COPD Flashcards
What are the main chronic conditions associated with breathlessness?
COPD
Asthma
Interstitial lung disease (Pulmonary fibrosis)
Bronchiectasis
Industrial or occupational lung diseases (asbetosis)
Lung cancer
What is asbestosis?
Chronic exposure to asbestos
What are the main causes of breathlessness?
Airways become inflamed and narrowed
Mucous plug, reduces cilia beating efficacy
Reduction in elasticity
What are the main acute conditions that cause breathlessness?
Flare up of asthma or COPD
Pulmonary embolism/clot in lungs
Pneumothorax/Collapsed lung
Accumulation of fluid of pleural cavity (heart failure), pleural effusion
What is dyspnoea?
breathlessness
What is orthopnea?
Breathlessness when lying flat
Why does heart failure contribute to dyspnoea?
Reduction in stroke volume due to inefficient contractile and diastolic time causes increased volume of blood in pulmonary capillaries –> accumulation of fluid within the pleural space
Why does orthopnea occur?
Systemic blood is redistributed, increasing volume present in the pulmonary capillaries
Reduction in respiratory rate when in sedentary position
Reduction in cardiac output due to decline in adrenaline.
Added pressure onto lungs due to increased fluid accumulation
Which cardiovascular/systemic conditions cause breathlessness?
Congestive heart failure Pulmonary oedema Valvular defects Acute coronary syndrome Anaemia
What happens during hyperventilation?
Smooth airway muscles and intercostal muscles become tense
Why does a panic attack result in breathlessness?
Exaggerated and accelerated build up of physical responses.
Respiratory rate increases
Adrenaline and cortisol is released
What are the symptoms of anxiety?
Syncope, sweating, vomiting, pounding heart, shaky limbs.
Why does obesity increase breathlessness?
Intercostal muscles weaken, weak muscles have a greater respiratory demand, requiring more oxygen to perform.
Increased effort to expire and be mobile.
Additional weight around abdomen and chest, restricts lung movement
Which BMI score is associated with obesity?
25+
What condition occurs due to obesity derived breathlessness?
Obesity hypoventilation
What is obesity hypoventilation?
Poor breathing contributes to reduced oxygen levels, and elevated carbon dioxide concentrations in blood.
What is grade 1 on the degree of breathlessness?
Not troubled by breathlessness except on strenuous exercise
Short of breath when hurrying on the level of walking up a slight hill
Grade 2
Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace
grade 3
What is grade four on the degree of breathlessness?
Stops for breath after walking about 100 yards or after a few minutes on level ground
What is grade five on the degree of breathlessness?
Too breathless to leave the house, breathless when undressing
What clinical investigations are performed to investigate FEV1 and FVC?
Breathing and lung function tests using a spirometer
How can the breathing rate be measured?
Number of breaths per minute
Auscultate and palpate the chest during breathing
Why should heart rate and rhythm be examined for patients presenting breathlessness?
To identify heart failures and the accumulation of fluid within the pleural cavities
What clinical examinations are performed for patients presenting breathlessness?
Monitor temperature Measure, weight, waist, height, BMI Examine the head, neck, armpits, and identify swollen lymph glands for signs of pathology Percussion Auscultation Palpate
What does crackling indicate during auscultation?
Pulmonary fibrosis
How is blood saturation monitored?
Pulse oximeter
Why is smoking a considerable factor?
Susceptibility to lung cancer, emphysema, COPD and CVD
Why should a chest radiography be performed?
Identify signs for heart failure, and pulmonary pathology (pleural effusion)
Why should an ECG be performed?
Signs of heart failure, arrhythmia, and pulmonary embolism
Why should spirometry be performed?
Signs of obstructive or restrictive patterns associated with interstitial lung disease
Why should a full blood count be performed?
Check for anaemia
Why should urea and electrolytes + random blood glucose be measured?
Test for renal failure and diabetes (Metabolic acidosis and breathlessness)
Why is a thyroid function test conducted?
Detect thyroid disease
What factors are measured to assess heart failure for patients without history of myocardial infarction?
BNP
NTproBNP
When should a chest radiography and referral to respiratory specialist occur?
Patients with suspected bronchiectasis
Define FEV1:
Forced expiratory volume in the first second
The volume of air that is expelled from the lungs within one second
Which parameters are compared during measurement of FEV1/FVC`?
