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CSI > COPD > Flashcards

COPD Flashcards

1
Q

What are the 4 MAIN causes of Breathlessness

A
  • 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

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2
Q

Can all conditions that cause long term breathlessness be treated?

A

Some can, but some cannot be fully reversed

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3
Q

What are the different ways in which lung conditions can cause breathlessness?

A

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

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4
Q

What are examples of lung conditions that cause long term breathlessness

A
  • COPD
  • asthma
  • interstitial lung disease including pulmonary fibrosis
  • bronchiectasis
  • lung cancer
  • industrial or occupational lung diseases such as asbestosis - caused by asbestos
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5
Q

What are examples of lung conditions that causes acute short term breathlessness

A
  • 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
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6
Q

Why do people experience long term breathlessness due to heart failure

A

This is due to problems with the rhythm, valves or cardiac muscles of the heart

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7
Q

How can heart failure cause breathlessness

A

Heart cant pump blood to meet demand due to exercise

lungs becomes congested and filled with fluid

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8
Q

Why is breathlessness often worse when lying flat

A

Heart failure can be worse at night or when asleep

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9
Q

What are examples of heart conditions that cause acute breathlessness

A
  • Heart attack
  • abnormal heart rhythm; may feel heart miss a beat or feel palpitations
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10
Q

Why do people feel short of breath when they’re anxious or afraid

A

Normal response as body thinks it’s a stressful situation and body is preparing for action

you breathe faster and tense your breathing muscles

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11
Q

Describe how levels of fitness affect breathing

A

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

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12
Q

How does having an unhealthy weight make you feel breathless

A

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

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13
Q

Wat can people who are severely overweight develop?

A

Hypoventilation syndrome- this is when poor breathing leads to lower oxygens levels and higher CO2 levels in blood

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14
Q

What are the OTHER reasons for long term breathlessness

A
  • 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
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15
Q

What is a panic attack

A

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

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16
Q

What do people who have panic attack feel (symptoms)?

A
  • Can’t breathe- very frightening
  • have a pounding heart
  • sweat
  • feel sick
  • have shaky limbs
  • feel you’re not connected to your body
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17
Q

What symptoms are very similar to anxiety

A
  • Breathlessness
  • tightness in chest
  • getting tired easily
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18
Q

How can physical health impact mental Health in terms of anxiety

A

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

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19
Q

Why is it better to bring someone with you to the doctors if you’re worried about breathlessness

A

You may not be breathless at the time of consultation. The person can help describe the sympotoms to the doctor better

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20
Q

What will a doctor show you to help you describe your breathlessness

A

MRC BREATHLESSNESS SCALE

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21
Q

What does the MRC breathlessness scale does or doesnt recognise?

A

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

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22
Q

Outline the MRC breathlessness scale in terms of grade

A
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23
Q

During the consultation, what is also important to tell your doctor

A
  • 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.

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24
Q

What questions will my doctor ask?

A
  • 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?
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25
Q

What are the likely test that a doctor will perform to diagnose what’s causing breathlessness

A
  • 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
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26
Q

If the doctor spots that you’re anxious or depressed during the consultation, what may they ask you to do?

A

To complete a short questionnaire

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27
Q

What FURTHER tests may you be referred for

A
  • 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
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28
Q

How long does it take to get a diagnosis

A

Takes some time- variable

they may be repeated tests and various treatments be tried before cause is identified

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29
Q

When should investigations be arranges to identify or confirm underlying cause of breathlessness

A

No indication for emergency admission

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30
Q

When diagnosis cannot be confidently identified by clinical features ALONE what initial investigation should you do?

A
  • 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
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31
Q

If initial investigations do not identify with cause of breathlessness what should you do?

A

Reassess for risks factors and clinical features of pulmonary embolism, if this is suspected, arrange urgent referral for further investigations

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32
Q

If there’s suspected asthma or COPD, what should you do and what results confirm airway obstruction

A

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

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33
Q

What are the clinical features of distinguishing asthma from COPD

A
  • 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
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34
Q

What should you consider if asthma and COPD CANNOT be distinguished by clinical features alone

A
  • 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

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35
Q

Once confirmed it;s COPD, what should you arrange for people with this?

