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Year 3 - CR > COPD > Flashcards

COPD Flashcards

1
Q

What is the definition of COPD

A

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.

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2
Q

What is COPD predominantly caused by

A
  • smoking

- occupational exposures

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3
Q

What cause exacerbations

A
  • rapid sustained worsening of symptoms beyond normal day to day variations
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4
Q

What is the definition of chronic bronchitis

A

the presence of chronic productive cough and sputum for at least 3 months in each of two successive years

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5
Q

What is emphysema

A
  • emphysema in anatomic terms is enlarged alveolar spaces and loss of alveolar walls
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6
Q

What is COPD characterised by

A
  • 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.
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7
Q

How do you work out pack years

A

Pack Years
• Pack Years = Number of Packs/day X Years smoked
• One pack = 20 Cigarettes (was lower and therefore cheaper)

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8
Q

What can cause COPD

A
  • smoking
  • coal
  • cotton
  • cement
  • cadmium
  • (Corn) grain
  • infections than lead to progressive Alpha 1 antitrypsin deficiency
  • alpha 1 antitrypsin deficiency
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9
Q

What is COPD an umbrella term for

A
  • Covers the irreversible aspect of chronic bronchitis, emphysema and asthma
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10
Q

Describe the pathophysiology of chronic bronchitis

A
  • Hypertrophy of mucus secreting glands
  • increase in mucous production and sputum expectoration
  • infiltration of bronchial walls with inflammatory cells which leads to airway narrowing
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11
Q

Describe the pathophysiology of emphysema

A
  • loss of elastic recoil - airflow limitation and air trapping
  • bulla formation
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12
Q

describe what cells are involved in asthma

A
  • CD4+ T lymphocytes
  • eosinophils
  • macrophages
  • mast cells
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13
Q

Describe what cells are in COPD

A
  • CD8+ T lymphocytes
  • macrophages
  • neutrophils
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14
Q

who does COPD tend to present in

A
  • over 35

- smoker/ex smoker

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15
Q

name the symptoms of COPD

A
  • exertional breathlessness
  • chronic cough
  • regular sputum production
  • frequent winter bronchitis
  • wheeze
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16
Q

What are the investigations and diagnosis tools used in COPD

A

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

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17
Q

What are the signs of COPD

A
  • tachypnoea
  • use of accessory muscles of respiration
  • hyperinflation
  • ↓expansion
  • resonant or hyperresonant percussion note
  • quiet breath sounds (eg over bullae)
  • wheeze
  • cyanosis
  • cor pulmonale.
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18
Q

describe the difference MRC dyspnea scales

A

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

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19
Q

What are the clinical signs of COPD

A
  • wheeze
  • tachypnea
  • prolonged expiration
  • use of accessory muscles
  • pursed lip breathing
  • hyper-inflated lungs
  • cyanosis
  • heart failure
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20
Q

What is hoover’s sign

A
  • refer to the paradoxical inspiratory retraction of the rib cage and lower intercostal interspaces
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21
Q

What is Dahl’s sign

A

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)

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22
Q

Describe how the ABCD assessment tool works

A

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

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23
Q

What are the goals of COPD management

A
  • relieve symptoms
  • prevent disease progression
  • improve exercise tolerance
  • improve health status
  • prevent and treat complications
  • prevent and treat exacerbations
  • reduce mortality
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24
Q

describe the post bronchodilator grade

A 
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%
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25
Q

Name some smoking cessation drugs

A
  • Varenicline (champix)
  • nicotine replacement therapy
  • bupropion (zyban)
26
Q

How does varenicline (champix) work

A
  • selective nicotine receptor partial agonist
27
Q

How do you do nicotine replacement therapy

A
  • use as a replacement therapy in abrupt cessation or to slowly reduce

Various form

  • patches
  • gum, lozenges, oro-nasal spray
  • inhalation
28
Q

What does the treatment for COPD do

A
  • decrease symptoms
  • decrease exacerbations
  • slow decline in FEV1
  • not life prolonging
29
Q

what can reduce serious illness in COPD patients

A

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

30
Q

What are the drugs that are used in COPD

A
  • Short acting bronchodilators
  • anti-cholinergic
  • long acting bronchodilators: LABA, Anti-cholinergics
  • Inhaled corticosteroids
  • Phosphodiesterase inhibitors: Theophyllines, Roflumilast
31
Q

