COPD Flashcards
Define COPD
- airflow obstruction
- not fully reversible
- progressive in LT
- does not change over several months
- smoking cause
- occupational exposures contribute
Define exacerbations
Rapid sustained worsening of symptoms beyond normal day to day variations
Define chronic bronchitis
presence of chronic productive cough and sputum for at least 3 months in each of 2 successive years
Define emphysema
Enlarged alveolar spaces and loss of alveolar walls
How to calculate pack years
= number of packs per day x years smoked
How many cigarettes in a pack?
20
Causes of COPD
- tobacco smoke
- indoor air pollution (smoke, biomass fuels)
- occupational dusts, chemical agents and fumes
- outdoor air pollution
Pathophys of chronic bronchitis
- hypertrophy of mucus secreting glands
- increased mucus production
- infiltration of bronchial walls with inflammatory cells = airways narrow
Pathophys of emphysema
- loss of elastic recoil = airflow limitation and air trapping
- bulla formation
`Difference between asthma and COPD Pathophys
- asthma mostly reversible
- asthma causes CD4+ lymphocytes activating eosinophils, macrophages, mast cells
- COPD causes CD8+ lymphocytes activating macrophages and neutrophils
COPD symptoms
- over 35
- smoker/ex
- exertional breathlessness
- chronic cough
- regular sputum production
- frequent winter bronchitis
- wheeze
- morning cough with sputum
- peripheral oedema
Diagnostic factor main for COPD
FEV1<80
Stages of COPD
1 = FEV1>80 2 = 50-79 3 = 30-49 4 = <30
Management for COPD
- treat airflow obstruction
- monitor treatment adherence
- follow over time
- consider pulmonary rehab? (if MMRC > or equal to 2)
- assess gas exchange of MMRC =2 or greater
What do normal spirometry values vary with?
- age
- height
- race
Modified MRC Dyspnea Scale
0 = breathless with strenuous exercise 1 = SOB when hurrying on level or walking up slight hill 2 = walk slower than people of same age on level as breathless or have to stop for breath when walking on my own pace on the level 3 = stop for breath walking 100m or after a few mins on level 4 = too breathless to leave house or breathless when dressing/undressing
COPD symptoms presentation how
- age
- COPD symptoms slowly progressive
- smoking history long
- dyspnea during exercise
- irreversible airflow limitation
Asthma symptoms presentation how
- child
- symptoms vary day to day
- symptoms at night or early morning
- allergy/rhinitis/eczema
- FH
- largely reversible
Peak flow with COPD
- reduced
- little day to day variation
- asthma diurnal variation and day to day
Bronchodilator response
- symptomatic response
- asthma symptomatic and lung function response
Corticosteroid response
- small response to lung function
- better with asthma
COPD signs
- wheeze
- tachypnoea
- prolonged expiration
- accessory muscle use
- pursed lip breathing
- hyper inflated lungs
- cyanosis
- HF
- Dahl’s sign
Refined ABCD Assessment Tool
A = 0-1 exacerbations and mMRC 0-1 B = 0-1 exacerbations and mMRC ≥ 2 C = ≥ 2 exacerbations or ≥ 1 leading to hospital admission and mMRC 0-1 D = ≥ 2 exacerbations or ≥ 1 leading to hospital admission and mMRC ≥2
3 stages of smoking cessation
ask
advice
act
Smoking cessation drugs
- varenicline (Champix)
- nicotine replacement therapy
- bupropion (Zyban)
- E-cigarettes (not safe LT)
MOA of varenicline
- selective nicotine receptor partial agonist
Forms of nicotine replacement
- use in abrupt cessation or to slowly reduce
- patches
- gum/lozenges/ oro-nasal spray
- inhalator
Vaccines
- influenza vaccine
- reduce serious illness
- pneumococcal polysaccharide for >65 years or if <65 and FEV1 <40% predicted
Drugs used
- short acting bronchodilators with anticholinergics
- LABA with anticholinergics
- inhaled corticosteroids
- phosphodiesterase inhibitors
Examples of short acting bronchodilators
Salbutamol
Terbutaline
Anticholinergics to use with short acting bronchodilators
Ipratropium bromide
LABA e.g
Formoterol
Salmeterol
Vilanterol
Indacterol
Anticholinergics to use with LABAs
Aclidinium
Glycoppyroium
Tiotropium
Phosphodiesterase Inhibitor e.g.
Theophyllines
Roflumilast
What treatment to use for group A?
- bronchodilator
What treatment to use for Group B?
LABA or LAMA
What treatment to use for group C?
LAMA
What treatment to use for Group D?
- LAMA or LAMA + LABA or ICS + LABA
Non pharm treatments
- REHAB
- oxygen therapy (>15 hours per day long term with chronic resp failure)
- lung volume reduction surgery
- lung transplant
Complications
Resp Failure
Cor Pulmonale
Define Resp Failure
PaO2<7 and/or PaCO2 6.5
Define cor pulmonale
Heart disease 2ndry to chronic lung disease
When to ABG
FEV1<30%
Cor Pulmonale
O2 sats <92% on air
How to treat Resp Failure
Long term oxygen therapy
NIV
When is LTOT life prolonging?
- use >15 hrs/day
- PaO2 <7.3 or <8 with polycythaemia, nocturnal hypoxaemia, peripheral oedema, pulmonary hypertension
Define nocturnal hypoxaemia
<90% for >30% of night
What should pulmonary rehab include?
Physical training
Disease education
Nutritional advice
Psychological and behavioural support
Palliative Treatments
Fans for dyspnoea Anxiety/Insomnia = CBT Nutrition support Pulmonary rehab Opiates for breathlessness SSRI for depression and anxiety
Define exacerbation
- in course of disease
- change in patients baselines
- change in dyspnea, cough, sputum volume and purluence
- beyond normal variation
- acute onset
- may warrant medication change
Differentials of exacerbation
Pneumonia Pneumothorax Malignancy PE HF/ACS
Investigations for exacerbation
- ox sats
- ABG
- sputum and blood cultures
- CXR
- ECG
- Bloods (eosinophil count, U&E, CRP, theophylline, cardiac enzymes)
- CT
Infective organisms in exacerbations
- often viral
- pneumonia
- H influenzae
- M. catarrhalis
Strep pneumoniae
Management of exacerbations
- bronchodilators (nebulised or air)
- steroids
- AB
- hospital at home team?
Which steroids to give in exacerbation?
- prednisolone
- 30-40mg
- OD
- max 5 days
Procedure for AB treatment in exacerbation
- if purulent sputum or pneumonia on CXR
- Empircal Rx with aminopenicllin or tetracycline
- change if cultures/sensitivies known
Oxygen in exacerbation
- aim for 88-92%
- ABG to exclude hypercapnia
- exclude acidosis
- NIV if no improvement of resp acidosis
