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afsha respiratory > COPD > Flashcards

COPD Flashcards

1
Q

characterised by

A

persistent respiratory symptoms and airflow limitation that is usually progressive and not fully reversible

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2
Q

is air flow limitation in COPD reversible?

A

not fully reversible

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3
Q

air flow limitation is due to a combination of …

A

small airways disease (obstructive bronchiolitis) and parenchymal destruction (emphysema)

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4
Q

4 main symptoms of COPD

A

wheeze
dyspnoea (SOB)
chronic cough
regular sputum production

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5
Q

what is the main RF For development and exacerbations of COPD

A

tobacco smoking

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6
Q

Main risk factor for development and exacerbations: tobacco smoking.
Name 3 other RF

A

Environmental pollution and occupational exposures
Genetic factors e.g. hereditary alpha-1 antitrypsin deficiency
Poor lung growth during childhood

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7
Q

true or false - genetic factors can increase risk of COPD

A

true e.g. . hereditary alpha-1 antitrypsin deficiency

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8
Q

what is cor pulmonale

A

abnormal enlargement of the RV due to lung disease
causes HF

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9
Q

what is ashtma-COPD overlap syndrome and what blood test can indicate this

A

Characterised by persistent airflow limitation that displays features of asthma and COPD

high eosinophils = asthma features

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10
Q

non drug treatment for stable COPD

A
  • stop smoking
  • pulmonary rehabilitation
  • if excessive sputum production: active cycle of breathing techniques and ho to use positive expiatory pressure devices (physiotherapist)
  • if BMI abnormal or changes over time - refer for dietic input
  • some pt may be deemed appropriate for surgery
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11
Q

non drug treatment for pt with excessive sputum production

A

taught active cycle of breathing techniques, and how to use positive expiratory pressures devices by a physiotherapist

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12
Q

name 2 vaccinations that should be offered to all pt

A

inactivated influenza
pneumococcal

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13
Q

who would you consider nebulised treatment in instead of inhaler therapy

A

patients with distressing or disabling breathlessness despite maximal use of inhalers, and continued if an improvement is seen in symptoms, ability to undertake activities of daily living, excess capacity, or lung function

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14
Q

initial empirical treatment for all pt with COPD

+ what to consider before stepping up

A

short acting brochodilator - SABA or SAMA (IPRATROPIUM) prn to relieve breathlessness and exercise limitation

before considering step up treatment, ensure COPD is confirmed spirometricallly, relevant vaccines have been given, non drug treatment options have been optimised e.g. smoking cessation, and that a short acting bronchodilator is being used.

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15
Q

initial empirical treatment for all pt with COPD is to give a short acting bronchodilator prn (e.g. SAMA or SABA).
What is step up treatment for pt w/o asthmatic features or features that suggest steroid responsiveness?

A
  • if continue to be breathless or have exacerbations: offer LABA + LAMA
  • if LAMA given, discontinue SAMA
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16
Q

true or false - SABA prn may be continued in all stages of treatment of COPD

A

true

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17
Q

If a patient who is on LAMA + LABA (+ SABA prn) had severe exacerbations (requiring hospitalisation) or at least 2 moderate exacerbations (requires systemic CCs and/or abx) within 1 year, consider the addition of …

A

ICS

triple therapy with ICS, LABA, LAMA

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18
Q

If ICS is given, how often to review and what needs to be documented?

A

annually
document reason for continuing

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19
Q

If a pt who is on LAMA + LABA (+prn SABA) whose day to day symptoms continue to adversely impact QoL, consider …

A

trialling ICS for 3 months
if symptoms improved, continue triple therapy and review at least annually
if no improvement, step back down to LAMA + LABA

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20
Q

1st line empirical for all pt with COPD is with a SA bronchodilator (e.g. SAMA, SABA). What is step up treatment for pt with asthmatic features or features suggesting steroid responsiveness?

A
  • if pt continues to be breathless of have exacerbations, consider treatment with LABA and ICS
  • if ICS given, review annually + document reason for continuation
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21
Q

If patient is on SAMA/SABA + LABA + ICS and have severe exacerbation (requiring hospitalisation) or at least 2 moderate exacerbations (requiring systemic CCs and/or abx) within a year, or who continue to have day to day symptoms adversely impacting their QoL… what is step up treatment?

