COPD Flashcards

1
Q

What is COPD?

A

A progressive disease characterised by reduced lung function that is not fully reversible and exacerbations

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2
Q

What is the pathogenesis of COPD?

A

Exposure to noxious particles causes activation of inflammatory cells
These infiltrate the walls of bronchi and bronchioles and release protases
Protases cause inflammation of the airways, alveolar wall destruction and mucociliary dysfunction
Inflammation causes fibrosis and thickening of alveolar walls

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3
Q

What are some inflammatory cells involved in the pathogenesis of COPD?

A

Macrophages
Neutrophils
Cytokines
Proteases

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4
Q

What are the two conditions that are components of COPD?

A

Emphysema

Chronic bronchitis

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5
Q

What is emphysema?

A

Irreversible alveolar wall destruction leading to impaired gas exchange

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6
Q

What is chronic bronchitis?

A

Mucus hypersecretion
Partially reversible
Causes chronic productive cough

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7
Q

How does smoking contribute to COPD?

A

By inactivating alpha-1 antitrypsin

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8
Q

What are the risk factors for COPD?

A
SMOKING
Alpha-1 antitrypsin deficiency
Toxic gases
Occupational dusts (cadmium, coal)
Low birthweight
Childhood respiratory infections
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9
Q

What are the symptoms of COPD?

A

Daily cough
- Productive or unproductive
- Frequently morning cough but becomes constant as disease progresses
Progressive breathlessness
Wheeze
Cold that seems to ‘settle in the chest’
Frequent lower respiratory tract infections

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10
Q

What are the signs of COPD?

A

Reduced breath sounds
Wheeze
Accessory muscles of respiration are used
Barrel chest (broad deep chest suggesting hyperinflation)
Poor chest expansion
Hyper-resonance
Coarse crackles in exacerbations

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11
Q

What are the systemic effects of COPD?

A
Hypertension
Osteoporosis
Depression
Weight loss
Reduced muscle mass with general weakness
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12
Q

How does COPD progress?

A
  1. Progressive airflow obstruction
  2. Impaired alveolar gas exchange
  3. Respiratory failure - decrease in PaO2, increase in PaCO2
  4. Pulmonary hypertension
  5. Right ventricular hypertrophy or failure
  6. Death
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13
Q

How is COPD diagnosed?

A

Spirometry - FEV1/FVC <0.7

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14
Q

What investigations are done in exacerbation of COPD?

A
Careful history
CT scan
Echo
ECG
Sputum culture
Pulse oximetry 
ABG in unwell patients with abnormal pulse oximetry
CXR
FBC
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15
Q

What will spirometry show in COPD?

A

FEV1:FVC ratio is reduced (<70%)
PERF is low
FVC decreased

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16
Q

What is the treatment plan for COPD?

A

Breathless without frequent exacerbations: LABA/LAMA
Eosinophils >300: LABA/LAMA/ICS
Frequent exacerbations: trial of LABA/LAMA/ICS

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17
Q

What general management should be done in COPD?

A
Smoking cessation
Influenza and pneumococcal vaccination
Pulmonary rehabilitation
Oxygen
Active lifestyle and exercise
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18
Q

What are the ‘asthmatic features or features suggesting steroid responsiveness’:

A

Any previous diagnosis of asthma or atopy
Higher blood eosinophil count
Substantial variation in FEV1 over time
Substantial diurnal variation in PEFR

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19
Q

What diseases are associated with COPD?

A
Ischaemic heart disease
Hypertension
Diabetes
Heart failure
Cancer
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20
Q

Which diseases do COPD patients commonly develop?

A
Heart failure
Oedema
Respiratory failure
Pulmonary hypertension (cor pulmonale)
Acute exacerbations
21
Q

What are the most common organisms responsible for an acute exacerbation of COPD?

A

Haemophilus influenza (no 1)
Strep pneumoniae
Moraxella catarrhalis
Human rhinovirus

22
Q

Do patients with COPD have higher or lower numbers of goblet cells?

A

Higher

Mucin secreting cells

23
Q

Are the lymphocytes in COPD mainly CD4 or CD8?

A

CD8

24
Q

What are differential diagnoses for COPD?

