COPD Flashcards
What are the 4 MAIN causes of Breathlessness
- Heart conditions
- Lung conditions
- Anxiety
- being unfit
there’s more and if you get breathless every day, you might be diagnosed with one or more of theses causes
Can all conditions that cause long term breathlessness be treated?
Some can, but some cannot be fully reversed
What are the different ways in which lung conditions can cause breathlessness?
Some conditions causes inflammation and narrowing of airways OR fill airways with phlegm so that its harder for air toy move in and out lungs
some make lungs stiff and less elastic so it’s harder for them to expand and fill with air
What are examples of lung conditions that cause long term breathlessness
- COPD
- asthma
- interstitial lung disease including pulmonary fibrosis
- bronchiectasis
- lung cancer
- industrial or occupational lung diseases such as asbestosis - caused by asbestos
What are examples of lung conditions that causes acute short term breathlessness
- A flare up of asthma or COPD
- Pulmonary embolism or blood clot in lung
- lung infection suc as pneumonia or tuberculosis
- pneumothorax or collapsed lung
- build up of fluid in lungs or lining of lungs- caused by liver diseases or cancer or infection or heart not pumping blood efficiently
Why do people experience long term breathlessness due to heart failure
This is due to problems with the rhythm, valves or cardiac muscles of the heart
How can heart failure cause breathlessness
Heart cant pump blood to meet demand due to exercise
lungs becomes congested and filled with fluid
Why is breathlessness often worse when lying flat
Heart failure can be worse at night or when asleep
What are examples of heart conditions that cause acute breathlessness
- Heart attack
- abnormal heart rhythm; may feel heart miss a beat or feel palpitations
Why do people feel short of breath when they’re anxious or afraid
Normal response as body thinks it’s a stressful situation and body is preparing for action
you breathe faster and tense your breathing muscles
Describe how levels of fitness affect breathing
If unfit, the breathing muscles get weaker as we dont use them as often
Weaker muscles need more oxygen to work, hence the weak your muscles, the more breathless we feel
How does having an unhealthy weight make you feel breathless
Underweight- breathing muscles are weaker
Overweight- it takes more effort to breathe and move around. Having more weight around chest and abdomen restricts movement of Lungs.
those with BMI over 25 have higher chance of having breathlessness than people with healthy weight
Wat can people who are severely overweight develop?
Hypoventilation syndrome- this is when poor breathing leads to lower oxygens levels and higher CO2 levels in blood
What are the OTHER reasons for long term breathlessness
- Smoking
- kidney disease
- Thyroid disease
- anaemia- lack of iron in body leads to few red blood cells
- Scoliosis and kyphosis- shape of spine affect how ribs and lungs expand
- conditions that affect muscles like DMD and myasthenia gravis or motor neurone disease
What is a panic attack
When normal body’s response is exaggerated and there’s a rapid build up of physical responses
the body tries to take in more oxygens and breathing quickens
the body also release hormones so your heart beats faster and your muscles tense
What do people who have panic attack feel (symptoms)?
- Can’t breathe- very frightening
- have a pounding heart
- sweat
- feel sick
- have shaky limbs
- feel you’re not connected to your body
What symptoms are very similar to anxiety
- Breathlessness
- tightness in chest
- getting tired easily
How can physical health impact mental Health in terms of anxiety
Those with long term conditions like lung condition may feel that they are not in control of the condition and may feel anxious which can exarcebate breathlessness
Why is it better to bring someone with you to the doctors if you’re worried about breathlessness
You may not be breathless at the time of consultation. The person can help describe the sympotoms to the doctor better
What will a doctor show you to help you describe your breathlessness
MRC BREATHLESSNESS SCALE
What does the MRC breathlessness scale does or doesnt recognise?
It DOES NOT recognise how you think or feel about getting out of breath
However, it helps to show what your breathlessness stops you from doing
Outline the MRC breathlessness scale in terms of grade
During the consultation, what is also important to tell your doctor
- What you used to be able to do but now you can not do anymore
- What people of your age around you do that you think you should be able to do
- what your personal goals are for your day to day activity
may be useful to use local landmarks such as bus stops, shops and hills to help.
What questions will my doctor ask?
- How long have you been feeling breathless and how quickly did it come on?
- Does it come and go or is it there all the time?
- Is there any pattern to your breathlessness?
- Does it start or get worse at any particular time of day?
- Does it come on or get worse when you lie flat?
- Does anything bring it on? For example, pollen, pets or medication?
- Do you smoke?
- Do you also have a cough, or bring up phlegm?
