COPD Flashcards
What is COPD?
- a disease characterised by persistent expiration symptoms + airflow obstruction
- due to airways (bronchitis) and/or alveolar (emphysema) abnormalities
- caused by significant exposure to noxious particles or gas
What is COPD caused by?
Significant exposure to noxious particles or gases e.g. smoking, soot
Symptoms of COPD
Shortness of breath
Chronic productive cough
Chronic sputum production
Recurrrent lower respiratory tract infections
Risk factors for COPD
- Smoking
- Host factors e.g. genetics, congenital abnormalities | alpha 1 anti trypsin deficiency
- Occupation
- Indoor/outdoor pollution
- Illicit drug use e.g. heroin
What causes airflow limitation in COPD?
- Small airways disease: airway inflammation, airway fibrosis > increased airway resistance (+ loss of radial traction)
- Parenchymal destruction: loss of alveolar attachments > decrease of elastic recoil
Signs of COPD
- purse lip breathing
- prolonged expiratory phase
- hyperinflation or barrel shaped chest
- visible use of accessory muscle
- Tachypnoea
- wheeze on auscultation
- rales (crackles)
- hypoxemia + hypercapnia
Signs of late COPD
- flapping tremor (hypercapnia)
- central cyanosis (hypoxia)
- right sided heart failure signs e.g. distended neck veins, ankle oedema
What is needed to diagnose COPD?
Spirometry test
Investigations for COPD
- spirometry
- BMI
- CXR + CT thorax to exclude other diagnosis
- FBC for polycythemia due to chronic hypoxia, anaemia+ infection
- sputum culture
- ECG + echo to assess heart failure + cor pulmonale
- serum alpha-1 antitrypsin
How can you differentiate between asthma and COPD using spirometry?
- asthma is reversible so if you give bronchodilators (SABA - salbutamol) the FEV1:FVC will increase (by at least 12%)
- COPD is irreversible so bronchodilators wont increase ratio
How much must the FEV1:FVC increase after the use of bronchodilators for the condition to be deemed reversible (asthma)?
At least 12%
What two main conditions is COPD used to describe?
Emphysema: damaged air sacs
Chronic bronchitis: inflammation + productive cough
What is emphysema?
- condition in which destruction of the terminal bronchioles + distal air spaces occurs via the breakdown of elastin
- permanent enlargement of air spaces (bullae)
What is chronic bronchitis?
- condition where there is hypersecretion of mucus due to inflammation of large airways
- ciliary dysfunction > issue with clearance
- productive cough
What is used to grade dyspnoea?
MRC dyspnoea score
outline the MRC dyspnoea score
- grade 1: breathlessness on strenuous exercise
- grade 2: breathlessness on walking uphill
- grade 3: breathlessness that slows them down walking on the flat
- grade 4: breathlessness stops them from walking >100m on flat
- grade 5: unable to leave the house due to breathlessness
How can severity of COPD be graded?
using FEV1
- stage 1/mild: FEV1 >80% of predicted
- stage 2/moderate: FEV1 50-79%
- stage 3/severe: FEV1 30-49*
- stage 4/very severe: FEV1 <30%
What is exacerbation of COPD?
Acute worsening of respiratory symptoms that result in addition therapy
At least one major symptom:
- dyspnoea
- sputum volume
- sputum purulence
And one minor symptom:
- wheezing
- cough
- fever
management of COPD exacerbations
- oxygen: aim for 94-98% or 88-92% if T2RF or evidence of hypercapnia
- salbutamol + ipratropium nebulisers
- 30mg prednisolone STAT + OD for 7 days
- antibiotics if raised CRP/WCC or purulent sputum
- CXR
- consider NIV if T2FR + low pH
- ITU referral if pH <7.25
Outline non invasive ventilation
- involves using a full face mask, hood or tight fitting nasal mask to blow air forcefully into the lungs + ventilate them
- involves cycle of high (IPAP ~ 16-20) + low pressures (EPAP ~ 4-6)
What does the COPD care bundle consist of?
