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copd Flashcards

1
Q

What can lung conditions cause the airways to become?

A

Inflamed and narrowed or filled with phlegm hence its harder for air to move in and out of the lungs.

Can make the lungs stiff and less elastic so it’s harder for them to expand and fill with air.

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2
Q

Lung conditions that cause long-term (chronic) breathlessness:

A
  • COPD (O)
  • Obesity (R)
  • interstitial lung disease (ILD), including pulmonary fibrosis and sarcoidosis (R)
  • bronchiectasis (O)
  • industrial or occupational lung diseases such as asbestosis, which is caused by being exposed to asbestos
  • lung cancer
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3
Q

Lung conditions that cause short-term (acute) breathlessness:

A
  • flare-up of asthma or COPD
  • PE or blood clot on the lung
  • lung infection such as pneumonia or TB
  • pneumothorax or collapsed lung
  • build-up of fluid in your lungs or the lining of your lungs – this might be because your heart is failing to pump efficiently or may be because of liver disease, cancer or an infection
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4
Q

Explain how a heart condition can cause long-term (chronic) breathlessness.

A

Can be due to problems with the rhythm, valves or cardiac muscles of the heart. Heart can’t increase its pumping strength in response to exercise, or the lungs become congested and filled with fluid often worse when supine (so when sleeping).

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5
Q

Heart conditions that cause acute breathlessness include:

A

Heart attack (MI)
Abnormal heart rhythm (atrial fibrillation)

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6
Q

Explain how anxiety can cause SoB.

A

Feeling SoB when anxious or afraid is a normal response to stressful situations; the body is preparing for action as you get more anxious, you may start to breathe faster and tense your breathing muscles. Physical health can also impact mental health, especially if living with a lung condition you might get anxious if you don’t feel in control of your condition

If you have a lung condition, you may have symptoms that make you feel anxious. Sometimes the symptoms of lung conditions e.g. breathlessness, tightness in your chest or getting tired very easily are similar to feelings of anxiety.

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7
Q

What is a panic attack?

A

When the body’s normal response is exaggerated, you get a rapid build-up of physical responses; breathing quickens and your body also releases hormones so your heart beats faster and your muscles tense

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8
Q

In addition to feeling you can’t breathe during a panic attack what else happens?

A
  • have a pounding heart
  • feel faint and sick
  • sweat
  • have shaky limbs
  • feel that you’re not connected to your body
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9
Q

What happens if you breathe too quickly in response to panic attack?

A

You may breath in more oxygen than your body needs → Called hyperventilation

When you do this, the delicate balance of the gases in your lungs is upset. An amount of carbon dioxide normally stays in the blood. If you breathe in too much air too often, the carbon dioxide is pushed out through the lungs and this affects the messages the brain receives to tell you to breathe.

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10
Q

Explain why being unfit or having an unhealthy weight can lead to SoB.

A

When we are unfit, our muscles (including respiratory muscles) get weaker. Weaker muscles need more oxygen to work, so the weaker our muscles, the more breathless we feel.

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11
Q

Being an unhealthy weight can also contribute to make us feel breathless. List all the reasons why.

A

If you’re underweight, your respiratory muscles will be weaker.

If you’re overweight, it takes more effort to breathe and move around.

Having more weight around the chest and stomach restricts how much your lungs can move.

People who are a BMI of 25 or more are more likely to get breathless compared to people with a healthy weight.

People who are severely overweight can develop obesity hypoventilation syndrome; when poor breathing leads to lower oxygen levels and higher carbon dioxide levels in their blood.

Maintaining a healthy weight may help you to manage your breathlessness better and be more active.

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12
Q

Other causes of long-term (chronic) breathlessness.

A
  • smoking
  • conditions that affect how your muscles work, such as muscular dystrophy, MG or motor neurone disease
  • postural conditions that alter the shape of your spine, and affect how your ribs and lungs expand - for example scoliosis and kyphosis
  • anaemia
  • kidney disease
  • thyroid disease
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13
Q

What are the barriers to diagnosing breathlessness?

A
  • think breathlessness is as a normal part of ageing, so don’t tell their doctor
  • feel responsible for causing their illness and don’t feel they deserve help
  • not realise they can get any help for their breathlessness
  • not actually feel out of breath when they see their doctor (would be sitting down and may have only walked a short distance), so may forget what their breathlessness feels like and find it hard to describe
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14
Q

What can patients do to help a doctor diagnose breathlessness?