- Do you get chest pain, palpitations or ankle swelling?
- How active are you usually?
- What’s your job or occupation?
- Is your breathlessness related to certain times at work?
- Do you have a history of heart, lung or thyroid disease or of anaemia?
- Have you made any changes in your life because of your shortness of breath?
- Do you feel worried or frightened, depressed or hopeless?
- What have you done to help you cope with the way you’re feeling?
What are the likely test that a doctor will perform to diagnose what’s causing breathlessness
- do some breathing and lung function tests
- check the number of breaths you take every minute, listen to your chest, and look and feel how your chest moves as you breathe
- check your heart rate and rhythm and check if fluid is building up in your ankles or lungs
- check your blood pressure and temperature
- check your height, weight, waist and body mass index
- examine your head, neck and armpits to see if your lymph glands are swollen
- look at your eyes, nails, skin and joints
- check your blood oxygen levels with a pulse oximeter
If the doctor spots that you’re anxious or depressed during the consultation, what may they ask you to do?
To complete a short questionnaire
What FURTHER tests may you be referred for
- Chest X ray
- spirometry test
- ECG- if breathlessness is intermittent you may be asked to wear a portable recorder for 24 hrs or 7 days.
- echocardiogram- non invasive ultrasound of heart to show how it’s working
- Blood tests- to detect anaemia, allergies or any thyroid, liver, kidney or heart problems
How long does it take to get a diagnosis
Takes some time- variable
they may be repeated tests and various treatments be tried before cause is identified
When should investigations be arranges to identify or confirm underlying cause of breathlessness
No indication for emergency admission
When diagnosis cannot be confidently identified by clinical features ALONE what initial investigation should you do?
- ECG- look for signs of arrhythmia, heart failure and pulmonary embolism
- Chest radiography- look for signs of heart failure and pulmonary pathology (including pleural effusion)
- Spirometry- look for signs of obstrucitve dieases or restrictive pattern associated with interstitial lung disease
- Full blood count - look for anemia
- Urea and electrolytes and random blood glucose levels- to tes for renal failure and diabetes as cause of metabolic acidosis and breathlessness
- Thyroid function test
- B -type natriuretic peptide (BNP) or N-terminal pro -B type natriuretic peptide (NTproBNP); to assess for heart failure
If initial investigations do not identify with cause of breathlessness what should you do?
Reassess for risks factors and clinical features of pulmonary embolism, if this is suspected, arrange urgent referral for further investigations
If there’s suspected asthma or COPD, what should you do and what results confirm airway obstruction
Assess airway obstruction by spirometry
Result to confirm airway obstruction- FEV1 is less than 80% of predicted value and FEV1/FVC ratio is 70 %
Nota bene: a normal peak expriatory flow rate doesnt exclude significant obstruction
What are the clinical features of distinguishing asthma from COPD
- Smoking history - almost always present with COPD
- Age- older than 35 yrs for COPD
- chronic productive cough- common with COPD, uncommon with asthma
- Breathelssness- progressive with COPD but variable with asthma
- Variabiltiy of symptoms - common with asthma but uncommon for COPD
- Night tree wakening of wheeze and breathlessness- common with asthma; uncommon with COPD
What should you consider if asthma and COPD CANNOT be distinguished by clinical features alone
- If you have asthma you’d have a large response to bronchodilators(more than 400mL) or prednisolone (30mg orally for 14 days)
- if FEV1 or FEV1/FVC ratio RETURN to NORMAL with drug therapy, then there’s no COPD
- if there’s asthma, then there’s significant diurnal/ day to day variability of serial peak flow measurement.
If doubt still remains, refer to specialist
Once confirmed it;s COPD, what should you arrange for people with this?