Name some short acting bronchodilators

A
  • salbutamol

- terbutaline

32
Q

Name some anti-cholinergic

A

Short-acting
- ipratroprium bromide

Long acting

  • aclidinium
  • glycoppyroium
  • tiotropium
33
Q

Name some LABA

A
  • indacterol
  • vilanterol
  • salmeterol
  • formoterol
34
Q

Name some phosphodiesterase inhibitors

A
  • Theophyllines

- roflumilast

35
Q

What drugs in the ABCD group should they receive

A

A
- bronchodilator

B
- LABA or LAMA

C
- LAMA

D
- LAMA or LAMA + LABA or ICS and LABA

36
Q

What are the non pharmacological treatment for COPD

A
  • 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
37
Q

what are the complications of COPD

A
  • respiratory failure

- cor pulmonale

38
Q

what COPD patients should you do an ABG in

A

– FEV1 <30% predicted
– Cor Pulmonale
– Oxygen Saturations <92% on air

39
Q

what does pulmonary rehabilitation include

A
  • All patients functionally disabled by CODP

includes

  • physical training
  • disease education
  • nutritional advice
  • psychological and behavioural support
40
Q

What is the palliative care offered for COPD

A

• 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

41
Q

what criteria is used for COPD exacerbation

A

Anthonisen criteria (AC)

42
Q

What makes up the Anthonisen criteria (AC)

A
  • increased dyspnea
  • increase sputum volume
  • increase sputum purulence
43
Q

what is the differential diagnosis for COPD exacerbations

A
  • Pneumonia
  • Pneumothorax
  • Malignancy
  • PE
  • Heart Failure/ACS
44
Q

What investigations do you use for exacerbations

A

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
45
Q

what organisms often cause COPD exacerbations

A

Often viral

  • H.influenzae
  • M. catarrhalis
  • Streptococcus pneumoniae
46
Q

What is the management of COPD exacerbations

A 
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

47
Q

What oxygen stats do you aim for in COPD

A

88-92%

48
Q

why do you do an ABG in COPD exacerbations

A
  • if hypercapnia
  • exclude acidosis
  • maximise medical therapy
  • NIV if no improvement
49
Q

What are the common causes of external breathlessness and cough

A
  • chest infection
  • asthma
  • angina
  • COPD
  • obesity
  • heart dysfunction
  • pneumonia
  • pulmonary embolism
50
Q

What are the major side effects of bronchodilators

A
  • trembling
  • headaches
  • dry mouth
  • muscle cramps
  • cough
51
Q

What are the major side effects of theophylline

A
  • anxiety
  • arrhythmias
  • diarrhoea
  • dizziness
  • potentially serious hypokalaemia
52
Q

What happens in overdose of theophylline

A
  • vomiting
  • agitation
  • restlessness
  • dilated pupils
  • sinus tachycardia
  • hyperglycaemia
  • Haematemesis
  • convulsions
53
Q

What does theophylline do

A

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.

54
Q

When do patients with COPD get non invasive ventilation

A

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.

55
Q

What is the role of community services in the management of COPD

A
  • smoking cessation
  • pulmonary rehabilitation
  • drug management
56
Q

What are the indications for long term oxygen therapy in patients with COPD

A

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%
57
Q

what is the benefit of long term oxygen therapy

A
  • if you have It at 2l/min for 15-19 hours a day it improves survival
58
Q

What are complications that can develop from COPD

A
  • respiratory failure
  • lung infections
  • collapsed lung
  • sleep problems - obstructive sleep apnoea
  • pneumothorax
  • depression and anxiety
59
Q

What is the management of stable COPD

A

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

60
Q

What is the drug management of stable COPD

A
  • 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
61
Q

What is the prophylactic antibiotic therapy given to COPD patients

A
  • Azithromycin prophylaxis is recommended in selection patients - Check LFTS and exclude QT prolongation before hand
62
Q

What is a sign of increased carbon dioxide

A
  • warm peripheries

Year 3 - CR (44 decks)

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