COPD Flashcards
What is COPD? [3]
Long term deterioration
Bronchitis - obstruction
Emphysema - hyperinflation
What is bronchitis?
What are the pathological changes you can see? [4]
Any changes on CXR?
- Presence of productive cough for 3 months
- Mucous gland hypertrophy = repeated infection
- Increased goblet cells
- Inflammation + fibrosis
- Obstruction due to airway and alveoli damage
- Normal CXR just inflammation
Emphysema pathophysiology [5]
- Inflammation causes increase in size of airspaces due to dilation and destruction of walls
- Leads to collapse and trapped air = hyperinflation
- Lung tissue for gas exchange destroyed
- Increased compliance
- Decreased recoil so expiration difficult
How do each of the 3 main risk factors of COPD lead to lung inflammation?
Smoking
Environment - smoking / pollution / infection
Leads to free radicals
Anti-protease inactivated
Genetics (a1-AT deficiency)
Lungs unable to prevent damage
Leads to inflammation -increased cytokines, protease and oxidative stress
How is A1AT deficiency inherited?
A1AT pathogenesis
AR
A1AT protects cells from damage so if deficient cannot protect from damage
A1AT pathophysiology, clinical manifestations [4]
Mx [3]
Emphysema LL Cirrhosis and HCC Cholestasis in children Think in young person with COPD /asthma Sx refractory to Rx Mx: - as for COPD - IV A1AT protein concentrations - lung volume reduction surgery, lung transplant
Smoking in pathogenesis of COPD [2]
Increases neutrophils and proteases which cause lung damage
Inactivate anti-proteases
What are the symptoms of COPD [6]
What happens in severe disease [2]
SOB Rapid shallow breath Prolonged wheeze Chronic cough sputum Frequent winter bronchitis Minimal variation
If severe
- Resp failure
- RHF + peripheral oedema
What are findings on examination [8]
- Cachexia
- Cyanosis
- Reduced chest expansion
- Accessory muscles, tachypnoea
- Barrel chest, Hyperinflated chest
- Decreased breath sounds
- Tremor, pursed lip breathing (CO2 retention)
What are signs of respiratory failure / RHF? [5]
Cyanosis, Accessory muscles Peripheral oedema Increased JVP Ascites Palpable liver
How is severity of COPD classed? [4]
FEV1 >80% = mild
50-79 = moderate
30-49 = severe
<30 = very severe
What is needed for diagnosis of COPD? [3]
What other investigations are needed? [5]
- Partly clinical diagnosis
- Spirometry - FEV1 <70
- PEFR low with minimal reversibility
Others: CXR Serum a1AT (deficiency) ECG + ECHO (cardiac failure) BMI - for baseline FBC (anaemia or polycythaemia from chronic hypoxia)
How do you manage COPD non-pharmacology? [7]
Smoking cessation Exercise Inhaler technique Vaccine - flu + pneumococcal Pulmonary rehab to improve exercise capacity Nutrition Psychological support
Rx COPD
First and second line
- SABA or SAMA as required
2a. Asthmatic features present: LABA + ICS
2b. No asthmatic features: LABA + LAMA
What do you do in an exacerbation of COPD? [5]
Bundle
Are they a retainer? Check with ABG and use controlled O2 therapy as appropriate.
Nebulisers as regular: salbutamol 2.5-5mg and ipratropium 500 micrograms every 6 hours
Prednisolone 40-50mg for 5 days
CXR
Consider antibiotics for chest infection
VTE prophylaxis
2nd line
Aminophylline, magnesium
Referral to respiratory
Referral to ITU
COPD nurse input
Spirometry
Carbocisteine, nebulised saline
BMI weight, nutrition
What are definite indications of LTOT [5]
Requirements for LTOT [3]
Severe airflow obstruction PO2 <7.3 after bronchodilator or nocturnal hypoxaemia Oedema Pulmonary hypertension Polycythaemia
Requirements:
- Falls risk
- Burns, fire risk
- Cannot smoke on LTOT
Why should you be careful when giving O2 in COPD and what is aim?