Arrange chest radiography to exclude other serious lung pathology such as lung cancer
FBC- to identify anaemia or polycythaemia
What should you do if there’s suspected heart failure
- Perform ECG for ALL people with this
- For people without history of MI, check BNP or NTproBNP and refer to specialist assessment and echocardiography if it’s raised above agreed levels for referral
- For people with history of MI, refer directly for urgent specialist assessment to be seen within 2 weeks
What should you do if theire’s suspected bronchiectaisis
- Arrange chest radiography- to exclude other symptoms
- refer to respiratory specialist fpr confirmation of diagnosis by High resolution CT
What should you do if there’s suspected abdominal splinting secondary to ascites
- Arrange abdominal ultrasound scan to confirm presence of ascites and to exclude or confirm liver cirrhosis and peritoneal cancer
- arrange other investigations guided by relevant clinical findings=- like ESR and liver function tests; for signs of cancer
- awaitng results of investigation should not delay urgent referral if cancer is suspected
What should you do is there’s suspected lung/pleural cancer
Urgent chest X-ray should be performed (WITHIN 2 WEEKS); but it depends on specific patients and their conditions
There is suspected lung or pleural cancer
What are the extra indications for performing a chest X ray for a patient who is 40 yrs and older AND have breathlessness
- If they have ever smoked
- exposed to asbestos
- have the following unexplained symptoms like: cough, fatigue, chest pain, weight loss and appetite loss
There’s suspected lung/pleural cancer
What are the extra indications to perform an urgent Chest X ray for patients that are 40 yrs and older but this time there’s no breathlessness
- Persistent/ recurrent chest infection
- finger clubbing
- supraclavicular lymphadenopathy or persistent cervical lympahdenopathy
- Chest signs consistent with lung cancer or pleural disease
- Thrombocytosis
What are the history presenting complaints showed by Mr Craven
- Can’t go up stairs/ run to catch the bus- its a lot harder
- Pace has gone down overtime
- Has shortness of breath on exertion- caused by hypoxia
What are the respiratory differential diagnosis for shortness of breath on exertion
- Asthma
- COPD
- Pulmonary fibrosis
- Lung cancer
- Pulonary embolism
- Pneumothorax
- Lower respiratory tract infection
- Consolidation
Wha are the cardiovascular/systemic differential diagnosis for shortness of breath on exertion
- Congestive heart failure
- Pulmonary oedema
- Valvular defects
- Acute coronary syndrome
- Anaemia
- Renal/liver failure
- Deconditioning
What are the physical examinations you need to do to hone down the diagnosis
- Look for abnormal lung sound- auscultation; for COPD ther’s turbulent flow of air in the lungs
- Look for Crackling in the chest- this is for pneumonia
- Barrel chest- hyperexpanded lungs and full of air
- look for Tar staining on nails
- Listen two heart- for leaky valves/stenosis
- Club finger
What investigations may you want to perform on Mr Craven
- Chest X ray
- ECG
- Blood test
- Spirometry
- Thyroid function test
Look at Mr Craven’s spirometry results:
what defect does he have.
justify it extensively
Describe an Obstrucitve lung defect
Airways are affected; they are narrow
CANNOT GET ENOUGH AIR OUT
Give examples of obstructive lung defects
- COPD
- Asthma
- Tumours in lungs
- Chronic bronchitis
- Emphysema
Describe Restrictive lung disease
Lungs can’t expand to it’s fullest. FVC decreased but FEV1 is the same
airways aren’t affected
difficulty getting air INTO THE LUNGS
Give examples of disease that causes restrictive lung defects
Pulmonary fibrosis- scarring in lungs; cant expand and recoil to take in as much air
Scoliosis/Kyphosis- distorted shape of spin so ribs can’t move in efficient way to expand lungs to take in air
Obesity
Muscular dystrophy- respiratory muscles
What diseases is COPD made up of
Bronchitis and Emphysema
Some people have both or predominantly (not exclusively) one
What is the pathophysiology of bronchitis (COPD)
Airway epithelium becomes irritated and causes inflammation
this leads to excess mucus secretions by goblet cells and submucosal glands
The irritantion causes hypertrophy oif goblet cells and submucosal glands to make more mucus
Mucus causes productive coughing
Explain the pahtophysiology of emphysema (COPD)
Destruction of alveoli walls (elastin); this reduces SA and SA:V ratio
Less ventilation and gas exchange- there’s much larger air spaces
there’s less recoil, which means that there’s less pressure to keep airways patent
Shape of alveoli isn’t the same
What is the criteria for diagnosis of bronchitis
3 months coughing period for CONSECUTIVE 2 YEARS (i.e. 6month in total)
Look at Mr Craven X ray result
what can you conclude
- Flattened diaphragm
- Heart is smaller and elongated
- Gas bubbles is elongated
One of the signs on CXR is hyperinflation of lungs- how can you discern that on a chest XRay
- More than 7 ANTERIOR ribs are at MC line; not very sensitive
- Flattening of diaphragm- more sensitive
- heart appear smaller and narrow- sometimes with air visible below inferior border
What are bullae
How can this be caused?
