COPD Flashcards
What does COPD stand for?
Chronic obstructive pulmonary disease
What is COPD?
Chronic, slowly progressive disorder characterised by airflow obstruction that does not change markedly over several months
Which gender gets COPD?
Male
Causes of COPD
Smoking (85%) Chronic asthma Passive smoking Maternal smoking Air pollution Occupation (15-20%)
Examples of occupations causing COPD
Coal mining Hard rock mining Tunnel working Concrete manufacturing Construction Farming Foundry working Plastics Textiles Rubber Leather
What does a1-antitrypsin do?
Neutralises enzymes released by neutrophils
Genotypes of a1-antitrypsin deficiency
Normal genotype - PiMM (86%)
Troublesome genotype PiZZ (10-20%)
What can happen in a1-antitrypsin deficiency?
Bad emphysema can develop very quickly as nothing to neutralise the neutrophils
People tend to develop COPD at younger age
What is the most important cause of COPD?
Smoking
What % of smokers develop significant COPD?
20%
When would COPD tend to develop in non smokers?
Asthma
a1-antitrypsin
What is 1 pack year?
1 pack a day for a year
How many pack years does it usually take to develop COPD?
20 pack years
What is COPD defined by?
Airflow obstruction
Pathology of COPD
Luminal obstruction due to small airway narrowing and can be worsened by inflammation and mucus, leading to progressive breathlessness on exertion, along with coughing and wheezing
Breakage of alveolar cell membranes
What is a prime feature of COPD?
Mucus secretion
What is chronic bronchitis?
Sputum produced every day for at least 2 years
What is ACOS?
Asthma/COPD overlap syndrome
What conditions overlap to make up COPD?
Chronic bronchitis
Emphysema
Type of airflow obstruction in asthma
Reversible
Type of airflow obstruction in COPD
Fixed airflow obstruction
Presentation of COPD
SOB - gradual onset - little variation - progressively getting worse Cough - long history of 'smokers cough' - clear of mucoid sputum Wheeze - typically on exertion Progressive difficulty in performing ADLs Weight loss (severe disease,
Typical COPD patient
Patient >40+ years
Smoker / ex smoker
SOB on exertion
Cough
Differential diagnosis of COPD
Asthma Lung cancer LVF Fibrosing alveolitis Bronchiectasis TB Recurrent PE
If the patient has symptoms of COPD with haemoptysis, what conditions must be looked into?
Lung cancer
TB
Bronchiectasis
Examples of causes of peripheral oedema
Cor pulmonale
Severe disease
Respiratory failure
Signs of COPD
SOB walking into clinic, undressing Pursed lips Accessory muscles Cyanosis CO2 flap, tremor (B-agonists) Effects of steroids Hyperexpanded (barrel) chest Decreased expansion Less than 3 finger spaces between manubrium and larynx Laryngeal descent Paradoxical movement of ribs and abdomen Decrease in cardiac dullness to percussion Decreased breath sounds Prolonged expiration with wheeze Palpable liver Cor pulmonale
Why does pursed lips help in COPD?
Generates a bit more of a positive pressure which causes the airways to open up a bit more
Signs of steroid use
Thin skin
Bruising
Cushingoid
Do crackles occur in COPD?
NO
Signs of cor pulmonale
Increased JVP
Hepatomegaly
Ascites
Oedema
What are acute exacerbations of COPD caused by?
Viral/bacterial infection
Causes of acute exacerbation of COPD
Viral/bacterial infection
Sedative drugs
Pneumothorax
Trauma
Symptoms of acute exacerbation of COPD
Increased cough Increased sputum Increased SOB increased wheeze Unable to sleep Increased oedema, confusion, drowsiness
Investigations for acute exacerbations of COPD
CXR Blood gases FBC U and Es Sputum culture
What does spirometry rule out if the FEV1 is normal?
COPD
What is a normal FEV1?
> 80% predicted
What spirometry result would be abnormal?
FEV1 < 80% predicted with FEV1/FVC ratio < 70%
What is emphysema?
Damaged alveoli and so reduced gas transfer
In asthma, is the gas transfer affected?
No
How is fixed airflow obstruction demonstrated by spirometry?
Minimal bronchodilator reversibility
- Baseline, 15 mins post neb 2.5-5mg salbutamol, baseline 30 mins post neb 2.5-5mg salbutamol + 500ug ipratropium
Minimal response to oral corticosteriods
- 30 - 40mg prednisolone daily for 2 weeks
- measure baseline and final FEV1
What would a significant bronchodilator/steroid response suggest?
Asthma/asthmatic component
What bronchodilator response would be consistent with COPD?