If elevated PaCO2 (Type 2 respiratory failure) then body goes in to hypoxic drive (relies on low O2 not CO2)
Further oxygen = reduced drive and will lead to retention in CO2
pH should not be allowed to fall below <7.25
Requires artificial ventilation
Cor pulmonale pathophysiology [4]
- Hypoxic alveoli
- Vasoconstrict causing pulmonary hypertension
- Right ventricle hypertrophy
- Right sided HF
What are the signs of cor pulmonale [4]
Peripheral oedema
Raised JVP
Heave
Loud P2
How do you treat cor pulmonale [2]
Management of heart failure like furosemide etc
LTOT
What are pink puffer COPD [4]
- Increased alveolar ventilation
- Normal PaO2 and normal or low PaCO2
- SOB but no cyanosis
- Type 1 respiratory failure
What are blue puffer COPD [4]
- Deceased ventilation
- Low PaO2, High PaCO2
- No SOB but Cyanosed
- Insensitive to Co2
What are asthmatic features on top of COPD [3]
Previous Dx asthma or atopy
High blood IgE
Variation in FEV1
When should you consider a Dx [3]
> 35yo
Symptoms
Past or present smoker
What does spirometry show [4]
- PEFR reduced
- FEV1 reduced <80%
- FVC may be reduced
- Ratio <70% even post bronchodilator indicates COPD as non reversible
What does CXR show [5]
Low diaphragm Hyperinflated lungs Hyperlucent lung field Bullae / holes in the lungs Decreased lung markings
What will PFT show [2]
RV / TLC >30% due to hyperinflation
Decreased gas transfer
Prophylactic antibiotic in chronic mx of COPD [2]
5 indications
Azithromycin 250mg 3x per week
- Non-smoker
- Optimised medical mx but continue to have >1 of:
- > 4 exacerbations/year with sputum
- Prolonged exacerbation with sputum
- Exacerbations causing hospitalisation
What should you do before Azithromycin [4]
CT (bronchiectasis)
Sputum C&S to exclude atypical / TB
LFT
ECG as prolong QT
Summarise oral therapies (only to be tried after inhaled therapies have failed) [5]
Prophylactic antibiotics Theophylline Muclytic therapy Roflumilast CCS
Assessment for suitability of LTOT [2]
Assess with 2 ABG 3 weeks apart
Complications of COPD [8]
- Hypoxaemia > Resp failure
- Decreased ventilation of alveoli
- Decreased gas exchange due to loss of parenchyma - Hypercapnia
- No recoil so takes longer to expire
- Hyperinflation as air trapped - Chronic increased HCO3
- Acute exacerbation / infection
- Polycythaemia due to chronic hypoxia so kidney secrete more EPO
- Cor pulmonale
- Pneumothorax
- Lung cancer
What should you aim sats to be in COPD [3]
88-92%
94-98% if PCO2 normal
No high flow O2
What is CI in asthma / COPD
BB as bronchospasm
What improves long term outcome [3]
LTOT
Smoking cessation
Lung volume reduction - offer in late stages
Causative organisms for acute exacerbations:
Bacterial [3] (indicate most common)
Viral infection [3]
Bacterial
- H.influenza*
- Strep pneumonia
- Moraxella catarhalis
Viral
- Rhinovirus
- RSV
- Influenza
What are the symptoms [4]
Increase in:
SOB, Wheeze, Cough
Increase in sputum or purulence
Hypoxia, Confusion
Indications for hospital admission [9]
- Social difficulties can’t cope at home
- Severe SOB, poor deteriorating condition, cyanotic
- Poor level of activity or bedbound
- Already receiving LTOT
- Acute confusion
- Rapid onset
- SAO2 <90%
- CXR changes
- Respiratory distress eg pursed lip breathing
What investigations when admitted [9]
FBC, U+E, CRP ABG, ECG, CXR Blood culture if febrile Sputum MC&S if purulent Theophylline level
Which one do you treat first, hypoxia or hypercapnia?
How do you prescribe oxygen therapy for COPD acute admission? [3]
Give oxygen if sats low, hypoxia will kill faster than hypercapnia
Start at 28% Venturi mask on 4L/min in those at risk of hypercapnia but without hx respiratory acidosis
Do ABG within 1 hour of O2 therapy (adjust accordingly)
If critically unwell give with 15l non-rebreathe
Rx acute COPD [3]
- Give salbutamol and ipratropium bromide nebulizers back to back
- Prednislone 30mg 1w
- Antibiotics oral
Antibiotic options for acute exacerbation [3]
Amox
Tetracycline
Clarithroymycin
If still no response [6]
If giving O2 worsens condition then any more will worsen further IV hydrocortisone IV theophylline NIPPV - BiPAP Ventilation and intubation if fails Regular ABG
Why is BiPAP used
More useful in type 2 as alters pressure
When is CPAP used
Type 1 or pulmonary oedema as pushes fluid out
What is important in preparation of nebulizer in COPD patient?
nebuliser should be delivered by air instead of oxygen if hypercapnia or acidosis
What do you ask in Hx [4]
Usual and recent Rx
Home O2
Smoking status
Exercise capacity
What do you do for discharge [3]
GP follow up
Smoking
Vaccines
Indications for NIV [4]
- Blood pH 7.25-7.35
- Type 2 failure 2 to neuromuscular / OSA/ chest wall deformity
- Cardiogenic pulmonary edema unresponsive CPAP
- Weaning from tracheal ventilation
How do you differentiate exacerbation of COPD from pneumonia
CXR - consolidation
What is unusual for COPD to cause? [3]
Haemoptysis
Chest pain
DOES NOT cause clubbing
