COPD Flashcards
Definition?
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible. It encompasses both emphysema and chronic bronchitis.
Risk factors strong?
- Smoking
- Advanced age
- Genetics
- Occupational problems
Risk factors weak?
- White
- Air pollution
- Developmental problems
- Male
- Low SE status
Differentials?
- Asthma
- Congestive heart failure
- Bronchiectasis
- Tuberculosis
- Bronchiolitis
- Upper airway dysfunction
- Chronic sinusitis/post-nasal drip
- GORD
- ACE inhibitor induced chronic cough
- Lung cancer
Epidemiology?
Age: over 65’s
Sex: Male-recently equal
Ethnicity: White
Prevalence: Fourth leading cause of death in the world, 3 million in UK
Aetiology?
Smoking induces an inflammatory response, cilia dysfunction and oxidative stress by increasing proteinases that break down the cell lining in bronchioles
Clinical Presentation-common?
- Risk factors
- Cough
- SOB
Clinical Presentation-uncommon?
- Barrel chest
- Hyper-resonance on percussion
- Distant breath sounds and poor air movement
- Wheezing
- Coarse crackles
- Tachypnoea
- Asterixis
- Distended neck veins
- Swelling
- Fatigue
- Headache
- Cyanosis
- Hepatojugular reflux
- Loud P2
- Hepatosplenomegaly
- clubbing
Pathophysiology of Chronic Bronchitis?
• Inflammation causes mucociliary dysfunction and increased goblet cell secretions and numbers so more mucus is made
• Bronchoconstriction and mucus hypersecretion causes airway obstruction and chronic cough and wheezing in expiration
• Airway obs-alveolar hypoxia-V/Q mismatch and pulmonary VC-leads to pulmonary hypertension and backflow to RV and so cor pulmonale and increased JVP
• Also less circulatory volume causes RAAS activation and so extra fluid retention
Obstruction-leads to hypoxaemia and hypercapnia and resp acidosis and polycythaemia and lead to cyanosis
Pathophysiology of Emphysema?
- Inflammatory response due to irritants stimulating macrophages attracting neutrophils and that secrete elastase leading to elastin breakdown in alveoli walls and so recoil is lost so less ventilation
- Or a1 antitrypsin deficiency-more proteases and less anti-proteases-breakdown of elastin/alveoli walls
- Also destruction of capillary beds and alveoli wall leading to decreased perfusion
- Leads to air trapping in alveolus in exhalation-higher end expiratory vol-cant empty lungs and accessory muscle used-barrel chest
- Mismatched V/Q -hypoxaemia and hypercapnia
First line investigations and findings?
- spirometry (FEV1/FVC ratio <0.70),
- pulse oximetry (88-90% or pulse wave),
- ABG (PaCO₂ >50 mmHg and/or PaO₂ of <60 mmHg suggests respiratory insufficiency)
- CXR-increased anteroposterior ratio, flattened diaphragm, increased intercostal spaces, and hyperlucent lungs may be seen.
- FBC-raised haematocrit, possible increased WBC count
- BMI
- ECG-signs of right ventricular hypertrophy, arrhythmia, ischaemia
2nd line investigations and findings?
2nd line: • Pulmonary function tests • Chest CT • Sputum culture • Alpha-1 antitrypsin level • Exercise testing • Sleep study • Resp muscle function
Management group A?
Info, smoking cessation, vaccines, anxiety and depression, management, inhaled therapy
Management group B?
Info, smoking cessation, vaccines, anxiety and depression, management, inhaled therapy, oral therapy and oxygen therapy-LABA and LAMA
Management group C?
Info, smoking cessation, vaccines, anxiety and depression, management, inhaled therapy, oral therapy and oxygen therapy-LABA and LAMA and ICS
Management group D?
Info, smoking cessation, vaccines, anxiety and depression, management, inhaled therapy, oral therapy and oxygen therapy-LABA and LAMA and ICS, roflumilast and lung vol reduction/palliative care
Complications?
Cor pulmonale • Recurrent pneumonia • Depression and anxiety • Pneumothorax • Resp failure • Anaemia • Polycythaemia • Reduced quality of life • Lung cancer
Prognosis?
- 50% 5 yr mortality following hospitalisation for COPD exacerbation
- Outcomes vary per pt
- May need pulmonary rehab
Definition of exacerbation?
Acute worsening of respiratory COPD symptoms that requires further intervention
Risk factors of E-strong?
- Bacterial infection
- GORD
- Viral infection
- Pollutants
Risk factors of E-weak?
- Change in weather
* Atypical bacterial infection
Differentials of E?
- Acute exacerbation of asthma
- Congestive heart failure
- Pneumonia
- Pleural effusion
- Pneumothorax
- PE
- Cardiac ischaemia
- Cardiac arrhythmia
- Upper airway obstruction
- Inappropriate oxygen therapy
Aetiology of E?
- Exacerbations due to infections and pollutants causing airway inflammation and associated symptoms
- Bacterial-Haemophilus influenzae, Moraxella catarrhalis, strep. Pneumoniae and pseudomonas aeruginosa
Clinical Presentation of E?
- Dyspnoea
- Cough
- Increased sputum
- Wheeze
- Chest tightness
- Tachypnoea
- Tachycardia
- Risk factors
- Cor pulmonale
- Resp failure signs
- Fever
- GORD
Pathophysiology of E?
Sudden onset of inflammatory responses lead to airway obstruction
1st line investigations and findings of E?
• ABG-(PaO2<8.0 kPa (approximately 60 mmHg) indicatesrespiratory failure, pH <7.35 and PaCO2>6.5 kPa define acute respiratory acidosis)
• Pulse oximetry-low oxygen saturation, depressed below the patient’s baseline level
• ECG-may be right heart enlargement, arrhythmia, ischaemia
• FBC with platelets-may show elevated haematocrit, elevated WBC count, or anaemia
• Urea, electrolytes and creatinine-normal
• CRP-elevated CRP suggests presence of infection
• CXR-hyperinflation, flattened diaphragm, increased retrosternal air space (seen on lateral x-ray, if performed), bullae, and a small vertical heart suggesive
• Sputum microscopy, culture and gram stain-bacterial infection
Vit D-<10 ng/mL or <25 nM indicates severe deficiency
2nd line investigations and findings of E?
- Blood cultures-sepsis
- Resp virus diagnostics-viral
- Cardiac troponin-MI
- Serum theophylline-therapeutic range: 10-20 mg/L (55–110 micromols/litre)
- Pro=BNP-normal BNP <100 picograms/mL but some variability according to gender and age
- CT chest-may still show presence of emphysema, even if no pneumonia, pleural effusion, malignancy, or pulmonary embolus present
- Spirometry-only if previous results are unavailable
Acute management?
- SABA
- ICS
- Oxygen -Start on 24-28% and titrate up/down depending on ABG or sats
- Ventilation
- Antibiotic therapy-amino penicillin, clavulanic acid, macrolides and tetracycline or ceftazidime for PA
- Supplemental-co-morbidities, fluid , nutritional, DVT prophylaxis
Monitoring?
- ABG, pulse oximetry
- Review meds and smoking cessation services
- Assisted discharge scheme
- Pulmonary rehab
- Education
- Supervision and correction of inhaler technique
- Assessment and management of comorbidities
- Telemonitoring
- Continuing patient contact.
Complications of E?
- Mechanical ventilation and ventilator-associated pneumonia
- Antibiotic-related diarrhoea
- Mechanical ventilation and ventilator-associated barotrauma
- Hypotension due to mechanical ventilation
