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YR6: RESPIRATORY > COPD > Flashcards

COPD Flashcards

1
Q

Define COPD

A

Chronic, progressive lung disorder characterised by persistent resp Sx + airflow obstruction

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2
Q

What causes the airflow obstruction in COPD?

A

Chronic inflammation caused by exposure to noxious particles/ gases

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3
Q

What is COPD the preferred term for?

A

Chronic bronchitis, emphysema + chronic obstructive airways disease

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4
Q

What is emphysema?

A

destruction/ damage of alveoli
Leads to permanent enlargement + loss of elasticity
Defined by structural changes: enlargement of air spaces

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5
Q

What is chronic bronchitis?

A

cough + sputum production for >, 3 months in each of 2 consecutive years
Defined by clinical features

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6
Q

What is the most common cause of COPD?

A

Smoking

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7
Q

What is a rare cause of COPD? When should this be considered?

A

Alpha 1 antitrypsin deficiency
In young patients / people who have never smoked.

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8
Q

Give 4 characteristics of chronic bronchitis

A

Narrowing of the airways resulting in bronchiole inflammation (bronchiolitis)
Bronchial mucosal oedema
Mucous hypersecretion
Squamous metaplasia

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9
Q

What characterises emphysema?

A

Destruction + enlargement of alveoli
Loss of elasticity that keeps small airways open in expiration
Progressively larger spaces develop called bullae (diameter > 1 cm)

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10
Q

List 3 symptoms of COPD

A

Chronic cough
Sputum production
Dyspnoea

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11
Q

List 5 signs of COPD

A

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

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12
Q

What is cor pulmonale?

A

Right HF secondary to respiratory disease
Leads to increased resistance to blood flow in pulmonary circulation

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13
Q

List 5 signs of cor pulmonlae

A

Peripheral oedema
Raised JVP
Systolic parasternal heave
Loud S2
Hepatomegaly

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14
Q

What are the signs of CO2 retention?

A

CO2 retention flap
Bounding pulse
Warm peripheries

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15
Q

What are the key investigations for COPD?

A

FBC: anaemia, secondary polycythaemia
CXR: r/o lung cancer, TB, HF.
Post-bronchodilator spirometry: FEV1 + FVC

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16
Q

What would be found on spirometry in COPD?

A

FEV1/FVC <0.7: obstructive picture

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17
Q

What are the stages of severity defined by in COPD?

A
  1. FEV1 >,80% (+ Sx) mild
  2. FEV1 50-79% moderate
  3. FEV1 30-49% severe
  4. FEV1 <30% very severe
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18
Q

What would be found on pulmonary function tests in COPD?

A

Obstructive pattern (flow vol loops)
Decreased TLCO

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19
Q

What CXR findings may be present in COPD?

A

May appear NORMAL
Hyperinflation (> 6 anterior ribs in MCL at diaphragm)
Flat hemidiaphragm
Bullae

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20
Q

When are blood and sputum cultures useful in COPD?

A

Acute infective exacerbations

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21
Q

What would you measure in a young patient who had never smoked if you suspected COPD?

A

Alpha 1 antitrypsin levels

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22
Q

Which tool can be used to assess severity of dyspnoea?

A

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

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23
Q

Which tool can be used to assess symptom severity in COPD?

A

COPD Assessment Tool (CAT)
Cough
Phlegm
Chest tightness
Breathlessness
Activity limitation
Confidence leaving home
Sleep (if affected by breathing)
Energy

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24
Q

Why is measurement of peak expiratory flow of limited use in COPD?

A

May underestimate degree of airflow obstruction

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25
Q

Describe the conservative management strategies for COPD

A

SMOKING CESSATION
Annual influenza vaccine
One-off pneumococcal vaccine
Pulmonary rehab (MRC >,3)

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26
Q

What is the first step of medical treatment for COPD?

A

SABA PRN (e.g. salbutamol)
or
SAMA PRN (e.g. ipratropium bromide)

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27
Q

What determines the 2nd step in medical management of COPD?

A

Asthmatic features/ features suggesting steroid responsiveness

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28
Q

Which 4 criteria indicate asthmatic/ steroid responsive features?

A

Any previous dx of asthma/ atopy
High blood eosinophil count
Variation in FEV1 over time (>,400ml)
Diurnal variation in PEFR (>20%)

29
Q

If a patient has no asthmatic features/ features suggesting steroid responsiveness, what is the 2nd step in medical management?

A

Add LABA + LAMA

If already taking a SAMA, discontinue + switch to a SABA

30
Q

If a patient has asthmatic features/ features suggesting steroid responsiveness, what is the 2nd step in medical management?

A

Add LABA + ICS

31
Q

If a patient is taking a LABA, ICS + SABA/SAMA what is the next stage of treatment?

A

Add LAMA
If already taking SAMA, discontinue + switch to SABA

32
Q

What type of inhalers do NICE recommend where possible?

A

Combined inhalers

33
Q

If COPD is not controlled by triple therapy with PRN SABA, what is the next stage of management?

A

Refer to Resp
Consider:
Oral Theophylline
Oral prophylactic Abx
Oral phosphodiesterase-4-inhibitors

34
Q

When is oral theophylline recommended?

