COPD Flashcards
What is the definition of COPD
Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.
What is COPD predominantly caused by
- smoking
- occupational exposures
What cause exacerbations
- rapid sustained worsening of symptoms beyond normal day to day variations
What is the definition of chronic bronchitis
the presence of chronic productive cough and sputum for at least 3 months in each of two successive years
What is emphysema
- emphysema in anatomic terms is enlarged alveolar spaces and loss of alveolar walls
What is COPD characterised by
- COPD is characterised by airflow obstruction that is not fully reversible.
• The airflow obstruction does not change markedly over several months and is usually progressive in the long term.
How do you work out pack years
Pack Years
• Pack Years = Number of Packs/day X Years smoked
• One pack = 20 Cigarettes (was lower and therefore cheaper)
What can cause COPD
- smoking
- coal
- cotton
- cement
- cadmium
- (Corn) grain
- infections than lead to progressive Alpha 1 antitrypsin deficiency
- alpha 1 antitrypsin deficiency
What is COPD an umbrella term for
- Covers the irreversible aspect of chronic bronchitis, emphysema and asthma
Describe the pathophysiology of chronic bronchitis
- Hypertrophy of mucus secreting glands
- increase in mucous production and sputum expectoration
- infiltration of bronchial walls with inflammatory cells which leads to airway narrowing
Describe the pathophysiology of emphysema
- loss of elastic recoil - airflow limitation and air trapping
- bulla formation
describe what cells are involved in asthma
- CD4+ T lymphocytes
- eosinophils
- macrophages
- mast cells
Describe what cells are in COPD
- CD8+ T lymphocytes
- macrophages
- neutrophils
who does COPD tend to present in
- over 35
- smoker/ex smoker
name the symptoms of COPD
- exertional breathlessness
- chronic cough
- regular sputum production
- frequent winter bronchitis
- wheeze
What are the investigations and diagnosis tools used in COPD
Consider in patients who are over 35 years of age who are smokers or ex-smokers
Investigations
- Post-bronchodilator spirometry to demonstrate airflow obstruction
- CXR - hyperinflation, bullae, flat hemidiaphragm, excludes lung cancer
- FBC – exclude secondary polycythaemia
- BMI calculation
What are the signs of COPD
- tachypnoea
- use of accessory muscles of respiration
- hyperinflation
- ↓expansion
- resonant or hyperresonant percussion note
- quiet breath sounds (eg over bullae)
- wheeze
- cyanosis
- cor pulmonale.
describe the difference MRC dyspnea scales
mMRC grade 0
- I only get breathless with strenuous exercise
mMRC grade 1
- I get short of breath when hurrying on the level or walking up a slight hill
mMRC grade 2
- I walk slower than people of the same age on the level because of breathlessness or I have to stop for breath when walking on my own pace on the level
mMRC grade 3
- I stop for breath after walking about 100m or after a few minutes on the level
mMRC grade 4
- I am too breathless to leave the house or I am breathless when dressing or undressing
What are the clinical signs of COPD
- wheeze
- tachypnea
- prolonged expiration
- use of accessory muscles
- pursed lip breathing
- hyper-inflated lungs
- cyanosis
- heart failure
What is hoover’s sign
- refer to the paradoxical inspiratory retraction of the rib cage and lower intercostal interspaces
What is Dahl’s sign
Dahl’s sign, a clinical sign in which areas of thickened and darkened skin seen on the lower thighs and/or elbows, is seen in patients with severe chronic respiratory disorders such as chronic obstructive pulmonary disease (COPD), interstitial lung disease, congestive heart failure (CHF)
Describe how the ABCD assessment tool works
A - mMRC of 0-1, and CAT <10, 0 or 1 moderate or severe exacerbation (not leading to hospital admission)
B - mMRC > 2, CAT > 10, 0 or 1 moderate or severe exacerbation (not leading to hospital admission)