- inhaler technique review
- smoking cessation support
- referral to pulmonary rehabilitation
- review of medications
- follow up OP appointments
- info about support groups, self-management booklets + oxygen alert card
Common bacteria that cause COPD
- Haemophilus influenzae
- Streptococcus pneumoniae
- Haemophilus parainfluenzae
- Moraxella catarrhalis
- how many need to know?
Common viruses that cause COPD
- rhinoviruses
- coronavirus
- influenza
- parainfluenza
- adenovirus
Long term management of COPD
- smoking cessation
- pneumococcal + annual flu vaccine
- pulmonary rehabilitation (exercise, nutritional advice + disease education)
- long term oxygen therapy if chronic hypoxia
. - initial medical treatment: SABA + SAMA e.g. salbutamol | ipratropium bromide
- second step if no asthmatic or steroid responsive features: LABA + LAMA combination *e.g. anoro ellipta, utibro breezhaler**
- second step if asthmatic or steroid responsive features: LABA + ICS combination ** *e.g. seretide, fostair
- final step: LABA, LAMA + ICS combination e.g. trimbow
Medication management of COPD
- initial medical treatment: SABA + SAMA PRN e.g. salbutamol | ipratropium bromide
- second step if no asthmatic or steroid responsive features: LABA + LAMA combination e.g. anoro ellipta, utibro breezhaler
- second step if asthmatic or steroid responsive features: LABA + ICS combination e.g. seretide, fostair
- final step: LABA, LAMA + ICS combination e.g. trimbow
What therapies improve the symptoms of COPD?
- pulmonary rehabilitation (exercise, nutritional advice + disease education)
- bronchodilators
- lung transplant
- long term oxygen therapy
- lung volume reduction surgery
- mucolytics
Outline long term oxygen therapy
When is it offered?
- used to protect organs when hypoxic
- used at least 16 hours/day
- patient must not smoke + not retain high levels of CO2
- offered if pO2 consistently <7.3kPa or <8kPa with cor pulmonale
What therapies improves the risk of COPD?
- stop smoking
- oxygen therapy
- anti inflammatories
- non-invasive ventilation
- flu vaccine
- healthy diet
When is ambulatory oxygen given?
If patient desaturates when they walk (>4%)
What epithelial cells line the airways?
Ciliated pseudostratified columnar
Goblet cells
How does exposure to triggers cause COPD?
Hypertrophy + hyperplasia of:
- bronchial mucinous glands (main bronchi)
- goblet cells (bronchioles)
Production of mucous > obstruction of airways
Smoking also shortens cilia > harder to move mucous
FEV1 and FVC in patient with COPD
FEV1 - very low
FVC - low
Complications of COPD
- cor pulmonale
- respiratory failure
- pneumothorax
- recurrent pneumonia
How can COPD cause cor pulmonae (right sided heart failure)
- vasoconstriction to a large proportion of lungs
- increased pulmonary vascular resistance
- pulmonary hypertension
- more work for right side of heart
- right sided heart failure
How can alpha-1 antitrypsin deficiency causes COPD?
- alpha-1 antitrypsin is a antiproteinase
- the deficiency leads to an imbalance in proteinases + antiproteinases
- this leads to destruction of alveolar walls + emphysema
Typical colour of purulent sputum
Yellow or green
Follow ups for COPD
- review mild, moderate or severe COPD at least once a year
- review very severe COPD (<30% FEV1) at least twice a year
- check inhaler technique
- record smoking status + BMI
- assess for complications
- ensure flu, covid + pneumococcal vaccines have been offered
What does ‘ blue bloaters’ and ‘ pink puffers’ mean?
- blue bloaters: chronic bronchitis - cyanotic + overweight, peripheral oedema, wheezing
- pink puffers: emphysema - older, thin, SOB, use of accessory muscles
What medications can be used for palliative management of breathlessness?
- opiates *e.g. oral morphine**
- benzodiazapines e.g. lorazepam
- oxygen