A

Arrange chest radiography to exclude other serious lung pathology such as lung cancer

FBC- to identify anaemia or polycythaemia

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36
Q

What should you do if there’s suspected heart failure

A
  • 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
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37
Q

What should you do if theire’s suspected bronchiectaisis

A
  • Arrange chest radiography- to exclude other symptoms
  • refer to respiratory specialist fpr confirmation of diagnosis by High resolution CT
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38
Q

What should you do if there’s suspected abdominal splinting secondary to ascites

A
  • 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
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39
Q

What should you do is there’s suspected lung/pleural cancer

A

Urgent chest X-ray should be performed (WITHIN 2 WEEKS); but it depends on specific patients and their conditions

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40
Q

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

A
  • If they have ever smoked
  • exposed to asbestos
  • have the following unexplained symptoms like: cough, fatigue, chest pain, weight loss and appetite loss
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41
Q

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

A
  • Persistent/ recurrent chest infection
  • finger clubbing
  • supraclavicular lymphadenopathy or persistent cervical lympahdenopathy
  • Chest signs consistent with lung cancer or pleural disease
  • Thrombocytosis
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42
Q

What are the history presenting complaints showed by Mr Craven

A
  • 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
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43
Q

What are the respiratory differential diagnosis for shortness of breath on exertion

A
  • Asthma
  • COPD
  • Pulmonary fibrosis
  • Lung cancer
  • Pulonary embolism
  • Pneumothorax
  • Lower respiratory tract infection
  • Consolidation
44
Q

Wha are the cardiovascular/systemic differential diagnosis for shortness of breath on exertion

A
  • Congestive heart failure
  • Pulmonary oedema
  • Valvular defects
  • Acute coronary syndrome
  • Anaemia
  • Renal/liver failure
  • Deconditioning
45
Q

What are the physical examinations you need to do to hone down the diagnosis

A
  • 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
46
Q

What investigations may you want to perform on Mr Craven

A
  • Chest X ray
  • ECG
  • Blood test
  • Spirometry
  • Thyroid function test
47
Q

Look at Mr Craven’s spirometry results:

what defect does he have.

justify it extensively

A
48
Q

Describe an Obstrucitve lung defect

A

Airways are affected; they are narrow

CANNOT GET ENOUGH AIR OUT

49
Q

Give examples of obstructive lung defects

A
  • COPD
  • Asthma
  • Tumours in lungs
  • Chronic bronchitis
  • Emphysema
50
Q

Describe Restrictive lung disease

A

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

51
Q

Give examples of disease that causes restrictive lung defects

A

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

52
Q

What diseases is COPD made up of

A

Bronchitis and Emphysema

Some people have both or predominantly (not exclusively) one

53
Q

What is the pathophysiology of bronchitis (COPD)

A

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

54
Q

Explain the pahtophysiology of emphysema (COPD)

A

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

55
Q

What is the criteria for diagnosis of bronchitis

A

3 months coughing period for CONSECUTIVE 2 YEARS (i.e. 6month in total)

56
Q

Look at Mr Craven X ray result

what can you conclude

A
  • Flattened diaphragm
  • Heart is smaller and elongated
  • Gas bubbles is elongated
57
Q

One of the signs on CXR is hyperinflation of lungs- how can you discern that on a chest XRay

A
  • 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
58
Q

What are bullae

How can this be caused?

A

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
59
Q

How can you discern Bullae on a CXR

A

Area of low density- BLACKER

May be outlined resembling bubbles

60
Q

What are the ways to help those with COPD to cope to improve quality of life (prognosis of disease )

A
  • 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
61
Q

What are the nutritional ways of helping those with COPD

A

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
62
Q

What are the main categorises of inhaled medications for COPD

A
  • Inhaled Bronchodilators -Muscarinic ANTAGONIST & Beta 2 adrenoceptor AGONIST
  • Anticholinergic- aclidiniune to opppose resting bronchoconstriction
  • theophyline
  • Steroid inhalers
63
Q

What is the significance of Beta agonist and muscarinic antagonist

A

Can be short acting or long acting

Hence can be used for rescue therapy or maintenance therapy

64
Q

Give examples of SABA and LABA

short acting and long acting Beta agonist

A

SABA- SALBUTAMOL (Ventolin)

LABA:

  • Formoterol
  • Salmeterol (Serevent)
65
Q

Give examples of SAMA and LAMA

A

SAMA- Ipratropium bromide (ATROVENT)

LAMA

  • tiortropium (SPIRIVA)
  • Glycopyrronium
66
Q

What are examples of inhaled Corticosteroids that can be used alone in treatment

what is it’s significance

A

Beclometasone and flucticasone (Flixotide )

THEY CANNOT BE USED IN TREATMENT OF COPD

67
Q

Give an example of an ICS that can be used in combination with an inhaled bronchodilator

e.g. with LABA

A

Fluticasone + Vilaterol; this together makes RELVAR

68
Q

What are the combinations of drugs in a single inhaler

A

SABA + SAMA

LABA + LAMA

LABA + ICS

LABA + LAMA + ICS

69
Q

What is pitting oedema

A

Right side of the heart isn’t working and hence there’s a collection of blood i systemic circulation

70
Q

Do smokers say in a consultation that they cough ?