A
  • Use an online breath test to find out if your breathlessness is something to get checked out with your doctor.
  • Bring someone with them who can help describe their breathlessness
  • think about how they will be describing their breathlessness in advance of seeing a doctor e.g. what they used to be able to do but can’t any more, what people of their age around them do that they find difficult and what their personal goals are for their day-to-day activity
  • use local landmarks such as bus stops, shops and hills to help you describe these things
  • record the sort of activities that make them out of breath to show their doctor what it looks or sounds like
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15
Q

What tools can doctors use to diagnose breathlessness?

A
  • Use the MRC breathlessness scale
  • Ask questions about breathlessness
  • Do some tests to help diagnose what’s causing the breathlessness
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16
Q

MRC Breathlessness Scale

A

Grade 0: Dyspnoea only with strenuous exercise

Grade 1: Dyspnoea when hurrying or walking up a slight hill

Grade 2: Walks slower than people of the same age because of dyspnoea or has to stop for breath when walking at own pace

Grade 3: Stops for breath after walking 100 yards (91m) or after a few minutes

Grade 4: Too dyspnoeic to leave house or breathless when dressing

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17
Q

Questions Dr’s may ask about breathlessness?

A

Duration, Onset, Frequency, Pattern, Time

Relieving factors e.g. lying flat

Exacerbating factors e.g. pollen, pets, medication

Smoking

Coughing/phlegm, Chest pain, palpitations, ankle swelling

Normal activity levels

History of heart, lung or thyroid disease, or of anaemia

Feeling worried, frightened, depressed or hopeless

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18
Q

What tests may help doctors to help diagnose the cause of breathlessness?

A

Lung function tests, chest auscultation, HR and rhythm, fluid build up in ankles or lungs, BP and temperature, BMI, swollen glands, signs of anxiety

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19
Q

Possible additional tests at GP surgery, local testing centre or hospital

A

CXR

Spirometry test

ECG - if breathlessness is intermittent, wear a portable recorder for 24 hours or 7 days to record heart’s electrical activity

Echocardiogram - this is a non-invasive ultrasound of heart which can tell how well it’s working

Blood tests to detect anaemia, allergies or any thyroid, liver, kidney or heart problems

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20
Q

What is SoB on exertion?

A

When you have additional requirements on top of your baseline needs, and don’t acquire enough oxygen to meet the needs.

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21
Q

What is FVC?

A

The amount of air that can be forcibly exhaled from your lungs after taking the deepest breath possible.

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22
Q

What is FEV1?

A

Maximum amount of air that the subject can forcibly expel during the first-second following maximal inhalation.

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23
Q

What is the normal FEV1/FVC ratio?

A

0.7

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24
Q

Describe the mechanism of Restrictive Diseases

A
  1. Lung capacity is restricted, so FVC is lower
  2. If airways are unaffected, FEV1 will be normal
  3. Therefore FEV1/FVC ratio could be slightly increased

OR

  1. If FEV1 is proportionally lower, FEV1/FVC ratio could be normal
  2. Won’t necessarily affect rate of flow but affects lung volume
  3. Can’t fully fill lungs
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25
Q

What are some causes of Restrictive Diseases?

A
  • scoliosis
  • interstitial lung disease e.g. pulmonary fibrosis; alveoli are less stretchy so can’t get as much air in
  • MD
  • obesity
  • sarcoidosis, an autoimmune disease
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26
Q

Spirometry results of RD

A

FEV1/FVC = normal/slightly higher

FVC = lower

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27
Q

Describe the mechanism of Obstructive Diseases

A
  1. Measure on outflow with FVC.
  2. FVC is normal; although airways are tighter, they can get a normal amount of air in and out, just takes longer.
  3. FEV1 is lower because they can’t get air out quick enough.
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28
Q

What are some causes of OD?

A
  • COPD which includes emphysema and chronic bronchitis
  • asthma
  • bronchiectasis
  • CF
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29
Q

Spirometry results of OD:

A

FEV1/FVC = normal/lower

Confirmed if FEV1 = <80% of the predicted value and FEV1/FVC = <70%

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30
Q

What 2 conditions can lead to COPD?

A

Bronchitis and emphysema

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31
Q

Explain the pathophysiology of bronchitis.

A
  • could be caused by infection
  • thickened airway walls
  • narrower lumen
  • overproduction of mucus due to overactivity/increased number of goblet cells in response to inflammation and irritants
  • symptoms could include phlegm cough (had for at least 3 months for 2 consecutive years)
32
Q

Explain the pathophysiology of emphysema.

