COPD Flashcards
what does spirometry look like in COPD?
BIG decrease in FEV1, some decrease in FVC, therefore FEV1:FVC is decreased (normal is >70%)
Post bronchodilator there is some improvement (as opposed to obstruction from fibrosis that does not improve
What ages are normally involved and what is the average age of presentation
normally in middle aged and older
onset usually in 5th and 6th decades (40+)
what is the prevalence?
12.5% of those 45-70yrs
What factors are involved in causing COPD
Smoking (20/day for >20yrs) air pollution airway infection occupation - dusts, silica, cadmium Familial predisposition A1-ATD (emphysema) Broncial Hyper responsiveness age gender TB exposure
What factors are involved in causing COPD
Smoking (20/day for >20yrs) air pollution airway infection occupation - dusts, silica, cadmium Familial predisposition A1-ATD (emphysema) Broncial Hyper responsiveness CF IV drug use
Unless there is a hx of smoking or fam hx of A1ATD then it is not COPD
What is COPD
A respiratory dx characterised by airflow obstruction that is not fully reversible.
Airflow limitation is generally progressive and associated with abnormal inflammatory response of the lungs to noxious airborne agents (smoke)
2 types - emphysema and chronic bronchitis
What signs are there in COPD
tachypnoea reduced chest expansion hyper inflated lungs hyper-resonant percussion decreased breath sounds +/- Wheeze pursed lip breathing "pink puffer" - always breathless (more often emphysema) "blue bloater" - oedantous and central cyanosis (more often chronic bronchitis) signs of resp failure signs of Cor pulmonale
what are the signs of respiratory failure
???????
what are the signs of Cor pulmonale
cyanosis, peripheral oedema, Incr JVP 4th Heart sound diastolic mumur from pulm regurg hepatomegaly +/- ascites crepitations at lung bases +/- pleural effusionn
How do you investigate COPD (and expected results needed to indicate COPD)
Pulmonary Fn Tests
- Spirometry - post-SABA FEV1/FVC of <80%
CXR
How do you investigate COPD (and expected results needed to indicate COPD)
Pulmonary Fn Tests
- Spirometry - post-SABA FEV1/FVC of <80%
Pulmonary function testing (PFT) reveals airflow obstruction, as evidenced by an increased forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) ratio. Administration of bronchodilators has no effect, unlike the reversible obstruction seen in asthma.
CXR - hyperinflation, barrel chest, narrow mediastinum, bronchovascular markings, small heart
CT - bronchial wall thickening, alveolar septal destruction and airspace enlargement,, bullae
Blood Gas - normal or Increased PaCO2, decreased PaO2
ECG - Cor Pulmonale
FBC - anaemia, polycythaemia, but Hb and PCV may be raised.
What are the dx processes occurring in COPD types.
In chronic bronchitis, there is diffuse hyperplasia of mucous glands with associated hypersecretion and bronchial wall inflammation.
Emphysema involves the destruction of alveolar septa and pulmonary capillaries, leading to decreased elastic recoil and resultant air trapping.
What are the disease processes occurring in COPD types.
In chronic bronchitis, there is diffuse hyperplasia of mucous glands with associated hypersecretion and bronchial wall inflammation.
Emphysema involves the destruction of alveolar septa and pulmonary capillaries, leading to decreased elastic recoil and resultant air trapping.
Understanding Lung FN tests
- what is normal for FEV1 to FVC ratio
- what happens to FEV1 and FVC in restrictive lung dx
- What happens in obstructive dx
- Fev1 is normally 80% of FVC = 0.8
- FEV1 AND FVC are both reduced almost equally = normal to increased FEV1:FVC ratio in restrictive dx i.e. 1.0
- FEV1 is MORE reduced than FVC in obstructive dx = FEV1:FVC is reduced in obstructive dx e.g. 0.5 (50%)
What signs are there on X-ray for COPD
- chronic bronchitis on chest radiography :
- -nonspecific
- increased bronchovascular markings
- -cardiomegaly.
-Emphysema
–lung hyperinflation
– flattened hemidiaphragms,
–a small heart,
– possible bullous changes.
On the lateral radiograph,
–a “barrel chest” with widened anterior-posterior diameter may be visualized.
What are the features on CT of COPD
In chronic bronchitis, bronchial wall thickening may be seen in addition to enlarged vessels. Repeated inflammation can lead to scarring with bronchovascular irregularity and fibrosis.
Emphysema is diagnosed by alveolar septal destruction and airspace enlargement, which may occur in a variety of distributions. Centrilobular emphysema is predominantly seen in the upper lobes with panlobular emphysema predominating in the lower lobes. Paraseptal emphysema tends to occur near lung fissures and pleura. Formation of giant bullae may lead to compression of mediastinal structures, while rupture of pleural blebs may produce spontaneous pneumothorax / pneumomediastinum.
