COPD Flashcards
Which bugs most commonly cause an exacerbation of COPD
Bacteria:
- Haemophilus influenzae (most common cause)
- Streptococcus pneumoniae
- Moraxella catarrhalis
Viral
- Respiratory viruses (e.g. human rhinovirus)
Clinical features of acute exacerbation of COPD
- dyspnoea
- cough
- wheeze
- more sputum/ change in colour
- hypoxia
- confusion
how should an exacerbation of COPD be treated in the community?
- increase frequency of bronchodilator use
- consider giving via nebuliser
- prednisolone 30 mg daily for 5 days
- Oral antibiotics (amoxicillin or clarithromycin or doxycycline)
What would make you consider admitting a patient with an exacerbation of COPD?
- severe breathlessness
- acute confusion
- cyanosis
- oxygen saturation <90%
- social reasons e.g. inability to cope at home
- significant comorbidity (such as cardiac disease or insulin-dependent diabetes)
How should an exacerbation of COPD be managed when patients are admitted to hospital?
- Oxygen therapy (venturi mask)
- Nebulised SABA and SAMA (salbutamol and ipratropium)
- oral prednisolone or IV hydrocortisone
- IV theophylline
- NIV if T2RF
At what pH can NIV be used?
respiratory acidosis
pH 7.25-7.35
*can be used if pH < 7.25 but need monitoring in HDU and a lower threshold for intubation
Causes of COPD
Most common:
- Smoking
Genetic:
- Alpha-1 antitrypsin deficiency
Others:
cadmium (used in smelting)
coal
cotton
cement
grain
Investigations if suspecting COPD
- spirometry (obstructive pattern)
- CXR: hyperinflation, bullae, flat hemidiaphragm
- FBC: exclude secondary polycythaemia
In COPD the FEV1/FVC ratio is <70%. COPD is then graded based on the FEV1 % of predicted. Describe the 4 stages
> 80% Stage 1 - Mild
50-79% Stage 2 - Moderate
30-49% Stage 3 - Severe
< 30% Stage 4 - Very severe
For how long should patients with LTOT be using supplementary oxygen?
for at least 15 hours a day
When should you consider an LTOT assessment for patients with COPD?
very severe (FEV1 < 30%)
cyanosis
polycythaemia
peripheral oedema
raised JVP
O2 sats <92% on room air
What investigation is used to assess patients for LTOT?
ABG on 2 occasions at least 3 weeks apart to assess accurate pO2
What pO2 on ABG assessment should instigate LTOT
pO2 of < 7.3 kPa
OR a pO2 of 7.3 - 8 kPa and one of the following:
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension
Before starting LTOT what must you ensure about the patients home environment?
Home risk assessment:
- risks of falls from tripping over the equipment
- risks of burns and fires
- ensuring neither the patient nor any family at home are smokers
Non-pharmacological management of COPD
> smoking cessation
annual FLU vaccine
pneumococcal vaccine
pulmonary rehab
First line COPD treatment
SABA (salbutamol) or SAMA (ipratropium)
For patients who remain breathless or have exacerbations despite using short-acting bronchodilators, the next treatment step is determined by whether they have ‘asthmatic features’. Describe these features.
- previous diagnosis of asthma/atopy
- high eosinophil count
- variation in FEV1 over time (at least 400 ml)
- diurnal variation in peak flow
If a patient has no asthmatic features/ features suggesting steroid responsiveness, what is the next step of treatment after short-acting bronchodilators?
LABA + LAMA
(if already taking a SAMA, discontinue and switch to a SABA)
If a patient has Asthmatic features/features suggesting steroid responsiveness, what is the next step of treatment after short-acting bronchodilators?
LABA + ICS
then if necessary:
LABA+ICS+LAMA
If swapped onto a LAMA, patients should discontinue a SAMA and be given a SABA instead. TRUE/FALSE?
TRUE
When is oral theophylline considered
after unsuccessful trials of short and long-acting bronchodilators
OR people who cannot used inhaled therapy
What prophylactic antibiotics can be used in COPD?
Azithromycin (only in selected patients)
What investigations should be completed prior to starting a patient on prophylactic azithromycin?
LFTs
ECG to exclude QT prolongation
Who should receive mucolytics?
Patients with chronic productive cough
Discontinue if symptoms do not improve with this
In what patients are PDE-4 inhibitors (e.g. Roflumilast) recommended?
FEV1 <50% of predicted
> 2 exacerbations in past year despite triple inhaled therapy (LABA+LAMA+ICS)
Clinical features of cor pulmonale
- peripheral oedema
- raised JVP
- systolic parasternal heave
- loud P2
Management of cor pulmonale
- loop diuretic for oedema,
- consider long-term oxygen therapy (LTOT)
- ACEi, Ca2+ channel blockers and alpha blockers are not recommended by NICE
In patients with stable COPD, what 3 interventions can improve survival
- smoking cessation
- LTOT
- lung volume reduction surgery in selected patients