These are air filled spaces with thin walls bordered by only remnants of alveolar septa or pleura
- Alveoli gets damaged (in emphsyema)- they do me a large singular unit
- the outside wall is really delicate and they can easily pop
- this can cause pneumothorax and it appears blacker in X-RAY
How can you discern Bullae on a CXR
Area of low density- BLACKER
May be outlined resembling bubbles
What are the ways to help those with COPD to cope to improve quality of life (prognosis of disease )
- Smoking cessation services
- Nicotine replacement; patches, gum or nicotine inhalers
- Medication to help to stope smoke
- Rescue pack- help with infective flares of COPD which exarcebates it. This include a pack of antibiotics and oral steroid
- Keep well in cold; flu jab and pneumoccocal vaccine
What are the nutritional ways of helping those with COPD
They may be malnourished- muscles are weaker so cant contract to explained lungs
refer to dietician to optimise food intake and lead to healthy weight
- Fruit and veg to boost immune system
- Softer and moister food if struggling to eat
What are the main categorises of inhaled medications for COPD
- Inhaled Bronchodilators -Muscarinic ANTAGONIST & Beta 2 adrenoceptor AGONIST
- Anticholinergic- aclidiniune to opppose resting bronchoconstriction
- theophyline
- Steroid inhalers
What is the significance of Beta agonist and muscarinic antagonist
Can be short acting or long acting
Hence can be used for rescue therapy or maintenance therapy
Give examples of SABA and LABA
short acting and long acting Beta agonist
SABA- SALBUTAMOL (Ventolin)
LABA:
- Formoterol
- Salmeterol (Serevent)
Give examples of SAMA and LAMA
SAMA- Ipratropium bromide (ATROVENT)
LAMA
- tiortropium (SPIRIVA)
- Glycopyrronium
What are examples of inhaled Corticosteroids that can be used alone in treatment
what is it’s significance
Beclometasone and flucticasone (Flixotide )
THEY CANNOT BE USED IN TREATMENT OF COPD
Give an example of an ICS that can be used in combination with an inhaled bronchodilator
e.g. with LABA
Fluticasone + Vilaterol; this together makes RELVAR
What are the combinations of drugs in a single inhaler
SABA + SAMA
LABA + LAMA
LABA + ICS
LABA + LAMA + ICS
What is pitting oedema
Right side of the heart isn’t working and hence there’s a collection of blood i systemic circulation
Do smokers say in a consultation that they cough ?
No, they dont notice the coughing as it’s not a problem to them
What causes chest pain?
is it present in COPD
Irritation of pleura (it’s sensitive)
Heart or lung problem (pulmonary embolism) can present as chest pain
COPD doesnt cause chest pain
What questions do you ask to hone down differential diagnosis
- Any chest pain
- Infection?
- Coughing?
- is it worse when lying down?- HEART problem will cause back log of blood in the lungs. This is worse when lying down as theyre’s no gravity to help
What are the fundamentals of COPD care?
- Offer treatment and support to stop smoking
- Offer pneumococcal and influenza vaccinations
- Offer pulmonary rehabilitation if indicated
- Co-develop a personalised self-management plan
- Optimise treatment for co-morbidities
N.B. These treatments and plans should be revisited at every review
What are the criteria for starting inhaled therapy
- All the above interventions have been offered (if appropriate), and
- Inhaled therapies are needed to relieve breathlessness and exercise limitation, and
- People have been trained to use inhalers and can demonstrate satisfactory technique
Review medication and assess inhaler technique and adherence regularly for all inhaled therapies. THEN OFFER SABA OR SAMA to use as needed
What are the pathways for treatment if the person is limited by symptoms or has excerbations despite treametment with SABA or SAMA
draw flowchart
It depends whether the person has asthmatic features/features suggesting steroid responsive OR NOT
What are the different substances/objects that can help you stop smoking . When are they most effective
- Nicotine Replacement therapy
- Vareniciline
- E cigarettes
- Buproprion
Most effective when used alongside NHS stop smoking services
How does Vareniciline (Champix) work?
In 2 ways
- Reduce cravings for nicotine like NRT
- Also blocks the rewarding and reinforcing effects of smoking
its the most effective medicine for helping people stop smoking
How can you get and use Vareniciline (champix)
Only on prescription: form GP or NHS stop smoking service
Taken as 1 to 2 tablets a day. You should start taking it a week or 2 before you try to quit
course of treatment usually lasts 12 weeks but can be longer
Who can use Vareniciline?
Safe for most EXCEPT:
- Children under 18
- women who are pregnant or breastfeeding
- people with severe kidney problems
What are the possible side effects of Vareniciline
- feeling and being sick
- difficulty sleeping (insomnia), sometimes with vivid dreams
- dry mouth
- constipation or diarrhoea
- headaches
- drowsiness
- dizziness
How does Buproprion (Zyban) work?