A

No, they dont notice the coughing as it’s not a problem to them

71
Q

What causes chest pain?

is it present in COPD

A

Irritation of pleura (it’s sensitive)

Heart or lung problem (pulmonary embolism) can present as chest pain

COPD doesnt cause chest pain

72
Q

What questions do you ask to hone down differential diagnosis

A
  • 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
73
Q

What are the fundamentals of COPD care?

A
  • 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

74
Q

What are the criteria for starting inhaled therapy

A
  • 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

75
Q

What are the pathways for treatment if the person is limited by symptoms or has excerbations despite treametment with SABA or SAMA

draw flowchart

A

It depends whether the person has asthmatic features/features suggesting steroid responsive OR NOT

76
Q

What are the different substances/objects that can help you stop smoking . When are they most effective

A
  • Nicotine Replacement therapy
  • Vareniciline
  • E cigarettes
  • Buproprion

Most effective when used alongside NHS stop smoking services

77
Q

How does Vareniciline (Champix) work?

A

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

78
Q

How can you get and use Vareniciline (champix)

A

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

79
Q

Who can use Vareniciline?

A

Safe for most EXCEPT:

  • Children under 18
  • women who are pregnant or breastfeeding
  • people with severe kidney problems
80
Q

What are the possible side effects of Vareniciline

A
  • feeling and being sick
  • difficulty sleeping (insomnia), sometimes with vivid dreams
  • dry mouth
  • constipation or diarrhoea
  • headaches
  • drowsiness
  • dizziness
81
Q

How does Buproprion (Zyban) work?

A

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

82
Q

Where can you get Buproprion from and how do you use it

A

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

83
Q

Who can take Buproprion?

A

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
84
Q

What are the possible side effects of Buproprion

A
  • dry mouth
  • difficulty sleeping (insomnia)
  • headaches
  • feeling and being sick
  • constipation
  • difficulty concentrating
  • dizziness
85
Q

How does e cigarrettes work and how can you get them

A

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

86
Q

How does NRT work?

A

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

87
Q

How can you get NRT and what are the different forms they are available in

A

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
88
Q

What compare the different effects of the different NRT products

A

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

89
Q

Hw long does Treatment with NRT last for

A

8-12 weeks before you gradually reduce the dose and eventually stop

90
Q

What are the possible side effects of NRT

A
  • 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

91
Q

Who can use NRT?

A

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

92
Q

Can NRT and Vareniciline be prescribed together?

A

NO

also Vareniciline and Buproprion should not be prescribed together

93
Q

For NRT, when should subsequent prescription be given to pregnant women

A

Women who have demonstrated that they are still not smoking

94
Q

What are concomitant drugs

A

Polycyclic aromatic hydrocarbons (in tobacco) increase metabolism of some rugs by inducing hepatic enzyme, hence requiring an increase in dose

95
Q

What approach should be used for smokers who are unwilling/not ready to quit smoking

A

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

96
Q

What are the withdrawal side efffects of quitting smoking

A

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
97
Q

Describe the concept of Non drug treatment

A

Abrupt quitting is the best chance of lasting success. Howver most effective is with drugs

referred to NHS smoking service

98
Q

Describe the steps in choosing the right inhaler for the patient . Action 1

A
99
Q

Describe the “Action 2” in choosing the right inhaler for he patient

A
100
Q

For pMDI; what is the formulation, metering system, advantages and disadvantages

A
101
Q

For pMDI with SPACER, what is the formulation, metering system, advantages and disadvantages

A
102
Q

For DPI, what is the formulation, the metering system, the advantages and disadvantages of using it

A
103
Q

For SMI (Respimat), what is he formulation, the metering system, the advantages and disadvantage of using it

A
104
Q

What are the effects of using spacer

A

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

105
Q

How do you use and maintain a spacer?

A

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.

CSI (17 decks)

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