COPD Flashcards
Define COPD
Chronic, progressive lung disorder characterised by persistent resp Sx + airflow obstruction
What causes the airflow obstruction in COPD?
Chronic inflammation caused by exposure to noxious particles/ gases
What is COPD the preferred term for?
Chronic bronchitis, emphysema + chronic obstructive airways disease
What is emphysema?
destruction/ damage of alveoli
Leads to permanent enlargement + loss of elasticity
Defined by structural changes: enlargement of air spaces
What is chronic bronchitis?
cough + sputum production for >, 3 months in each of 2 consecutive years
Defined by clinical features
What is the most common cause of COPD?
Smoking
What is a rare cause of COPD? When should this be considered?
Alpha 1 antitrypsin deficiency
In young patients / people who have never smoked.
Give 4 characteristics of chronic bronchitis
Narrowing of the airways resulting in bronchiole inflammation (bronchiolitis)
Bronchial mucosal oedema
Mucous hypersecretion
Squamous metaplasia
What characterises emphysema?
Destruction + enlargement of alveoli
Loss of elasticity that keeps small airways open in expiration
Progressively larger spaces develop called bullae (diameter > 1 cm)
List 3 symptoms of COPD
Chronic cough
Sputum production
Dyspnoea
List 5 signs of COPD
Barrel-shaped over-inflated chest
Hyper-resonance on percussion
Distant breath sounds + wheeze on auscultation
Prolonged expiratory phase
Use of accessory muscles / pursed lip breathing
What is cor pulmonale?
Right HF secondary to respiratory disease
Leads to increased resistance to blood flow in pulmonary circulation
List 5 signs of cor pulmonlae
Peripheral oedema
Raised JVP
Systolic parasternal heave
Loud S2
Hepatomegaly
What are the signs of CO2 retention?
CO2 retention flap
Bounding pulse
Warm peripheries
What are the key investigations for COPD?
FBC: anaemia, secondary polycythaemia
CXR: r/o lung cancer, TB, HF.
Post-bronchodilator spirometry: FEV1 + FVC
What would be found on spirometry in COPD?
FEV1/FVC <0.7: obstructive picture
What are the stages of severity defined by in COPD?
- FEV1 >,80% (+ Sx) mild
- FEV1 50-79% moderate
- FEV1 30-49% severe
- FEV1 <30% very severe
What would be found on pulmonary function tests in COPD?
Obstructive pattern (flow vol loops)
Decreased TLCO
What CXR findings may be present in COPD?
May appear NORMAL
Hyperinflation (> 6 anterior ribs in MCL at diaphragm)
Flat hemidiaphragm
Bullae
When are blood and sputum cultures useful in COPD?
Acute infective exacerbations
What would you measure in a young patient who had never smoked if you suspected COPD?
Alpha 1 antitrypsin levels
Which tool can be used to assess severity of dyspnoea?
MRC dyspnoea scale
1. Only breathless on strenuous exercise
2. SOB hurrying/ walking up slight hill
3. Walks slower than contemporaries due to breathlessness/ has to stop
4. Stops for breath after a few mins/ 100m
5. Too breathless to leave house/ breathless dressing
Which tool can be used to assess symptom severity in COPD?
COPD Assessment Tool (CAT)
Cough
Phlegm
Chest tightness
Breathlessness
Activity limitation
Confidence leaving home
Sleep (if affected by breathing)
Energy
Why is measurement of peak expiratory flow of limited use in COPD?
May underestimate degree of airflow obstruction
Describe the conservative management strategies for COPD
SMOKING CESSATION
Annual influenza vaccine
One-off pneumococcal vaccine
Pulmonary rehab (MRC >,3)
What is the first step of medical treatment for COPD?
SABA PRN (e.g. salbutamol)
or
SAMA PRN (e.g. ipratropium bromide)
What determines the 2nd step in medical management of COPD?
Asthmatic features/ features suggesting steroid responsiveness
Which 4 criteria indicate asthmatic/ steroid responsive features?
Any previous dx of asthma/ atopy
High blood eosinophil count
Variation in FEV1 over time (>,400ml)
Diurnal variation in PEFR (>20%)
If a patient has no asthmatic features/ features suggesting steroid responsiveness, what is the 2nd step in medical management?
Add LABA + LAMA
If already taking a SAMA, discontinue + switch to a SABA
If a patient has asthmatic features/ features suggesting steroid responsiveness, what is the 2nd step in medical management?
Add LABA + ICS
If a patient is taking a LABA, ICS + SABA/SAMA what is the next stage of treatment?
Add LAMA
If already taking SAMA, discontinue + switch to SABA
What type of inhalers do NICE recommend where possible?
Combined inhalers
If COPD is not controlled by triple therapy with PRN SABA, what is the next stage of management?
Refer to Resp
Consider:
Oral Theophylline
Oral prophylactic Abx
Oral phosphodiesterase-4-inhibitors
When is oral theophylline recommended?
After trials of short + long acting bronchodilators
OR
to those who can’t used inhaled therapy
When are prophylactic antibiotics indicated in COPD?
When continuing to have exacerbations despite not smoking + having optimised standard Tx
What is the recommended antibiotic for prophylaxis in COPD?