Height, gender and age
What is the average deviation for FEV1?
80-120%
How are the FEV1 values impacted by an obstructive disorder?
Reduction
Obstruction to airflow, reduces the rate of air being transmitted across the bronchioles and expired
What is FVC?
Forced vital capacity
The volume of air that can be forcibly expelled from the lungs after complete inspiration (L)
What is the average FEV1/FVC ratio?
70-80% (Declines with age)
How is the FEV1/FVC ratio influenced in obstructive conditions?
Diminished due to increased airway resistance (FEV1), FVC is minimally reduced, therefore fev1 is significantly effected, resulting in a reduced ratio
What is the average range for COPD for FEV1/FVC ratio?
less than 80%-45%
How is the FEV1/FVC ratio impacted in restrictive conditions?
FEV1 and FVC both reduced proportionally, therefore the value may be normal or increased due to decreased lung compliance
What factors reduces FVC?
Cancer, emphysema, pneumonia, fibrosis, muscular dystrophy, cystic fibrosis and scoliosis
What two conditions are classified under COPD?
Emphysema and chronic bronchitis
What clinically defines chronic bronchitis?
Productive cough for greater than 3 months annually
2+ consecutive years
Which cells are responsible for hypersecretion of mucous?
Goblet cells
By what mechanism does mucous hypersecretion via submucosal glands and goblet cells?
Hypertrophy
Hyperplasia
What causes the sensory activation of mucous secretin?
Pollutants
Cilia
Tobacco smoke
Which factor produced by epithelial cells activates fibroblasts?
TGF-B
Which factor is secreted by macrophages to recruit further macrophages?
MCP-1
Which chemotactic factors cause neutrophil activation?
CXCL8 (IL-8)
LTB4
Which type of proteases are released by neutrophils?
Neutrophil elastase and metalloproteinase
How does neutrophil elastase impact COPD?
Causes alveolar detachment , subsequently reducing the elasticity of the bronchioles and the capacity to be held open.
lumen of the bronchioles are therefore reduced, obstructing inspiratory and expiratory airflow.
Why does mucous hypersecretion exhibit a problem?
Formation of mucous plug within the lumen of bronchioles, reduces cilia beating efficacy
Difficulty to remove bacteria, increases risk of infection
What is the pathophysiology of emphysema?
Disrupted balance between elastase and anti-elastase, increased elastase activation rustles in increased elastin hydrolysis within the alveolar wall, and respiratory bronchioles. Reduces elastic recall, latency to be maintained during exhalation is lost = airway collapse
Which diameter of the chest increases due to hyperinflation, and increased residual air?
Anterior-posterior diameter
How can hyperinflation be identified upon examination?
Hyperessonance during percussion
Which volumes increase due to COPD (Lung function)?
Total lung capacity
Residual volume
Which capacities are reduced in COPD?
Inspiratory and expiratory
Why does cyanosis suggest COPD?
Chronic hypoexmia causes pulmonary vessel constriction, hypoxic vasoconstriction leads to pulmonary hypertension.
Increases afterlaod on right ventricle, difficulty to eject volume, causes jugular venous distension,
Cyanosis
Which FEV/FVC ratio is indicative of COPD?
Less than 70%
What effect does bronchodilators have on PFT results?
Less than 12% change in FEV1 =COPD
Greater = asthma
Why should A1AT screening be conducted?
Patients under age 45
No associated risk (no smoking or occupational dust exposure)
A1AT deficiency (autosomal dominant disorder)
What is A1AT deficiency?
Inhibition of A1AT transportation from liver, therefore there is a deficiency in lungs, and elastase accumulates to damage parenchyma
What X-ray features depict COPD?
Hyperinflated lungs
Anterior 7 ribs form mid-clavicular line visible
Diaphgramn is flattened
Heart visually smaller and narrower, air visible below inferior border
Bullae
What are bullae?
Pockets of air, forming near the surface of the lung, bull can be enlarged (greater than 1cm), occupying significant space within the lung.
How are bullae depicted on a radiograph?
Relatively darker patches on radiograph,
What are blebs?
Small bullae
What occurs due to ruptured bullae?
Causes air to escape and lung collapse = spontaneous pneumonthorax
What are the symptoms of pneumothorax?
Sharp chest pain and increased breathing difficulties
What are B2 adrenergic receptors?