A

After trials of short + long acting bronchodilators
OR
to those who can’t used inhaled therapy

35
Q

When are prophylactic antibiotics indicated in COPD?

A

When continuing to have exacerbations despite not smoking + having optimised standard Tx

36
Q

What is the recommended antibiotic for prophylaxis in COPD?

A

Azithromycin

37
Q

What tests needs to be performed before starting azithromycin prophylaxis?

A

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

38
Q

How should dose of oral theophylline be adjusted if co-prescribed with Azithromycin/ fluoroquinolones?

A

Reduce dose theophylline

39
Q

Give an example of a phosphodiesterase-4 (PDE-4) inhibitor. What does this do?

A

Roflumilast
Reduce risk of exacerbations in patients with severe COPD with hx of frequent exacerbations

40
Q

When is PDE-4 inhibitor therapy recommended?

A

Severe COPD; post-bronchodilator FEV1 of <50%
+
had >,2 exacerbations in the previous year despite triple inhaled therapy (LAMA, LABA + ICS)

41
Q

In which patients should mucolytics be considered?

A

Chronic productive cough + continue if Sx improve

42
Q

Name a drug that can be used to treat oedema in cor pulmonale

A

Loop diuretic e.g. Furosemide

43
Q

Which 3 interventions may improve long term survival in those with stable COPD?

A

SMOKING CESSATION
LTOT: if fit criteria
Lung volume reduction surgery in selected

44
Q

List 6 indications for assessment for LTOT

A

V severe airflow obstruction; FEV1 <30%
Cyanosis
Polycythaemia
Peripheral oedema
Raised JVP
O2 sats ,<92%

45
Q

Describe assessment for LTOT

A

ABG on 2 occasions at least 3w apart in patients with stable COPD on optimal Mx

46
Q

When should LTOT be offered?

A

pO2 <7.3 kPA
or
7.3-8 kPA + 1 of:
secondary polycythaemia
peripheral oedema
pulmonary HTN

47
Q

LTOT therapy is NOT offered to which patients?

A

Those who continue to smoke despite offer of cessation advice + Tx

48
Q

What risk assessment should be performed prior to offering LTOT?

A

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

49
Q

List 3 other management strategies used for COPD

A

Prevent infective exacerbations: pneumococcal + influenza vaccination
Pulmonary rehabilitation
Oxygen Therapy: used if PO2 <7.3 during clinical stability

50
Q

List 6 possible complications of COPD

A

Acute respiratory failure
Infections
Pulmonary HTN
Right heart failure
Pneumothorax (secondary to bullae rupture)
Secondary polycythaemia

51
Q

What measure confirms the presence of obstructive disease consistent with COPD?

A

Post-bronchodilator FEV1/FVC <0.7

52
Q

What is used to classify the severity of COPD?

A

FEV1

53
Q

What is an acute exacerbation of COPD?

A

Acute onset, sustained worsening of Sx from their usual stable state

54
Q

List 4 causes of acute exacerbation of COPD

A

Bacterial respiratory tract infection
Viral respiratory tract infection
Smoking
Environmental pollutants

55
Q

What is the most common cause of an infective exacerbation of COPD?

A

Haemophilus influenzae

56
Q

List 3 common bacterial causes of infective exacerbations of COPD

A

Haemophilus influenzae
Streptococcus pneumoniae
Moraxella catarrhalis

57
Q

What % of exacerbations of COPD are due to viral infections? Which is the most common?

A

~30%
Human rhinovirus

58
Q

How may an acute exacerbation of COPD present?

A

increase in dyspnoea, cough, wheeze
increase in sputum/ change in colour
may be hypoxic +/- acute confusion

59
Q

How should acute exacerbations of COPD be managed in primary care?

A

Increase frequency of bronchodilator use
Prednisolone 30mg OD for 5 days

60
Q

When should antibiotics be prescribed for acute exacerbations of COPD in primary care? Which antibiotics?

A

If sputum is purulent/ clinical signs of pneumonia

Amoxicillin/ Clarithromycin/ Doxycycline

61
Q

What 5 signs and symptoms indicate a need for admission in acute exacerbation of COPD?

A

Severe breathlessness
Rapid onset Sx
Acute confusion/ impaired consciousness
Cyanosis
Worsening peripheral oedema

62
Q

Which 3 results from investigations indicate need for admission due to acute exacerbation of COPD?

A

O2 sats <90%
New arrhythmia
Changes on CXR

63
Q

List 4 general/ management focused factors indicate need for admission in acute exacerbations of COPD

A

Already on LTOT
Inability to cope at home/ living alone
Poor/ deteriorating general condition inc. significant co-morbidity
No response to initial Tx

64
Q

Describe management of severe exacerbation of COPD

A

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

65
Q

What target saturation for oxygen should be used in COPD exacerbations?

A

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

66
Q

When should NIV be used in acute exacerbations of COPD?

A

Type 2 respiratory failure
Typically pH 7.25-7.35

67
Q

If using NIV when a patient is more acidotic (pH <7.25) what is required?

A

HDU: more monitoring
+
Lower threshold for intubation + ventilation

68
Q

What settings are typically used on BiPAP for type 2 respiratory failure?

A

Expiratory positive airway pressure: 4-5cm H2O
Inspiratory positive airway pressure: 12-15cm H2O

YR6: RESPIRATORY (38 decks)

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