Insignificant bronchodilator / steroid response
Investigations for COPD
Spirometry Full pulmonary testing - Lung volumes - carbon monoxide gas transfer CXR ECG Blood gases FBC ECG Sputum sample
What may be seen on a CXR in COPD?
Hyperinflated lung fields (>10 posterior ribs)
Flattened diaphragms
Lucent lung fields
Bullae
Decreased PaO2 on blood gas indicates what?
Type 1 respiratory failure
Decreased Pa02 and increased PaCO2 indicates what?
Type 2 respiratory failure
What would be seen on a FBC in COPD?
Secondary polycythaemia (hct > 0.52)
What may be seen on an ECG in COPD?
Right axis deviation
P pulmonale
T wave insertion
Inflammation type in COPD
Neutrophilic
How to prevent disease progression in COPD?
Smoking cessation
How to relieve breathlessness in COPD?
Inhalers
How to prevent exacerbations of COPD?
Inhalers
Vaccines
Pulmonary rehabilitation
How to manage complications of COPD
Long term oxygen therapy
Non pharmacological management of COPD
Smoking cessation Vaccines (flu, pneumococcal) Pulmonary rehabilitation Nutritional assessment Psychological support
Inhaled therapy for COPD
Short acting bronchodilators - SABA (Salbutamol) - SAMA (ipratropium) Long term bronchodilators - LAMA - LABA High dose ICS and LABA - relvar - fostair
As there is more symptoms/exacerbations - staging of T for COPD
- SABA
- LAMA or LABA
- Further bronchodilator (LAMA and LABA)
- Triple therapy (ICS, LAMA, LABA)
What does LTOT stand for?
Long term oxygen therapy
What Pa02 should LTOT be used at?
< 7.3 kPa
- 3 - 8 kPa if
- polycythaemia
- nocturnal hypoxia
- peripheral oedema
- Pulmonary HTN
Presentation of COPD exacerbation
Increasing SOB Cough Sputum volume Sputum purulence Wheeze Chest tightness
Management of acute exacerbation of COPD
SABA
Steroids
- prednisolone 40mg per day for 5 - 7 days
Antibiotics (if evidence of infection)
When should hospital admission be considered if unwell?
Tachypnoea
Low oxygen sats (<90-92%)
Hypotension etc
Ward based management of acute exacerbation of COPD
Oxygen target sats 88 - 92%
Nebulised bronchodilators
Corticosteriods
Antibiotics
How can evidence of bronchodilators be assessed/
Clinical
ABG
What should be done in acute respiratory failure?
Non invasive ventilation (NIV)
Management of COPD
Nebulised bronchodilator B2 and antimuscarinic O2 oral / IV corticosteriods Antibiotics Diuretic IV aminophylline Respiratory stimulant NIV
An organism causing pneumoniae in a COPD patient is most likely to be what?
Haemophilus influenzae
Treatment for COPD (steps)
1st line
- SABA or SAMA
Next step is determined to do with whether there is asthmatic features/responsiveness
No asthmatic features
2. Add LABA or LAMA. Also if already taking a SAMA, switch to a SABA
Asthmatic features / responsiveness
2. LABA + ICS
3. Triple therapy i.e. LAMA + LABA + ICS. If already taking a SAMA, switch to a SABA
What NICE criteria would suggest that a patient has asthmatic features/responsiveness in COPD?
Any previous secure diagnosis of asthma or atopy
A higher eosinophil blood count
Substantial variation in FEV1 over time (at least 400ml)
Substantial diurnal variation in PEFR (at least 20%)
What prophylaxis may be done in select patients with COPD?
Azithromycin
Monitoring of azithromycin
LFTs
ECG to exclude QT prolongation
Who with COPD should be considered to get mucolytics?
Chronic productive cough and continued if symptoms improve
Treatment of cor pulmonale
Loop diuretic
Oxygen long term
What vaccinations should a COPD patient get?
Annual flu
One off pneumococcal
What pH does NIV show most benefit?
7.25 - 7.35
What pH should invasive ventilation be carried out?
< 7.25
What can large bullae in COPD mimic?
A pneumothorax
What is the severity of COPD judged by?
FEV1
1st line antibiotics for an infective exacerbation of COPD
Amoxicillin or clarithromycin or doxycycline
In alpha-1-antitrypsin deficiency, where is empysema more prominent in the lungs and how does this compare to in COPD?
Lower lobes in A1ATD
Upper lobes in COPD
1st line pharmacological management of COPD
SABA or SAMA
What criteria should be used to determine if patients having an exacerbation of COPD should require antibiotics?
Those with purulent sputum or clinical signs of pneumonia
From the NICE guidelines, it is recommended that patients who have had frequent exacerbations of their COPD should be given what?
A home supply of prednisolone and antibiotics