A
  • interconnections between alveoli gets broken down and results in increased sacs results in smaller SA:V ratio, resulting in less efficient GE
  • no elastic recoil that helps to push air out
  • narrowing of airways
33
Q

What are the signs of emphysema in this CXR?

A

Smaller heart (floating)

Smaller + flattening of diaphragm

Gastric bubble

Hyper-expansion (more air in spaces than you would expect)

More than 7 anterior ribs seen

34
Q

What are the signs of hyperinflation?

A
  • more than 7 anterior ribs visible at the mid-clavicular line (although this is not particularly sensitive)
  • flattening of the diaphragm (may be a more sensitive sign)
  • heart may appear small and narrow, sometimes with air visible below the inferior border (floating heart sign)
  • emphysema on CXR can be seen as hyperinflation, there may also be a bullae present
35
Q

What is bullae?

A

Air-filled spaces with thin wall, bordered only by remnants of alveolar septae or pleura.

Often caused by emphysema.

36
Q

What does bullae look like on a CXR?

A

Areas of low density → Black = lots of air

May be outlined by resembling bubbles.

37
Q

What lifestyle approaches should patients with dyspnoea have?

A

Smoking cessation, change in nutrition, avoiding lower respiratory tract infections

38
Q

Non drug methods of smoking cessation

A
  • Nicotine replacement therapy: eg- gum, patches
  • Behavioural change approaches
  • Smoking cessation counselling
  • GP support
39
Q

Drugs for smoking cessation

A
  • Varenicline
  • Bupropion
40
Q

How do varenicline and bupropion help with smoking cessation?

A

Nicotine targets the brain’s reward pathway, making an individual feel reward after smoking. Dopaminergic neurons are stimulated in this pathway to cause reward.

Varenicline and bupropion interfere with this dopaminergic-induced reward, lessening the feeling of reward after smoking.

41
Q

How do cigarettes induce lung damage?

A
  • components of cigarette smoke activate macrophages
  • macrophages recruit neutrophils which release proteases and oxidants
  • causes imbalance in proteases and oxidants and anti-proteases and anti-oxidants
  • XS proteases and oxidants damage lung parenchyma which leads to emphysema (and inflammation and bronchitis)
42
Q

Pros and Cons of nicotine replacement:

A

Nicotine has negative effects on CVS

However, it does not damage lungs so nicotine replacement will remove damage of lungs caused by smoking

43
Q

Changes in nutrition for patients with COPD:

A

Low-carbohydrate diets are good for COPD patients. This is because carbohydrate generates a lot of carbon dioxide, which must be expired, so patients need to breathe more when they eat more carbohydrates.

Fruits and vegetables: contain antioxidants, which can combat oxidant-induced damage.

Anti-inflammatory components (eg: omega-3, vitamin D)

44
Q

Avoiding lower respiratory tract infections:

A

Respiratory tract infections can trigger COPD exacerbations.

Methods of avoiding respiratory tract infections:

  • Vaccinations
  • Wearing masks
  • Wash hands
  • Investigating home environment: a damp home environment with mould may increase risk of contracting respiratory tract infections
45
Q

What are the three inhaled medications for COPD?

A

Short-acting bronchodilator therapy

Long-acting bronchodilator therapy

Inhaled corticosteroids (ICS)

46
Q

Describe the mechanism of short-acting bronchodilator therapy

A
  • Beta-2 agonists; SNS dilates airways through beta adrenergic receptors
  • Muscarinic antagonists; antagonistically works against paraNS that keeps airways constricted
  • both come in long acting and short acting forms
47
Q

What are examples of short-acting bronchodilator therapies?

A
  • short acting beta agonists (SABA) → Salbutamol (Ventolin)
  • short acting muscarinic antagonists (SAMA) → Ipratropium bromide (Atrovent)
48
Q

Describe the mechanism of long-acting bronchodilator therapy

A
  • Beta-2 agonists; SNS dilates airways through beta adrenergic receptors
  • Muscarinic antagonists; antagonistically works against paraNS that keeps airways constricted
  • both come in long acting and short acting forms
49
Q

What are some examples of long-acting bronchodilator therapies?

A
  • Long acting beta agonists (LABA) →Formoterol, Salmeterol (Serevent)
  • Long acting muscarinic antagonists (LAMA) → Tiotropium (Spiriva), Glycopyrronium
50
Q

Describe the mechanism of ICS

A
  • Anti-inflammatory for airways
  • reduces the risk of flare-ups or exacerbations
  • useful for people whose condition is an overlap of asthma and COPD
  • numerous different inhaler devices exist
  • numerous drug combinations exist within a single inhaler
51
Q

What are examples of ICS?

