COPD Flashcards

1
Q

Define COPD

A

Chronic progressive irreversible lung disorder characterised by airflow obstruction, chronic bronchitis and emphysema

Chronic Bronchitis: Chronic cough and sputum production on most days for at least 3 months per year over 2 consecutive years

Emphysema: permanent destructive enlargement of air spaces distal to the terminal bronchioles

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2
Q

Aetiology of COPD

A

Bronchial and alveolar damage due to environmental toxins i.e. smoking
May be caused by alpha-1 antitrypsin deficiency (<1%)
May overlap and co-present with asthma

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3
Q

Aetiology of chronic bronchitis and emphysema

A

Bronchitis: narrowed airways due to inflammation and mucosal oedema, hypersecretion and squamous metaplasia

Emphysema: destruction and enlargement of alveoli -> loss of elastic traction that keeps them open -> collapse -> bullae formation

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4
Q

Risk factors for COPD

A

Cigarette smoking
Advanced age, >65
Genetic factors, white ancestry
Exposure to air pollution, burning solid or biomass fuel
Occupation exposure to dusts, chemicals, vapours, fumes or gases
Developmentally abnormal lung
Male sex
Low socio-economic status
Rheumatoid arthritis

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5
Q

Symptoms of COPD

A

Cough (productive, continuous, chronic)
SOB
Fatigue
Wheeze
Weight or muscle loss
Headache
Reduced exercise tolerance

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6
Q

Signs of COPD on exam

A

Tachypnoea/resp. distress
Tripod position
pursed lip breathing
Tar staining

Asterixis
Use of accessory muscles
Hyperexpanded chest with reduced expansion
Reduced breath sounds
Hyperresonance
Wheeze
Coarse crackles

Signs of RHF (Cor Pulmonale)

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7
Q

Investigations for diagnosis of COPD

A

ECG: signs of RVH, arrhythmias, ischaemia (cor pulmonale)

FBC: Raised haematocrit, anaemia, possible leucocytosis | Secondary polycythaemia
Alpha-1 antriptrypsin levels: for young patients without smoking history
BNP: ?cor pulmonale

Spirometry/function tests: FEV1/FVC ratio <0.7
FEV1:
- Mild: >80% predicted
- Moderate: 50-80% predicted
- Severe: 30-50% predicted
- Very severe: <30% predicted
CXR:
- Increased anteroposterior ratio
- Flattened diaphragm
- Hyperexpanded chest
- Increased intercostal spaces
- Hyperlucent lungs
HRCT: hyperinflammation, bullae formation
Echo: ?cor pulmonale

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8
Q

Investigations for COPD exacerbations

A

ECG: ?cor pulmonale
Sputum cultures: ?infection

ABG: assess sats
FBC: Raised haematocrit, anaemia, possible leucocytosis | Secondary polycythaemia
Blood cultures: ?infection
CRP: ?infection
U&Es

CXR:
- Increased anteroposterior ratio
- Flattened diaphragm
- Hyperexpanded chest
- Increased intercostal spaces
- Hyperlucent lungs
CT: hyperinflammation, bullae formation
Echo: ?cor pulmonale

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9
Q

Features of an acute exacerbation of COPD

A

Worsening breathlessness with increased sputum volume and purulence
Cough
Wheeze
Fever
URTI in past 5 days

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10
Q

Admission criteria for COPD

A

Severe breathlessness
Inability to cope at home
Rapid onset of symptoms
Acute confusion or impaired consciousness
Cyanosis
SpO2 <90
Worsening peripheral oedema or new arrhythmia

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11
Q

Management for an acute exacerbation

A
  1. A-E assessment
  2. Oxygen - aim for 94-98 or (88-92% if stable)
    - 24% O2 via venturi
    - Do ABG <1 hour after changing oxygen
    - Aim to raise PaO2 >8 with <1.5kPa rise in PaCO2
  3. Nebulised bronchodilators with 6L/min O2 over 30-60 minutes
    - Salbutamol 5mg inhaled via nebuliser every 20-30 minutes
  4. Ipratropium inhaled 500 micrograms via nebuliser when required
  5. Steroids oral (prednisolone oral 30mg for 5 days) AND hydrocortisone IV 200mg
  6. Presence of purulent sputum or clinical signs of pneumonia (Raised WCC, CRP)
    - Abx e.g. amoxicillin, doxycycline, clarithromycin (SEVERE)
    - Infective exacerbation of COPD: first-line antibiotics are amoxicillin or clarithromycin or doxycycline
  7. Inadequate response to bronchodilator -> theophylline IV
  8. NIV
  9. Consider ITU admission
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12
Q

Conservative management for chronic COPD

A

STOP smoking
influenza (annual) and pneumococcal vaccines (one off)
Pulmonary rehab (aerobic exercise, strength training)
Breathing and chest physio
Mucolytics e.g. carbocysteine
Long-term oxygen therapy (LTOT)
BiPAP
Home news
Rescue pack:
- SOB not solved by inhaler → prednisolone
- Change in volume/colour sputum → doxycycline
Abx prophylaxis with azathioprine

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13
Q

Criteria for LTOT

A

NON-SMOKER +
- pO2 <7.3 kPa (x2 measurements)
- pO2 7.3-8 kPa +
– Secondary polycythaemia
– Peripheral oedema
– Pulmonary Hypertension

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14
Q

Medical management for chronic COPD

A
  1. SABA or SAMA
  2. No asthmatic features - LABA or LAMA
  3. Asthmatic features - LABA + ICS
  4. LABA + LAMA + ICS
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15
Q

What classifies a patient as asthmatic/steroid responsive in COPD

A

Any previous diagnosis of asthma or atopy
Higher eosinophil count
Substantial variation in FEV1 over time
Substantial diurnal variation in PEFR

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16
Q

What are the surgical options for COPD

A

Bullectomy
Lung reduction surgery (indication: heterogenous emphysema)
Endobronchial valve placement (valve placed in part of lung  iatrogenic distal collapse)
Lung transplant

17
Q

Give examples of the following:
SABA
SAMA
LABA
LAMA
ICS
Oral CS
LABA + ICS

A

SABA: Salbutamol 0.1mg
SAMA: ipratropoium
LABA: Formoterol, salmeterol
LAMA: tiotropium
ICS: beclemetasone, budesonide
Oral CS: prednisolone
LABA + ICS: symbicort, foster, seretide

18
Q

Complications of COPD

A

Cor pulmonale
Lung cancer
Recurrent pneumonia (esp. strep pneumoniae, influenza
Depression
Pneumothorax (bullae rupture)
Anaemia
Resp. failure
Polycythaemia

19
Q

Prognosis for COPD

A

Primarily influenced by severity and presence of co-morbs
Smoking cessation and oxygen supplementation are the only 2 factors that improve survival rate
High level of morbidity
3 year survival rate 90% <60yrs and FEV1 >50

20
Q

What is the criteria for antibiotic prophylaxis in COPD

A

> 3 exacerbations requiring steroid therapy and at least one exacerbation requiring hospital admission in the previous year

Prophylaxis with azithromycin