A

Add LAMA - this means discontinue SAMA (ipratropium)
triple therapy: LAMA, LABA, ICS
SABA can be continued at all stages of COPD treatment

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22
Q

prophylactic abx - which one and who for

A

after considering if respiratory specialist input is required, consider azithromycin unlicensed prophylaxis to reduce risk of exacerbation in pt two are NON smokers, have had all treatment options optimised and continue to either have prolonged or frequent (4 or more per year) exacerbations with production, or exacerbations resulting in hospitalisation

23
Q

before offering azithromycin prophylaxis abx to select patients, ensure you do the following

A
  • ensure sputum culture and sensitivity testing
  • CT scan of thorax to rule out other lung pathologies
  • baseline ECG to rule out QT interval prolongations
  • LFTs
24
Q

how often to review prophylactic azithromycin

A

after first 3 months
then at least 6 monthly thereafter
only continue if benefits outweighs risks

25
Q

This is recommended as add on treatment to bronchodilator therapy in pt with severe COPD with chronic bronchitis and a history of frequent exacerbations. It is a oral phosphodiesterase-4 inhibitors that can only be started by specialist

hint - ends in R…..last

A

Roflumilast (selective phosphodiesterase-4 inhibitor)

26
Q

Consider mucolytic treatment in which patients?

A

pt with chronic cough productive of sputum; only continue if symptomatic improvement is seen

27
Q

is antitussive treatment used in management of stable COPD? and name one antitussive

A

do not use - cough suppressants e.g. dextromethorphan

28
Q

When should MR theophylline be used?

A

MR theophylline should only be used after a trial of short acting and long acting bronchodilators, or if the pt is unable to use inhaled treatment

29
Q

management of exacerbations of COPD - action plan

A
  • create action plans together with pt for those at risk of exacerbations
  • in pt who have had exacerbation within last year, a short course of abx (non macrolide if on azithromycin prophylaxis) and oral CCs should be kept at home
  • pt needs to understand and be confident on when and how to take, and to report taking them to HCP
30
Q

true or false - patients who have had an exacerbation within the last year should keep a short course of abx (non macrolide if on azith prophylaxis) + oral CCs at home as rescue meds

A

true

31
Q

Can patients continue prophylactic azithromycin during an acute exacerbation that is being treated with abx?

A

Yes

32
Q

drug treatment of COPD exacerbations - bronchodilator

A
  • short acting inhaled bronchodilators, usually at higher doses than maintenance, through nebuliser or hand held device to manage breathlessness
  • choice should be dependence on dose requires, pt ability to use device etc
  • withhold LAMA if SAMA given!
33
Q

drug treatment of COPD exacerbation - CC

A
  • if no CI in pt who present at hospital with exacerbation, give short course oral prednisolone (along with other necessary therapy)
  • consider a short course for pt in community experiencing an exacerbation with significant increase in breathlessness that interferes with daily activities
  • 30 mg oral prednisolone once daily for 5 days
  • consider osteoporosis prophylaxis for pt who require frequent courses of oral CCs
34
Q

Long term oral CC not usually recommended for management of exacerbations. however in some pt they may need to be continues when withdrawal following an exacerbation is not possible. in this case use lowest possible dose. ensure to monitor for …

A

osteoporosis and give appropriate prophylaxis
start prophylaxis without monitoring for osteoporosis in pt aged over 65

35
Q

when can aminophylline be used in management of exacerbation of COPD

A

only use as add on treatment when inadequate respond to nebulised bronchodilators
ensure therapeutic drug monitoring performed and that previous oral theophylline use is considered to avoid toxicity

36
Q

is oxygen used in management of COPD exacerbations

A

If necessary, oxygen should be given to ensure oxygen saturation of arterial blood levels are kept within the target range for the patient

37
Q

what is hypercapnic ventilatory failure

A

Hypercapnic respiratory failure happens when you have too much carbon dioxide (CO2) in your blood. If your body can’t get rid of carbon dioxide, a waste product, there isn’t room for your blood cells to carry oxygen.
People with COPD are at higher risk of hypercapnia.

38
Q

management of COPD exacerbations - for patients with hypercapnic ventilatory failure, what should you do

A

use non invasive ventilation (NIV) if patients experience exacerbations despite optimisation of medical treatment
if deemed necessary, invasive ventilation for COPD exacerbations should be given in an ICU
doxapram should should only be given when NIV is inappropriate or unavailable in clinical setting

39
Q

after considering if respiratory specialist input is required, consider THIS ANTIBIOTIC AS unlicensed prophylaxis to reduce risk of exacerbation in pt two are NON smokers, have had all treatment options optimised and continue to either have prolonged or frequent (4 or more per year) exacerbations with production, or exacerbations resulting in hospitalisation

A

azithromycin

40
Q

true or false - azithromcyin prophylaxis can only be offered to patients who have had all treatment options optimised but still have either prolonged or frequent (4 or more/year) exacerbations with sputum production, or exacerbation resulting in hospitalisation, and they are NON SMOKERS

A

true

41
Q

dose and duration of prednisolone in exacerbation of COPD

A

30mg OD 5 days

42
Q

What are the three 1st choice oral abx for COPD exacerbation if abx is indicated?

