COPD Flashcards
What are the two conditions that are involved in COPD?
Chronic bronchitis- Inflammation of the airways
Emphysema- Alveolar destruction
what is the main cause of COPD?
Smoking
Also other pulmonary irritants
What is chronic bronchitis?
Inflammation of the airways which leads to airway obstruction and increase in mucous production
How is bronchitis clinically defined?
Having a productive cough for at least 3 months each year for 2 or more consecutive years
What happens with emphysema?
There is destruction of the alveolar walls, this reduces the elastic recoil and leads to air trapping and reduced ventilation
The loss of alveolar tissue also causes loss of gas exchange barrier
What might cause COPD in a young patient (<45 years old)?
Alpha 1 antitrypsin deficiency-
Elastase accumulates in the lungs causing breakdown of elastin. Alpha 1 antitrypsin accumulates in the liver and causes cirrhosis
What symptoms might someone with COPD describe?
Worsening breathlessness Productive cough (at least three months of a year for 2 consecutive years) Fatigue Reduced exercise tolerance Wheeze Chest tightness (due to obstruction)
What signs may you see in a patient with COPD during examination?
Barrel chest Central/Peripheral cyanosis Expiratory wheeze- due to obstruction Hyperresonance on percussion Signs of RHF
How is COPD diagnosed?
Spirometry- FEV1:FVC < 0.7
What are the spirometry findings for COPD?
FEV1: FVC <0.7
FEV1 less than 80% of predicted
Little improvement on reversibility testing
How should dyspnoea be graded?
MRC dyspnoea scare
What is grade 1 on the MRC dyspnoea scale?
Not troubled by breathlessness except on strenuous exercise
What is grade 2 on the MRC dyspnoea scale?
Short of breath when hurrying or walking up a whill
What is grade 3 on the MRC dyspnoea scale?
Walks slower than contemporaries on level ground because of breathlessness or has to stop for breath on level ground when walking at own pace
What is grade 4 on the MRC dyspnoea scale?
Stops for breath after walking about 100m or after a few minutes on level ground
What is grade 5 on the MRC dyspnoea scale?
Too breathless to leave the house or breathless when dressing or undressing
What FVC:FEV1 ratio suggestive obstructive lung disease?
FEV1:FVC >0.7
What can be done during spirometry to differentiate COPD from asthma?
Bronchodilator reversibility is seen in asthma
There is little bronchodilator reversibility in COPD
What is important to ask smokers at every appointment?
If they’ve considered quitting and recommend NHS stop smoking services
What other investigations should all patients have when suspecting COPD?
Spirometry is diagnostic
CXR- Exclude other pathologies
FBC- Anaemia or polycythaemia (secondary to hypoxia)
BMI
Other investigations depend upon the suspected cause
When might you ask patients to do serial at home peak flow measurements?
Exclude asthma if still diagnostic uncertainty
What cardiac investigations might you want to check for patients with COPD?
Bloods- BNP, FBC
CXR- Pulmonary oedema
ECG- Signs of ventricular hypertrophy, AF, other arrhythmia
ECHO
What blood test might you want to check in patients who are less than 45 who present with symptoms of COPD?
Serum alpha 1 antitrypsin
Causes lung and liver injury
What features would help you differentiate between COPD and asthma?
COPD is more likely to occur in older patients
COPD is more likely to occur in patients with a smoking history
COPD is associated with a chronic productive cough
Asthma is associated with symptoms in childhood
Asthma is associated with atopy
Asthma shows diurnal variation
Asthma shows bronchodilator reversibility with FEV1
What is used to assess the severity of airflow obstruction?
What are the percentage ranges?
FEV1
>80% = Mild 50-79% = Moderate 30-49% = Severe <30% = Very severe
What simple methods should be used in the management of COPD? Before drug therapy?
Stop smoking services
Pneumococcal or influenza vaccinations
Pulmonary rehabilitation if indicated
Develop a personalised self-management plan
Plan for exacerbations
What if the first thing to offer COPD patients experiencing breathlessness?