What is a good consultation checklist for Mx COPD
SMOKES
S- smoking cessation
M - medication - bronchodilators, Anticholinergics vaccination, corticosteroids
O - Oxygen - is it needed
K - Komorbidity - cardiac DysFn, sleep apnoea, osteoporosis, depression, asthma
E - Exercise and rehabilitation - physio for chest physio, breath exercises, aerobic exercise
S - Surgery - bullectomy, Lung Volume Reduction, Single Lung transplantation.
what is better for COPD pts long or short acting anticholinergics
Long acting antcholinergics - tiotropium 18mcg has reduced frequency of exacerbations compared with short acting ACHs (such as ipatropium)
who should have inhaled corticosteroids in COPD
Those with evidence of response
Those with FEV1 =/2 exacerbations requiring oral steroids in 12mths
what role do bronchodialtors have in COPD management?
They reduce wheezing and SOB
What bronchodilators are used in COPD Mx
long & short acting B2-Agonists (salbutamol, terbutaline & salmerterol, efometerol), long and short anticholinergics (ipatropium, tiotropium), and corticosteroids.
what drugs would you use in mild (60-70% predicted FEV1) COPD
bronchodialtor PRN (salbutamol/ipatropium)
What drugs would you use in moderate COPD (40-50%FEV1)
Regular combined therapy of salbutamol & ipatropium (including a long acting bronchodilator)
What drugs would you use in Severe COPD (<40% predicted FEV1)
Regular combined bronchodilators (salbutamol & ipatropium) and long acting bronchodilator. +/- inhaled corticosteroids.
What is the benefit of a long acting anticholinergic in COPD pts
Long acting ACH has shown to reduce COPD exacerbations when compared to short acting ACH
What benefit is there from O2 therapy in COPD
When used for >15hrs a day In those with significant hypoxaemia on breathing air (SaO2 88%) it can prolong life.
When is Antibiotic use appropriate in COPD patients.
Only during acute exacerbations - incr dyspnoea, sputum production or purulence, and cough. There is no evidence of long term use reducing exacerbations
Are Mucolytic agents or Antitussives useful in COPD?
Mucolytic agents can reduce the frequency and duration of exacerbations. Consider when there is chronic productive cough.
Antitussives on a regular basis are contraindicated in COPD.
What surgical options are there for patients with COPD?
Bullectomy, lung transplantation, lung volume reduction.
When do you refer to a specialist in COPD, and why?
EARLY. an early referral is appropriate as it will help: -clarify diagnosis consider other therapies, consider long term O2 facilitate pulmonary rehabilitation
List 4 signs that a pt with COPD requires hospital admission
- Rapid rate of onset of an acute exacerbation
- inability to cope at home
- severe breathlessness - unable to sleep or eat
- altered mental state (suggests sever hypercapnia)
- new arrhythmia
-cyanosis - significant co-morbidity
inability to walk between rooms when previously mobile.
What does the X in COPD-X management stand for?
management of eXacerbations
What signs/symptoms are required to make a diagnosis of COPD exacerbation
acute onset over minutes to hours of at least 2 of:
- Inc SOB - incl acces m.m. use
- reduced effort tolerance
- tachpnoea (>25breaths/min)
- increased fatigue
- increased cough & Sputum
- Increased Wheeze
How should a COPD exacerbation be Ix
consider CXR, Pulse oximetry and sputum culture
How do you treat COPD exacerbation
Bronchodilators (with Large Volume Spacer)
oral glucocorticoids (prednisolone 30-50mg usually for 7-14 days - no tapering required)
Rarely Abx
When is antibiotics use appropriate in a COPD exacerbation
when there is increasing SOB, and Cough AND Increased sputum volume and/or purulence.
What Antibiotics are used when a COPD exacerbation occurs
Only if indicated (cough, SOB, sputum volume, purulence )
- amoxycillin 500mg TDS 5/7
- doxy 200mg x1 day then 100mg for further 5 days
At what point should o2 therapy be considered?
when O2sats <92%. want to maintain above 90%
BEWARE HYPERCAPNIA
How can you confirm diagnosis of COPD
Only with Spirometry
what are the symptoms of Cor pulmonale
fatigue breathlessness on exertion +/- angina palpitations later after LV failure: peripheral oedema ascites syncope
what is Cor pulmonale
Right heart failure from chronic Pulmonary Hypertension
why findings on CXR would suggest Cor Pulmonale
Prominent right heart border
enlargement of the proximal pulmonary arteries
what findings would appear on ECG in COr Pulmonale
may be normal Right axis deviation tall peaked P wave in Lead II Dominant R wave in V1, T-Wave inversion in anterior leads Or RBBB
What does COPD-X stand for?
Confirm Diagnosis and assess Severity Optimise Fn Prevent Deterioration Develop Support Network and self-mx plan manage Exacerbations