A
Heart failure
Asthma
Bronchiectasis
TB
Lung cancer
Left heart failure
Interstitial lung disease
Cystic fibrosis
Idiopathic cough
25
Q

What is an exacerbation of COPD?

A

Acute worsening of respiratory symptoms that results in additional therapy

26
Q

What are the symptoms of an exacerbation of COPD?

A

May be precipitated by a viral or bacterial infection
Cough
Acute bronchospasm (coughing attack, tight chest, difficulty breathing)
Increase in sputum suggesting infectious cause

27
Q

What symptom can be used to differentiate COPD from heart failure?

A

Orthopnoea (breathlessness lying down that goes away sitting up) - not present in COPD

28
Q

What is the GOLD assessment of spirometry?

A

GOLD 1 - FEV1 >80% - mild
GOLD 2 - FEV1 50-79% - moderate
GOLD 3 - FEV1 30-49% - severe
GOLD 4 - FEV1 <30% - very severe

29
Q

How is spirometry used in COPD?

A

Used for diagnosis - not beyond that

30
Q

What system is used to assess severity of symptoms in COPD and what does it measure?

A

mMRC dyspnoea scale - measures severity of breathlessness

31
Q

What are the different grades in the mMRC dyspnoea?

A

Grade 0 - only breathless with strenuous exercise
Grade 1 - short of breath when hurrying on the level or walking up a slight hill
Grade 2 - walk slower than people of the same age on the level because of breathlessness or have to stop for breath when walking on my own pace on the level
Grade 3 - stop for breath after walking about 100 meters or after a few minutes on the level
Grade 4 - too breathless to leave the house or breathless when dressing or undressing

32
Q

What counts as severe exacerbations of COPD?

A

2+ or 1+ leading to hospital admission in a year

33
Q

What are the 2 main classes of drug used to treat COPD?

A

Muscarinic receptor antagonists

Beta-adrenoceptor agonists

34
Q

What is the action of muscarinic receptor antagonists?

A

Block muscarinic M3 ACh receptors to stop bronchoconstriction in airway smooth muscle - cause dilation of airways
Reduce bronchospasm
Decrease mucus secretion
Little effect on progression of disease

35
Q

What are examples of SAMAs?

A

Ipatropium

36
Q

What are examples of LAMAs?

A

Tiotropium
Glycopyrronium
Aclidinium
Umeclidinium

37
Q

What is the actin of beta-adrenoceptor agonists?

A

Bronchodilation

38
Q

What are examples of SABAs?

A

Salbutamol

39
Q

What are examples of LABAs?

A

Salmeterol

Formoterol

40
Q

When are ICS useful?

A

History of hospitalisations for exacerbations of COPD
2+ exacerbations of COPD per year
Blood eosinophils >300
History of or concomitant asthma

41
Q

When are ICS avoided?

A

Repeated pneumonia events
Blood eosinophils <100
History of mycobacterial infection

42
Q

What is the management for an exacerbation of COPD?

A
Increased short acting bronchodilators
Systemic steroids (prednisolone, no longer than 5 days)
Antibiotics only when indicated (5-7 days)
- Amoxicillin, doxycycline, clarithromycin
43
Q

When should you refer a COPD patient to secondary care?

A

Diagnosis uncertain
Rapidly declining FEV1
Consideration of LVRS (lung volume reduction surgery), bronchoscope valves or transplant
Exacerbation in elderly, frail or patients where home support is not sufficient

44
Q

What treatment is used in hypercapnia respiratory failure?

A

Non-invasive ventilation (NIV)

45
Q

How does non-invasive ventilation work?

A

Lowers the work of breathing to reduce pCO2

46
Q

What are the surgical options for treatment of COPD?

A

Bullectomy
Lung volume reduction surgery
Endobronchial valves and coils
Lung transplant

47
Q

When are patients given long term oxygen?

A

Patients with confirmed COPD who have stopped smoking for 3 months
With SaO2 <92% on 3 separate occasions spaced over 2 months, outwith exacerbations
Optimise COPD management and reassess - if still <92% refer to clinic for LTO

48
Q

When would antibiotics be warranted in an exacerbation of COPD?

A

Fever

Abnormal observations