C - mMRC of 0-1, and CAT <10, greater than 2 moderate or serve exacerbation or greater than 1 leading to hospital admission
D mMRC > 2, CAT > 10, greater than 2 moderate or serve exacerbation or greater than 1 leading to hospital admission
What are the goals of COPD management
- relieve symptoms
- prevent disease progression
- improve exercise tolerance
- improve health status
- prevent and treat complications
- prevent and treat exacerbations
- reduce mortality
describe the post bronchodilator grade
Post bronchodilator grade based on FEV1 number Gold 1 – mild - Greater than or equal to 80% Gold 2 - moderate - 50-79% Gold 3 – severe - 30-49% Gold 4 – very severe - Less than 30%
Name some smoking cessation drugs
- Varenicline (champix)
- nicotine replacement therapy
- bupropion (zyban)
How does varenicline (champix) work
- selective nicotine receptor partial agonist
How do you do nicotine replacement therapy
- use as a replacement therapy in abrupt cessation or to slowly reduce
Various form
- patches
- gum, lozenges, oro-nasal spray
- inhalation
What does the treatment for COPD do
- decrease symptoms
- decrease exacerbations
- slow decline in FEV1
- not life prolonging
what can reduce serious illness in COPD patients
influenza vaccines
- pneumococcal polysaccharide vaccine is recommended for COPD patients 65 years and older and for COPD patients younger than age 65 with an FEV1 < 40% predicted
What are the drugs that are used in COPD
- Short acting bronchodilators
- anti-cholinergic
- long acting bronchodilators: LABA, Anti-cholinergics
- Inhaled corticosteroids
- Phosphodiesterase inhibitors: Theophyllines, Roflumilast
Name some short acting bronchodilators
- salbutamol
- terbutaline
Name some anti-cholinergic
Short-acting
- ipratroprium bromide
Long acting
- aclidinium
- glycoppyroium
- tiotropium
Name some LABA
- indacterol
- vilanterol
- salmeterol
- formoterol
Name some phosphodiesterase inhibitors
- Theophyllines
- roflumilast
What drugs in the ABCD group should they receive
A
- bronchodilator
B
- LABA or LAMA
C
- LAMA
D
- LAMA or LAMA + LABA or ICS and LABA
What are the non pharmacological treatment for COPD
- Rehabilitation: all COPD patients benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue
- Oxygen therapy - long term administration of oxygen (>15 hours a day) to patients with COPD has been shown to increase survival
- Lung volume reduction surgery
- Lung transplantation
what are the complications of COPD
- respiratory failure
- cor pulmonale
what COPD patients should you do an ABG in
– FEV1 <30% predicted
– Cor Pulmonale
– Oxygen Saturations <92% on air
what does pulmonary rehabilitation include
- All patients functionally disabled by CODP
includes
- physical training
- disease education
- nutritional advice
- psychological and behavioural support
What is the palliative care offered for COPD
• Non-pharmacological:
– Fatigue: pulmonary rehab, nutrition support, mind-body interventions,
– dyspnoea- use of fans,
– anxiety, insomnia: CBT
• Pharmacological:
– Opiates for breathlessness,
– SSRI for depression and anxiety
what criteria is used for COPD exacerbation
Anthonisen criteria (AC)
What makes up the Anthonisen criteria (AC)
- increased dyspnea
- increase sputum volume
- increase sputum purulence
what is the differential diagnosis for COPD exacerbations
- Pneumonia
- Pneumothorax
- Malignancy
- PE
- Heart Failure/ACS
What investigations do you use for exacerbations
investigations used to gauge severity
- oxygen saturations
- ABG
- sputum and blood culutres
Exclude other diagnoses
- CXR
- ECG
- Bloods - eosinophil count, U&E, CRP
- CT/CTPA
what organisms often cause COPD exacerbations
Often viral
- H.influenzae
- M. catarrhalis
- Streptococcus pneumoniae
What is the management of COPD exacerbations
Management of COPD exacerbations Anthonisen criteria - Increased dyspnea - Increased sputum - Increased sputum purulence
Bronchodilators
- Nebulised air driven