Not sure exactly but it is thought to have an effect on parts of brain involved in addictive behaviour
Originally used to treat depression but since has been found to help people quit smoking
Where can you get Buproprion from and how do you use it
Only form prescription : GP or NHS stop smoking service
Taken as 1 to 2 tablets a day. Start taking it a week or 2 before you try to quit.
Course of treatment usually last 7 to 9 weeks
Reassement should occur shortly after supply finishes
Who can take Buproprion?
Safe for most people EXCEPT:
- Children under 18 years of age
- women who are pregnant or breastfeeding
- people with epilepsy, bipolar disorder or eating disorder
What are the possible side effects of Buproprion
- dry mouth
- difficulty sleeping (insomnia)
- headaches
- feeling and being sick
- constipation
- difficulty concentrating
- dizziness
How does e cigarrettes work and how can you get them
Delivers nicotine in vapour. Hence can inhale nicotine without harmful effects of smoking; it doesn’t contain tar or CO
not available on prescription but it’s cheaper tan cigarrettes.
most effective with NHS stop smoking service
How does NRT work?
Gives low level of nicotine without harmful effects of smoking
it helps reduce withdrawal effects such as bad moods and cravings which may occur when you stop smoking
How can you get NRT and what are the different forms they are available in
Bought from pharmacies or shop. Can also be prescribed form Gp or NHS stop smoking service
Available as:
- skin patches
- chewing gum
- inhalators (which look like plastic cigarettes)
- tablets, oral strips and lozenges
- nasal and mouth spray
What compare the different effects of the different NRT products
Patches relases nicotine slowly . Some are worn all the time and some are to be taken off at night
Inhalators, gums and spray act more quickly and may be better to help with cravings
No evidence to show that one product is better than others but a combination of skin patches with a faster acting form (like gum/ nasal spray) is often the best way to sue NRT
Hw long does Treatment with NRT last for
8-12 weeks before you gradually reduce the dose and eventually stop
What are the possible side effects of NRT
- skin irritation when using patches
- irritation of nose, throat or eyes when using a nasal spray
- difficulty sleeping (insomnia), sometimes with vivid dreams
- an upset stomach
- dizziness
- headaches
thye are usually mild but if troublesome, contact GP
Who can use NRT?
Most people INCLUDING
- adults or children OVER 12. Although children under 18 shouldn’t use lozenges without medical advice first
- breastfeeding women
- pregnant women - only if non drug treatment have failed; ie. cant stop by their own volition.
get medical advice first if you have kidney or liver problem or you’ve recently had a heart attack or stroke
Can NRT and Vareniciline be prescribed together?
NO
also Vareniciline and Buproprion should not be prescribed together
For NRT, when should subsequent prescription be given to pregnant women
Women who have demonstrated that they are still not smoking
What are concomitant drugs
Polycyclic aromatic hydrocarbons (in tobacco) increase metabolism of some rugs by inducing hepatic enzyme, hence requiring an increase in dose
What approach should be used for smokers who are unwilling/not ready to quit smoking
Use of NRT as part of Harm reduction approach;
This includes stopping smoking whilst using NRT to prevent relapse, and smoking reduction or temporary abstinence worth or without NRT
They should be advised that NRT will make it easier to reduce how much they smoke and increase chance to stop all together
What are the withdrawal side efffects of quitting smoking
Nicotine cravings
- irritability
- depression
- estlessnes
- poor concentration
- light headed ness
- sleep disturbance
- increased appetite - lead to weight gain. Less likely to occur if they stop with smoking cessation drugs
Describe the concept of Non drug treatment
Abrupt quitting is the best chance of lasting success. Howver most effective is with drugs
referred to NHS smoking service
Describe the steps in choosing the right inhaler for the patient . Action 1
Describe the “Action 2” in choosing the right inhaler for he patient
For pMDI; what is the formulation, metering system, advantages and disadvantages
For pMDI with SPACER, what is the formulation, metering system, advantages and disadvantages
For DPI, what is the formulation, the metering system, the advantages and disadvantages of using it
For SMI (Respimat), what is he formulation, the metering system, the advantages and disadvantage of using it
What are the effects of using spacer
No NEED to time breathing in with spraying
Also you can use less medicine
reduces risk of side effects: (voice changes, oral thrush-fungal infection particularly in kids)
help with asthma attack
How do you use and maintain a spacer?
Use correct technique; shown by doctor. Thus include “tidal breathing techniques” and “single breath and hold” technique
Clean it; especially the first time using it and then once a month afterwards. Clean according to manufacturer spec. A clean spacer gives you full benefits of medicine.
