income countries?
Tobacco smoke
What is the biggest risk factor for COPD in low income countries?
Exposure to indoor air pollution, such as use of biomass fuels for cooking and heating
What is Alpha-1 Antitrypsin deficiency?
Rare, inherited disease that presents with early onset COPD <45yrs
What is alpha-1 antitrypsin (AAT)?
A protein inhibitor made in the liver (limits damage caused by activated neutrophils releasing elastase in response to infection/cigarette smoke)
What percentage of smokers develop COPD during their lifetime?
<50%
What does smoking in pregnancy effect?
May affect foetal lung growth and priming of the immune system
What are common symptoms of COPD?
- cough
- breathlessness
- sputum
- frequent chest infections
- wheezing
What are some not so common symptoms of COPD?
- weight loss
- fatigue
- swollen ankles
What would you find during an examination that leads to diagnosed COPD?
- cyanosis (blue skin or lips)
- raised JVP
- cachexia (wasting syndrome that leads to loss of skeletal muscle and fat)
- wheeze
- pursed lip breathing
- hyperinflated chest
- use of accessory muscles
- peripheral oedema
What are the different levels of the mMRC dyspnoea (diss-knee-ah) scale?
0 - i only get breathless with strenuous exercise
1 - i get short of breath when hurrying on level ground or walking up a slight hill
2 - on level ground, i walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace
3 - i stop for breath after walking about 100 yards or after a few minutes on level ground
4 - i am too breathless to leave the house or i am breathless when dressing
What factors mean you should diagnose COPD?
- typical symptoms
- > 35 years
- presence of risk factor (smoking or occupational exposure)
- absence of clinical features of asthma
AND
- airflow obstruction confirmed by post-bronchodilator spirometry
What percentages in spirometry is associated with each stage?
Stage 1 - mild - 80% or higher
Stage 2 - moderate - 50-79%
Stage 3 - severe - 30-49%
Stage 4 - very severe - less than 30%
What are symptoms that get worse due to acute exacerbation of COPD?
- SOB
- wheeze
- chest tightness
- cough
- sputum (purulence/volume)
- unable to smoke
- systemic upset (eating, drinking, ADLs)
- temp
- fatigue
What are the additional signs of severe exacerbation of COPD?
- breathless (RR>25/min)
- accessory muscle use at rest
- purse lip breathing
- cyanosis (sats <92% on air)
- significant decrease in exercise tolerance
- signs of sepsis (if exacerbation caused by infection)
- fluid retention
- confusion
What are the differential diagnoses for acute exacerbation of COPD?
- pneumonia
- PE
- MI
- LVF
- lung cancer
- pleural effusion
- pneumothorax
What is the management plan for acute exacerbation of COPD?
- change in inhalers (technique, device, add bronchodilator, increase or add inhaled steroid)
- oral steroids (prednisolone tablets)
- antibiotics
- self management for select patients
What are the common triggers for acute exacerbation of COPD?
- viral/bacterial infection (most common)
- sedative drugs
- pneumothorax
- trauma
What tests would you perform for acute exacerbation of COPD?
- CXR
- blood gases
- full blood count (FBC)
- U&E
- sputum culture
- VTS
What is the treatment for acute exacerbation of COPD?
- oxygen
- nebuliser bronchodilator (B2 & anti-muscarinic)
- oral/IV corticosteroid +/- antibiotic
How do you measure severity of COPD?
- spirometry
- nature and magnitude of symptoms (MRC breathlessness scale + COPD assessment tool)
- history of moderate and severe exacerbations and future risk (number per year, hospitalisation?)
- presence of co-morbidity (heart disease, artial fibrillation, obesity…)
What is cor pulmonale?
Abnormal enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels
What are the clinical signs of cor pulmonale?
- tachycardic (HR > 100)
- oedematous (relating to edema, abnormally swollen with fluid)
- raised JVP
- congested liver
What does an ECG show for cor pulmonale?
- right axis deviation
- P pulmonale
- T wave inversion V1-V4
What does an echo show for cor pulmonale?
- pulmonary hypertension
- tricuspid regurgitation
What is secondary polycythaemia?
Where an underlying condition causes more erythropoietin to be produced than normal (usually in response to low oxygen), also causes an increase in haemoglobin production, haematocrit production and blood viscosity.
What are the symptoms of chronic bronchitis?
- daily productive cough for three months or more, in the last two consecutive years
- overweight
- cyanotic
- elevated haemoglobin
- peripheral oedema
- rhonchi (upper RI tract infection)
- wheezing
What are the symptoms of emphysema?
- permanent enlargement and destruction of airspaces distal to the terminal bronchiole
- older and thin
- severe dyspneoa
- quiet chest
- xray shows hyperinflation with flattened diaphragms
What parts of COPD can you treat?
- improve exercise tolerance
- prevent exacerbations
- nutrition/weight loss
- complications (cor-pulmonale, resp failure etc…)
- anxiety/depression
- co-morbidities
- dysfunctional breathing
- palliative care
What are the non-pharmacological managements of COPD?
- smoking cessation
- vaccinations (annual flu vaccine, pneumococcal vaccine)
- pulmonary rehabilitation
- nutritional assessment
- psychological support
What does the exacerbation of COPD present as?
- increasing breathlessness
- cough
- sputum volume (increases)
- sputum purulence (containin pus/more pus)
- wheeze
- chest tightness
What is the primary care management for exacerbation of COPD?
Short acting bronchodilators
- salbutamol and/or ipratropium
- neubulisers if cannot use inhalers
Steroids
- prednisolone 40mg per day for 5-7 days
Antibiotics
- most exacerbations are secondary to viral infection
- if there is evidence of infection (fever, increase in volume/purulence of sputum)
Consider hospital admission if unwell
- tachypneoa
- low oxygen sats (<90-92%)
- hypotension etc
What investigations would you do for exacerbation of COPD?
- full blood count
- biochemistry and glucose
- theophylline conc (in patients using theophylline prep)
- arterial blood gas (documenting the amount of oxygen given and by what delivery device)
- electrocardiograph
- CXR
- blood cultures in febrile patients
- sputum microscopy, culture and sensitivity
What is the ward based management for exacerbation of COPD?
- oxygen sat target 88-92%
- nebulised bronchodilators
- corticosteroids
- antibiotics (oral vs IV)
- assess for evidence of resp failure (clinical, ABG)
What is the palliative care like for end stage COPD?
Management of breathlessness and dysfunctional breathing
- pharmacological –> morphine
- psychological support
- palliative care referral
Anticipatory care plan
- hospital admission
- ceiling of treatment –> ward based, HDU, ventilation
- DNACPR