SABA or SAMA
e. g. Salbutamol
e. g. Ipratropium bromide
What factor determines the second step for the treatment of COPD if the person is breathless or has exacerbations despite treatment?
The presence of asthmatic features influences the next stage in the management.
Asthmatic features- LABA + ICS
No asthmatic features- LABA + LAMA
Offer smoking cessation at every stage
When should patients be moved up to step 2 of the management for COPD?
If they are still experiencing breathlessness
Experiencing exacerbations
What asthmatic features suggest that there might be a response to ICS and so ICS should be offered in combination with LABA?
Previous diagnosis of asthma
High blood eosinophil count
FEV1 variation
Substantial diurnal variation (At east 20%)
Offer smoking cessation at every stage
What is the second line management for COPD patients who do not show asthmatic features?
LABA and LAMA
e. g. Salmeterol
e. g. Tiotropium
Offer smoking cessation at every stage
What is the second line management for COPD patients who show asthmatic features?
LABA + ICs
e. g. Salmeterol/ Formoterol
e. g. Beclomethasone, Fluticasone
Note- for these combination inhalers are available
Offer smoking cessation at every stage
What is the third line management option for patients with COPD and asthmatic features? What are they already on due to second line therapy?
1st Line: SABA + SAMA (e.g. Salbutamol/ Ipratropium)
2nd Line: LABA + ICS (e.g. Salmeterol, Formoterol, Beclomethasone, Fluticasone)
3rd Line: LABA + ICS + LAMA (Tiotropium)
Offer smoking cessation at every stage
How should inhalers be prescribed?
Unlike most other medicines they should be prescribed using brand names
What might be given to reduce troublesome mucous production in COPD patients?
Carbocisteine syrup
What vaccinations should be given to COPD patients?
Influenza- annually
Pneumococcal- one off
What pharmacological methods may help with smoking cessation?
Nicotine replacement therapy
Varenicline
Bupropion
Last two are not suitable in pregnancy, and should be started 1-2 weeks before the quit date.
A combination of pharmacological therapy and behavioral therapy/psychological support is key. Refere to stop smoking services.
What does MDI stand for?
Metered dose inhaler
When might oral theophylline be used?
If there is a failure to respond to inhaled bronchodilator therapy
What might be used in patients with recurrent exacerbations of COPD?
Patients may be given prophylactic antibiotics if they are experiencing recurrent exacerbations
This is typically 4 or more times per year.
Be sure to do a sputum culture and sensitivity , include AFB/ZN staining to identify possible causes.
Also a CT scan should be performed to rule out other lung pathologies such as malignancy.
What antibiotic is typically used at a prophylactic dose in COPD patients?
Azithromycin 250 mg three times per week
What should be checked before starting patients on long term azithromycin?
ECG to rule out QT prolongation which azithromycin can cause
LFTs
Can also cause hearing loss and tinnitus but the risk is small, seek help if this happens
What features may indicate that oxygen therapy is needed in COPD patients?
Breathlessness at rest Severe airway obstruction (FEV1 <30%) Cyanosis Secondary polycythaemia Signs of RHF Oxygen saturations of 92% or less on room air
What investigation needs to be done to determine whether someone should be started on long term oxygen therapy?
ABG on 2 different occasions at least three weeks apart when COPD is stable
Who should be offered long term oxygen therapy?
PO2 <7.3 on 2 ABGs taken at least 3 weeks apart
Or 7.3 to 8 with:
- Polycythaemia
- PHTN
- Peripheral oedema
Minimum is to be on oxygen for at least 15 hours a day.
When should long term oxygen therapy not be offered?
The people who continue to smoke despite being offered smoking cessation services
What two risks need to be assessed when considering someone for at home oxygen therapy?
Risk of falls due to equipment tubing
Risk of fire
What surgical options may be considered in the management of COPD?
Lung volume reduction surgery
Bullectomy
Lung transplant
Refer to a specialist MDT
What should patients with COPD exacerbation be discharged with?
Plans for a rescue pack to be put in place with includes steroids and antibiotics. GPs may sort this. This can be kept at home and used when appropriate.