Steroids
- Prednisolone – 30mg to 40mg OD max for 5 days
Antibiotics
- If purulent sputum or pneumonia on CXR
- Empirical antibiotics with aminopenicllin or tetracycline
Consider hospital admission
Non invasion ventilation
- Acute exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical therapy
What oxygen stats do you aim for in COPD
88-92%
why do you do an ABG in COPD exacerbations
- if hypercapnia
- exclude acidosis
- maximise medical therapy
- NIV if no improvement
What are the common causes of external breathlessness and cough
- chest infection
- asthma
- angina
- COPD
- obesity
- heart dysfunction
- pneumonia
- pulmonary embolism
What are the major side effects of bronchodilators
- trembling
- headaches
- dry mouth
- muscle cramps
- cough
What are the major side effects of theophylline
- anxiety
- arrhythmias
- diarrhoea
- dizziness
- potentially serious hypokalaemia
What happens in overdose of theophylline
- vomiting
- agitation
- restlessness
- dilated pupils
- sinus tachycardia
- hyperglycaemia
- Haematemesis
- convulsions
What does theophylline do
Theophylline competitively inhibits type III and type IV phosphodiesterase (PDE), the enzyme responsible for breaking down cyclic AMP in smooth muscle cells, possibly resulting in bronchodilation.
When do patients with COPD get non invasive ventilation
People with an acute exacerbation of chronic obstructive pulmonary disease (COPD) and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical therapy have non‑invasive ventilation.
What is the role of community services in the management of COPD
- smoking cessation
- pulmonary rehabilitation
- drug management
What are the indications for long term oxygen therapy in patients with COPD
Benefit patients who have:
- PaO2 of < 7.3kPa when breathing air, measurements should be taken on two occasions at least 3 weeks apart after appropriate bronchodilator therapy
- PaO2 - 7.3-8kPa with secondary polycythaemia, nocturnal hyperaemia, peripheral oedema or evidence of pulmonary hypertension
- carboxyhemoglobin of <3%
what is the benefit of long term oxygen therapy
- if you have It at 2l/min for 15-19 hours a day it improves survival
What are complications that can develop from COPD
- respiratory failure
- lung infections
- collapsed lung
- sleep problems - obstructive sleep apnoea
- pneumothorax
- depression and anxiety
What is the management of stable COPD
General management
- Smoking cessation – offer nicotine replacement therapy, varenicline or bupropion
- Annual influenza vaccination
- One off pneumococcal vaccination
- Pulmonary rehabilitation
Bronchodilator therapy
- SABA or SAMA is first line
- If patient has asthmatic/steroid responsive features then LABA + ICS (if already taking a SAMA discontinue and switch to a SABA)
- If the paitent has no asthmatic/steroid responsive features then LABA and LAMA (if already taking a SAMA discontinue and switch to a SABA)
- Triple therapy – LABA + LAMA + ICS
- Then add inhaled tiotropium
Oral Theophylline
- NICE only recommends theophylline after trials of short and long acting bronchodilators or to people who cannot use inhaled therapy
Oral prophylactic antibiotic therapy
- Azithromycin prophylaxis is recommended in selection patients - Check LFTS and exclude QT prolongation before hand
What is the drug management of stable COPD
- SABA or SAMA is first line
- If patient has asthmatic/steroid responsive features then LABA + ICS (if already taking a SAMA discontinue and switch to a SABA)
- If the paitent has no asthmatic/steroid responsive features then LABA and LAMA (if already taking a SAMA discontinue and switch to a SABA)
- Triple therapy – LABA + LAMA + ICS
- Then add inhaled tiotropium
What is the prophylactic antibiotic therapy given to COPD patients
- Azithromycin prophylaxis is recommended in selection patients - Check LFTS and exclude QT prolongation before hand
What is a sign of increased carbon dioxide
- warm peripheries