Azithromycin
What tests needs to be performed before starting azithromycin prophylaxis?
CT thorax: to exclude bronchiectasis
Sputum culture: to r/o atypical infection + TB
ECG: to r/o QT prolongation as Azithromycin can prolong the QT interval
LFTs: baseline
How should dose of oral theophylline be adjusted if co-prescribed with Azithromycin/ fluoroquinolones?
Reduce dose theophylline
Give an example of a phosphodiesterase-4 (PDE-4) inhibitor. What does this do?
Roflumilast
Reduce risk of exacerbations in patients with severe COPD with hx of frequent exacerbations
When is PDE-4 inhibitor therapy recommended?
Severe COPD; post-bronchodilator FEV1 of <50%
+
had >,2 exacerbations in the previous year despite triple inhaled therapy (LAMA, LABA + ICS)
In which patients should mucolytics be considered?
Chronic productive cough + continue if Sx improve
Name a drug that can be used to treat oedema in cor pulmonale
Loop diuretic e.g. Furosemide
Which 3 interventions may improve long term survival in those with stable COPD?
SMOKING CESSATION
LTOT: if fit criteria
Lung volume reduction surgery in selected
List 6 indications for assessment for LTOT
V severe airflow obstruction; FEV1 <30%
Cyanosis
Polycythaemia
Peripheral oedema
Raised JVP
O2 sats ,<92%
Describe assessment for LTOT
ABG on 2 occasions at least 3w apart in patients with stable COPD on optimal Mx
When should LTOT be offered?
pO2 <7.3 kPA
or
7.3-8 kPA + 1 of:
secondary polycythaemia
peripheral oedema
pulmonary HTN
LTOT therapy is NOT offered to which patients?
Those who continue to smoke despite offer of cessation advice + Tx
What risk assessment should be performed prior to offering LTOT?
Risk of falls from tripping on equipment
Risk of burns + fires, + increased risk of burns + fires for those who live in homes where someone smokes
List 3 other management strategies used for COPD
Prevent infective exacerbations: pneumococcal + influenza vaccination
Pulmonary rehabilitation
Oxygen Therapy: used if PO2 <7.3 during clinical stability
List 6 possible complications of COPD
Acute respiratory failure
Infections
Pulmonary HTN
Right heart failure
Pneumothorax (secondary to bullae rupture)
Secondary polycythaemia
What measure confirms the presence of obstructive disease consistent with COPD?
Post-bronchodilator FEV1/FVC <0.7
What is used to classify the severity of COPD?
FEV1
What is an acute exacerbation of COPD?
Acute onset, sustained worsening of Sx from their usual stable state
List 4 causes of acute exacerbation of COPD
Bacterial respiratory tract infection
Viral respiratory tract infection
Smoking
Environmental pollutants
What is the most common cause of an infective exacerbation of COPD?
Haemophilus influenzae
List 3 common bacterial causes of infective exacerbations of COPD
Haemophilus influenzae
Streptococcus pneumoniae
Moraxella catarrhalis
What % of exacerbations of COPD are due to viral infections? Which is the most common?
~30%
Human rhinovirus
How may an acute exacerbation of COPD present?
increase in dyspnoea, cough, wheeze
increase in sputum/ change in colour
may be hypoxic +/- acute confusion
How should acute exacerbations of COPD be managed in primary care?
Increase frequency of bronchodilator use
Prednisolone 30mg OD for 5 days
When should antibiotics be prescribed for acute exacerbations of COPD in primary care? Which antibiotics?
If sputum is purulent/ clinical signs of pneumonia
Amoxicillin/ Clarithromycin/ Doxycycline
What 5 signs and symptoms indicate a need for admission in acute exacerbation of COPD?
Severe breathlessness
Rapid onset Sx
Acute confusion/ impaired consciousness
Cyanosis
Worsening peripheral oedema
Which 3 results from investigations indicate need for admission due to acute exacerbation of COPD?
O2 sats <90%
New arrhythmia
Changes on CXR
List 4 general/ management focused factors indicate need for admission in acute exacerbations of COPD
Already on LTOT
Inability to cope at home/ living alone
Poor/ deteriorating general condition inc. significant co-morbidity
No response to initial Tx
Describe management of severe exacerbation of COPD
Oxygen via 24-28% venturi to deliver 4L/min
Salbutamol 5mg nebs
+/ or Ipratropium 500 micrograms nebs
Prednisolone PO/ Hydrocortisone IV
IV Theophylline if not responding to nebs
What target saturation for oxygen should be used in COPD exacerbations?
Initially 88-92% for those with RFs for hypercapnia but no prior hx of resp acidosis
Adjust to 94-98% if pCO2 normal on ABG
When should NIV be used in acute exacerbations of COPD?
Type 2 respiratory failure
Typically pH 7.25-7.35
If using NIV when a patient is more acidotic (pH <7.25) what is required?
HDU: more monitoring
+
Lower threshold for intubation + ventilation
What settings are typically used on BiPAP for type 2 respiratory failure?
Expiratory positive airway pressure: 4-5cm H2O
Inspiratory positive airway pressure: 12-15cm H2O