A

Amoxicillin 500 mg three times a day for 5 days.
Doxycycline 200 mg on first day, then 100mg once a day for 5-day course in total.
Clarithromycin 500 mg twice a day for 5 days.

43
Q

First choice oral antibiotics for exacerbation of COPD include
Amoxicillin 500 mg TDS for 5 days.
Doxycycline 200 mg on first day, then 100mg OD for 5-day course in total.
Clarithromycin 500 mg BD for 5 days.

If the person is at higher risk of treatment failure (for example frequent antibiotic use; previous or current sputum culture with resistant bacteria or high risk of developing complications) consider prescribing this instead

A

co-amoxiclav 500/125 mg TDS a day for 5 days
Levofloxacin 5 days

44
Q

when is co-amoxiclav 500/125 mg three times a day for 5 days given for COPD exacerbation?

A

If the person is at higher risk of treatment failure (for example frequent antibiotic use; previous or current sputum culture with resistant bacteria or high risk of developing complications)

45
Q

true or false - consider emergency admission if the pt with COPD exacerbation has oxygen saturation less than 90% on pulse oximetry.

A

True

Give oxygen (if available) while awaiting emergency transfer to hospital and monitor response with pulse oximetry — refer to local protocols (or follow instructions on the person’s oxygen alert card if available).
Otherwise, initially give patients with COPD oxygen via a Venturi 24% mask at 2-3 l/min or Venturi 28% mask at a flow rate of 4 l/min or nasal cannula at a flow rate of 1-2 l/min (if a 24% mask is not available).
The target oxygen saturation should be 88– 92% in most cases.

46
Q

true or false - Do not refer the person for pulmonary rehabilitation if they:
Are unable to walk
Have unstable angina, or have had a recent myocardial infarction.

A

true

47
Q

true or false - The dose of theophylline should be reduced in people prescribed macrolide or fluoroquinolone antibiotics (or other drugs known to interact) for an exacerbation.

A

true

Drugs: VA CAC COC
valaciclovir aciclovir clarith azith ciprox COC they increase exposure to theophylline monitor and adjust dose

48
Q

discuss use of oral mucolytic therapy

A

Consider mucolytic therapy if a person with stable COPD develops a chronic cough productive of sputum.
Only continue the mucolytic if there is symptomatic improvement (such as reduction in frequency of cough and sputum production).
Mucolytics should not be used routinely to prevent exacerbations in people with stable COPD.

49
Q

prophylactic abx - dose and duration

A

Treatment with azithromycin 500 mg three times per week, should be considered for a minimum of 6–12 months to assess evidence of efficacy in reducing exacerbations.

50
Q

monitoring after starting oral macrolides

A

Liver function tests should be checked 1 month after starting treatment and then every 6 months. An ECG should be performed 1 month after starting treatment to check for new QTc prolongation. If present, treatment should be stopped.

51
Q

summarise all the steps in COPD exacberation treatment

A
  • SABA/SAMA for exacerbtion (withhold LAMA if SAMA given!!)
  • if inadequate response to nebulised bronchodilators, + IV aminphylline
  • oxygen if needed to keep oxygen saturation of arterial blood levels in range
  • if in hospital, give 30mg OD prednisolone 5 days (along with other therapies)
  • if in community, give 30mg OD prednisolone 5 days if signficant breathlessness
52
Q

When would you give short course of oral CCs in community to a patient who has had an exacerbation of COPD

A

only give if they have significant breathlessness

53
Q

Summarise the treatment pathway for COPD in a patient with asthmatic features

A
  1. SAMA or SABA
  2. LABA + ICS if symptoms still continue
  3. LABA + LAMA + ICS (if pt has severe exacerbation of 2+ moderate ones in a year, or if symptoms still continue)
54
Q

Summarise the treatment pathway for COPD in a patient WITHOUT asthmatic features

A
  1. SAMA/SABA
  2. LAMA + LABA
  3. LAMA + LABA + ICS (if severe exacerbation or 2+ moderate exacerbations). If a patient who was still symptomatic, trial ICS for 3 months, if no help then revert back to LAMA + LABA

afsha respiratory (22 decks)

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