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MSRA respiratory > COPD > Flashcards

COPD Flashcards

1
Q

what is first line treatment for COPD?

A

SABA or SAMA PRN
salbutamol/ipratropium

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2
Q

what is the second line treatment for COPD if there are asthmatic features or features suggestive of steroid responsiveness?

A

LABA + ICS regularly
SABA or SAMA PRN

salmeterol + beclometasone/fluticasone

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3
Q

what are asthmatic features or features suggestive of steroid responsiveness?

A

previous diagnosis of asthma or atopy
raised eisinophil count
substantial variation in FEV1 over time (At least 400ml)
substantial diurnal variation in PEFR (At least 20%)

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4
Q

what is the second line treatment of COPD if there are no asthmatic features or features suggestive of steroid responsiveness?

A

LABA + LAMA regularly
SABA PRN

salmeterol + tiotropium

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5
Q

what else is important as part of COPD management?

A

smoking cessation
one-off pneumococcal vaccine
annual influenza vaccine
pulmonary rehab if functionally disabled

consider:
long-term oxygen
lung volume reduction surgery in selected pts

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6
Q

what is third-line management of someone who has daily adverse symptoms with COPD w/o asthmatic features?

A

consider 3 month trial of LABA + LAMA + ICS

If no improvement, revert to LABA + LAMA

salmeterol + tiotropium + beclamatesone/fluticasone

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7
Q

what is third-line management of someone who has 1 severe or 2 moderate exacerbations/year with COPD w/o asthmatic features?

A

LABA + LAMA + ICS

ICS reduces frequency of exacerbations

salmeterol + tiotropium + beclamasone/fluticasone

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8
Q

what is third-line management of someone who has daily adverse symptoms or 1 severe or 2 moderate exacerbations/year with COPD with asthmatic features?

A

LABA + LAMA + ICS
salmeterol + tiotropium + beclamasone/fluticasone

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9
Q

what are features of cor pulmonale?

A

peripheral oedema
raised JVP
systolic parasternal heave
loud P2

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10
Q

how do you treat cor pulmonale?

A

loop diuretic for oedema
long-term oxygen therapy
ACE

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11
Q

when can you offer PDE-4 inhibitors (phosphodiesterase-4)

A

roflumilast
reduces the risk of COPD exacerbations if severe COPD + frequent exacerbations

if severe disease- FEV1 after a bronchodilator <50% of predicted normal

and

2 or more exacerbations/year despite triple inhaled therapy with LAMA + LABA + ICS

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12
Q

when do you consider mucolytics?

A

chronic productive cough
continue if symptoms improve

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13
Q

in which patients would you consider oral prophylactic antibiotic therapy for COPD?

A

they do not smoke
optimised standard treatment
continue to have exacerbations

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14
Q

what oral prophylactic antibiotic therapy can be used in COPD patients?

A

azithromycin

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15
Q

if starting oral prophylactic antibiotic therapy in COPD patients, what do you need to do first?

A

CT thorax to exclude bronchiectasis
sputum culture to exclude atypical infections + TB
LFTs
ECG to exclude QT prolongation

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16
Q

when do you consider starting oral theophylline?

A

after trials of SABA and LABA or to people who cannot use inhaled therapy

reduce dose if macrolide or fluoroquinolone abx are co-prescribed

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17
Q

what is the definition of COPD?

A

airway obstruction- FEV1<80%, FEV1:FVC <0.7

chronic bronchitis- productive cough for 3 months of 2 years

emphysema- histological diagnosis of enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls

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18
Q

what are the causes of COPD?

A

smoking
pollution
alpha-1 anti-trypsin deficiency

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19
Q

what are the symptoms of COPD?

A

productive cough
dyspnoea
wheeze
weight loss

20
Q

what are the signs of COPD?

A

tachypnoea
prolonged expiratory phase
hyperinflation (decreased cricosternal distance <3 fingers; loss of cardiac dullness; displaced liver edge)
wheeze
early-inspiratory crackles
cyanosis
signs of steroid use
cor pulmonale- raised JVP, oedema, loud P2

21
Q

describe pink puffers in emphysema

A

increased alveolar ventilation- breathless but not cyanosed
near normal paO2
normal or low paCO2
progress to T1RF

22
Q

describe blue bloaters in chronic bronchitis

A

decreased alveolar ventilation- cyanosed but not breathless
hypoxic and hypercapnic- rely on hypoxic drive
progress to T2RF

23
Q

what are the complications of COPD?