Sympathetic innervation stimulates bronchodilation
Adrenaline
Agonists
What are muscarinic acetylcholine receptors?
Parasympathetic innervation stimulates bronchoconstriction, thus anatagonists used
If there are no asthmatic features presented, what medication should be used?
LABA & LAMA combined therapy for additive benefit
What is rescue therapy?
SABAs, and SAMAs
What is maintenance therapy?
LABAs and LAMAs
Why is maintenance therapy used?
Symptom frequency increased despite use of short acting attend , FEV1 less than 60%
What drug treatments are used for COPD?
Antibiotics, Muscalytics, anti-inflammatory and antiproteases
anti oxidants
Why are vaccination programmes and antibiotics used?
accumulation of mucous within bronchioles due to mucous hypersecretion in addition to ineffective cilia beating, increases risk of infection
Vaccination (PPSV-23)
If there are asthamtic features, what medication to prescribe?
LABA ICs
When do you use a DPI?
Patient can perform quick and deep
What is a dpi?
Dry powder inhaler
If the patient can breathe slow and steady?
SMI or PDMI
What is an SMI?
Soft miss inhaler
What is PDMI?
Pressurised metered dose inhaler
If you have not used SMI in 3 months?
3 times priming
What do you do if inhale steroids?
Rinse mouth with water
What are the advantages of spacer?
Increases medication to the lung, reduces dosage
Faster medication to lungs
Less is absorbed by body, thus minimal side effects
What are the two techniques for spacers?
Tidal volume (Multiple breathing) Single breathing (Hold)
What effects of bupaprion hydrochloride?
Apatite changes, dizzieness
Effects of NRTs?
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
What are the side effects for Varenicyline?
feeling and being sick difficulty sleeping (insomnia), sometimes with vivid dreams dry mouth constipation or diarrhoea headaches drowsiness dizziness
Who cannot use bupoprion hydrochloride?
children under 18 years of age
women who are pregnant or breastfeeding
people with epilepsy, bipolar disorder or eating disorders
Who cannot use varenicline?
children under 18 years of age
women who are pregnant or breastfeeding
people with severe kidney problems
Hows does Varenicline affect smoking cessation?
Reduces cravings for nicotine
Inhibits reward pathway
What are the examples of the NHS stop smoking services?
Advice, drug treatment, and behavioural support
What is the most effective method of smoking cessation?
Abrupt quitting
What are the five fundamentals of COPD care?
Support to stop smoking Pneumoccocal and influenza vaccination Offer pulmonary rehabilitation Co develop a personalised self management pan Optimise treatment for comorbdities
If COPD has impact on quality of life?
ICS, lama AND LABA
What influences the choice for Varenicline and bupropion hydrochloride?
Adherence, preferences, and previous expereicen of smoking cessation aids
What are the examples of long acting NRT?
Transdermnal patch
What are the examples of a short acting NRT?
Lozenges, gum, sublingual tablets, oral sprays, inhalators, nasal sprays
If a patient expresses nicotine cravings how long should the transdermal patch be on for?
24 hours
How long should a transdermal patch be used for?
16 hours
What is the minimum duration of treatment for NRT post-quitting?
2 weeks after quitting date,
What is the harm reduction approach?
Smoking cessation using NRT, prevents relapse, and smoking reduction or temporary abstinence with or without
What are the advantages of E cigarettes in comparison to smoking?
no toxins being delivered, however nicotine still used
What powder is used for DPI?
Lactose
What is the formulation of SMI?
Aqueous solution
What is the metering system of a PMDI?
Metering valve and reservoir
When should a chest X-ray be done for patients with suspect pleural or lung cancer?
Ever smoked
exposed to asbestors
Cough, fatigue, chest pain, weight loss, appetite
performed within 2 weeks
What are ascites?
Abnormal buildup of fluid in the abdomen
What to do during urgent chest x-ray?
Finger clubbing
recurrent chest infections
Supraclavicaular lymphadenopathy
Chest signs
How long have you had these symptoms?
Chronic could be asthma, COPD, pulmonary fibrosis,
Acute: Pneumothorax
Are you waking up at night?
Heart failure.Lying down causes orthopnea, dud to redistribution of blood, increasing pressure on the pleural cavities.
Are you having chest pain?
Heart attacks, and angina
Pneumothorax,
Pulmonary embolism
Pneumonia