A

Alone - not licensed in COPD → Beciomestasone, Fluticasone (Flixotide)

In combination e.g. with a LABA → Fluticasone + Vilaterol (together = Relvar)

52
Q

Why are smoking cessation treatments good?

A

Reduces the risk of developing or worsening of smoking-related illnesses benefits begin as soon as a person stops smoking.

53
Q

What are the symptoms associated with smoking cessation treatments?

A

Nicotine cravings, irritability, depression, restlessness, poor concentration, light-headedness, sleep disturbances and increased appetite.

54
Q

What type of non-drug treatment offers the best chance of lasting success?

A

Stopping in one step (‘abrupt quitting’) offers the best chance of lasting success and that a combination of drug treatment and behavioural support is likely to be the most effective approach.

55
Q

What is ‘abrupt quitting’?

A

When a smoker makes a commitment to stop smoking on or before a particular date (the quit date), rather than by gradually reducing their smoking.

56
Q

What should choice of drug treatment for smoking cessation be based off?

A

Smoker’s age, likely adherence, preferences, whether they’re pregnant or breastfeeding, medical conditions, and previous experience of smoking-cessation aids, as well as contra-indications and side-effects of each preparation.

57
Q

What are the most-effective drug treatment options for smoking cessation?

A

Varenicline, or a combination of long-acting NRT (transdermal patch) and short-acting NRT (lozenges, gum, sublingual tablets, inhalator, nasal spray and oral spray), are the most effective treatment options and thus the preferred choices.

58
Q

What is used if the combination isn’t appropriate?

A

Bupropion hydrochloride or single therapy NRT should be considered instead.

59
Q

Should any combination of NRT, varenicline and bupropion hydrochloride be prescribed together?

A

No

60
Q

What was bupropion hydrochloride used to treat before it was found to help people quit smoking?

A

Depression

61
Q

What are e-cigarettes and why are they better than cigarettes?

A

Electronic device that delivers vapour composed of nicotine without the toxins found in tobacco smoke e.g. tar or CO.

Evidence suggests that e-cigarettes are substantially less harmful to health than tobacco smoking, but long-term effects are still largely unknown.

62
Q

What are the types of inhalers?

A

pMDI (pressurised Metered Dose Inhalers) (with or without spacer)

DPI (Dry powder Inhalers) (single/multiple dose)

SMI (Soft Mist Inhaler/Respimat) (jet/ultrasonic/mesh)

63
Q

pros of pMDI without spacer

A

portable and compact

multidose

relatively inexpensive

no contamination

available for most inhaled medications

64
Q

cons of pMDI without spacer

A

contains propellants

not breath actuated

often used incorrectly by patients

high oropharyngeal deposition

65
Q

pros of pMDI + spacer

A

low dependence on inspiratory flow rate

easier to coordinate

large drug doses delivered more conveniently

less oropharyngeal deposition

higher lung deposition than a pMDI

66
Q

what is pMDI?

A

drug suspended or dissolved in propellant (with surfactants and cosolvent), has a metering valve and reservoir

67
Q

What is a spacer?

A

A holding chamber; large, empty devices or tubes that help get the best from asthma medicine if using MDI.

68
Q

What are the advantages to using a spacer?

A

Using a spacer makes it easier to get the right amount of medicine straight to the lungs.

A spacer slows medicine down as it comes out of the inhaler so more is taken into lungs (i.e. medicine is more efficient). This is also means less medicine is absorbed into the rest of the body, lowering the risk of side effects.

69
Q

What is DPI?

A

Drug blend in lactose, or could be drug alone. Taken in capsules, blisters or reservoirs

70
Q

Pros of DPI

A

Portable and compact

Breath actuated (i.e. no coordination needed)

Does not contain propellants

71
Q

Cons of DPI

A

Requires a min. inspiratory flow

may not be appropriate for emergency situations

often used incorrectly by patients

most are moisture sensitive

72
Q

What is SMI? (Respimat)

A

Aqueous solution or suspension. A spring-loaded system provides the energy required to force aqueous solution from a reservoir through the uniblock to produce the soft mist

73
Q

Pros of SMI

A

Portable and compact

Multidose device

Low dependence of inspiratory flow rate

High fine particle fraction

High lung deposition

Does not contain propellants

74
Q

Cons of SMI

A

Not breath actuated

75
Q

What does breath actuated mean?

A

Inhaler drawn in by breath, so no need to press anything

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