A

acute exacerbations +/- infx
polycythaemia
pneumothorax- ruptured bullae
cor pulmonale
lung ca

24
Q

what are the CXR findings of COPD?

A

hyperinflation >6 ribs anteriorly - decreased cricosternal distance, displaced liver edge, loss of cardiac dullness
prominent pulmonary arteries
peripheral oligaemia
bullae

25
Q

what are the ECG findings in COPD?

A

p pulmonale- right atrial hypertrophy
RVH
RAD

26
Q

what are the spirometry findings for COPD?

A

FEV1:FVC<0.7
FEV1<80%
raised TLCO
raised residual volume

27
Q

what could be seen on ECHO with COPD patients?

A

pulmonary hypertension

28
Q

what is important to remember with flying in COPD patients?

A

FEV1<50% risky

29
Q

what is the aim with LTOT?

A

paO2>8 for >15h/day
increased survival by 50%

30
Q

when do you consider LTOT?

A

clinically stable non-smokers
paO2<7.3 (stable on 2 occassions 3 weeks apart)

or paO2 7.3-8 with PHT/cor pulmonale/polycythaemia/nocturnal hypoxaemia

terminally ill patients

31
Q

what classification assesses severity in COPD?

A

Gold classification
1 - mild: FEV1 ≥80% predicted.
2 - moderate: 50%-79% ≤ FEV1
3 - severe: 30%-49% ≤ FEV1
4 - very severe: FEV1 <30% predicted

32
Q

what are smoking cessation methods?

A

nicotine replacement therapy (patch + another method)
bupropion
varenicline

33
Q

what is the mechanism of action of bupropion?

A

a norepinephrine and dopamine reuptake inhibitor + nicotinic antagonist

should be started 1-2 weeks before the patients target date to stop

34
Q

when is bupropion contraindicated?

A

epilepsy
pregnancy
breast-feeding
eating disorder relative CI

35
Q

what is the mechanism of action of varenicline?

A

nicotinic receptor partial agonist
start 1 week before pt target stop date
12 weeks- monitor regularly to ensure not smoking

36
Q

when is varenicline contraindicated?

A

pregnancy
breast-feeding
caution in depression/self-harm

37
Q

what is the smoking cessation method used in pregnancy?

A

CBT, motivational interviewing, structured self-help and support from NHS stop smoking services

then can try NRT (Remove patches before going to bed)

38
Q

what is the treatment of acute exacerbation of COPD in type 2 respiratory failure despite medical therapy?

A

BiPAP
for assistance of ventilation

39
Q

what are the most common bacterial causes of COPD exacerbations?

A

haemophilus influenzae
streptococcus pneumoniae
moraxella catarrhalis

40
Q

what are the most common viral causes of COPD exacerbations?

A

human rhinovirus
30% of exacerbations

41
Q

as per NICE guidelines, recommend admission in COPD patients if any of the following criteria are met:

A

severe breathlessness
acute confusion or impaired consciousness
cyanosis
O2<90%
social - inability to cope at home/living alone
significant comorbidity eg cardiac disease or insulin-dependent diabetes

42
Q

how do you treat COPD exacerbation?

A
  1. increase frequency of bronchodilator use + consider giving via nebuliser
  2. prednisolone 30mg for 5 days
  3. abx if sputum is purulent or clinical signs of pneumonia- amoxicillin/clarithromycin/doxycycline
43
Q

what are common infective causes of COPD exacerbations?

A

bacteria
- haemophilus influenzae
- streptococcus pneumoniae
- moraxella catarrhalis

viruses
- human rhinovirus
30% exacerbations

44
Q

when do you recommend admission for exacerbation of COPD?

A

severe breathlessness
acute confusion or impaired consciousness
cyanosis
O2< 90%
social reasons
significant comorbidity (eg cardiac disease/ insulin-dependent diabetes)

45
Q

what initial BiPAP settings are used in COPD?

A

EPAP: 4-5
IPAP: 10 (RCP), 12-15 (BTS)

MSRA respiratory (14 decks)

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