COPD Flashcards
What is COPD?
- Progressive disorder characterised by airway obstruction with no reversibility
What is the difference between COPD and asthma?
- Asthma is reversible with bronchodilator whereas COPD is not
Chronic bronchitis is defined clinically as?
- chronic productive cough for 3 months over 2 consecutive years
- Sx improve if stop smoking
Emphysema is defined histologically as?
- enlarged air spaces distal to terminal bronchioles
- destruction of alveolar walls and no fibrosis on CT
What are the differentials for COPD?
How do you differentiate COPD from them?
- Lung cancer
- Fibrosis
- HF
- COPD does not cause clubbing
- rarely haemoptysis or chest pain
What are the RF for COPD?
- >35 years
- smoking (passive, active)
- pollution related
- a-1-antitrypsin deficiency
- occupational exposure - coal mining
What are the sx of COPD?
- chronic cough - usually productive
- sputum production
- SOB on exertion
- frequent bronchitis
- wheeze
What are the signs of COPD?
- General
- Tachypnoea
- use of accessory muscles
- hyperinflation
- cyanosis
- cor pumonale
- Palpation
- dec. cricosternal angle
- dec. expansion
- hyperresonant precussion
- Auscultation
- quiet breath sounds
- wheeze
What concerning features will prompt you to think of an alternative diagnosis?
- weight loss
- hemoptysis
- anorexia
- chest pain
- lymphadenopathy
- finger clubbing
- unexplained fatigue
What are the Cx of COPD?
- Acute exacerbations +/- infection
- Respiratory failure T2
- Cor pulmonale
- pneumothorax
- lung cancer
- polycythaemia
What scale would you use to assess the impact of their breathlessness?
Medical Research Council (MRC) Dyspnea Sclae
Describe the MRC Dyspnea scale
*grades 1-5
- Grade 1 – Breathless on strenuous exercise
- Grade 2 – Breathless on walking up hill
- Grade 3 – Breathless that slows walking on the flat
- Grade 4 – Stop to catch their breath after walking 100 meters on the flat
- Grade 5 – Unable to leave the house due to breathlessness
How would you diagnose COPD?
- Clinical presentation
- Spirometry
- Obstructive
Describe the grading of severity of airflow obstruction
*think 4 stages
- Stage 1: FEV1 80% or more of predicted (mild)
- Stage 2: FEV1 50-79% of predicted (moderate)
- Stage 3: FEV1 30-49% of predicted (severe)
- Stage 4: FEV1 <30% of predicted (very severe)
What Ix would you perform for COPD?
- Bedside
- Spirometry - obstructive pattern
- ECG - R A/V hypertrophy, due to cor pulmonale
- BMI
- sputum culture - assess chronic infection
- Bloods
- FBC - polycythaemia
- ABG - low PaO2/ high PaCO2
- Alpha-1 antitrypsin level
- Imaging
- CXR
- CT - assess fibrosis, cancer, bronchiectasis
What CXR features will you see in COPD?
- Hyperexpanded
- Flat hemidiaphragms
- Hypodense
- Large central pulmonary arteries
- Bullae +/-
- cardiomegaly
- sabre-sheath trachea (coronal narrowing with sagittal widening)
What CT features will you see in COPD?
- Bronchial wall thickening
- Scarring
- Airspace enlargement
What are the two tools used to assess severity of COPD?
- BODE index (body mass index, airflow obstruction, Dyspnoea, Exercise capacity)
- GOLD (global initiative for COPD)
What is the BODE index used for?
- predict outcome and number and severity of exacerbations
What is the GOLD tool used for?
- Categorizes severity of COPD into 4 stages absed on post-bronchodilator FEV1%
- Not useful in predicting total mortality for 3 years
What are the conservative mx for COPD?
- Smokig cessation
- Pneumococcal and anual flu vaccine
- education - check inhaler techniique
- pulmonary rehab
- self mx plan - acute excacerbation
How would you Mx chronic stable COPD?
* stepwise mx
First step
- SABA or SAMA, PRN
Second step (Ongoing symptoms despite SABA/SAMA or acute exacerbations)
- LABA+LAMA if no evidence of steroid responsiveness or asthmatic features), OR
- LABA+ICS if evidence of steroid responsiveness or asthmatic features
Third step: offer escalation to triple therapy (LABA + LAMA + ICS)
- Option 1 (already on LABA + LAMA): 3 month trial of triple therapy if clinical features impact quality of life. If no improvement, revert back to LABA + LAMA only
- Option 2 (already on LABA + LAMA): offer triple therapy if 1 severe or 2 moderate acute exacerbations within one year.
- Option 3 (already on LABA + ICS): offer triple therapy if clinical features impact quality of life or 1 severe or 2 moderate acute exacerbations within one year
What are the different types of delivery devices?
- metered dose inhalers (MDI)
- dry powder inhaler (DPI)
- soft mist inhaler (SMI)
- Spacers
- nebuliser
What is the pathophysiology of COPD?
- Small airway disease
- airway inflammation
- airwat fibrosis, luminal plugs
- Inc. airway resistance
- Parenchymal destruction
- loss of alveolar attachments
- decrease elastic recoil
Name an abx used for prophylaxis in COPD?
- Azithromycin
What are the criterias to consider Azithromycin in COPD?
- Pt dont smoke
- Optimised medication and inhalers
- Vaccinated
- Have been reffered to pulmonary rehabilitation
- Experience frequent excacerbation c putum production
What is the dose for Azithromycin?
- 250mg 3tw
What is the pathophysiology of COPD?
Chronic bronchitis
- Goblet cell hyperplasia
- mucus hypersecretion
- Chronic inflammation and fibrosis
- Narrowing of small airways
Alveoli
- alveoli collapse
- bullae formation
Cor pulmonale
- Chronic hypoxia > pulmonary vasoconstriction > increase pulmonary arterial pressure > R sided heart failure
- Inc JVP, cyanosis, ankle oedema, parasternal heave, hepatomegaly
In primary care, when would you refer COPD pt to clinician?
- Diagnostic uncertainty
- Severe COPD (FEV1 < 50%)
- Cor pulmonale
- Assessment for specialist therapy (i.e. long-term oxygen therapy or nebuliser therapy)
- Bullous disease
- Rapid decline in FEV1
- Assessment for surgical intervention (i.e. lung reduction surgery, transplantation)
- Assessment for pulmonary rehabilitation
What are the indications for long term oxygen therapy (LTOT)?
- Arterial Pa02 < 7.3 kPa, OR
- Arterial Pa02 < 8 kPa with any of:
- Pulmonary hypertension
- Peripheral oedema
- Secondary polycythaemia
*pt require 15hrs/day for benefit
What are the Cx of COPD?
- Exacerbated COPD
- T2RF
- Pneumonia
- Pheumothorax
- Polycythaemia vera
- Depression
What surgical options are available for COPD?
- lung reduction surgery
- bullectomy
- lung transplantation
What is the most effective way to stop decrease of FEV1 in COPD?
- Smoking cessation
When will you offer Pt LTOT in COPD?
- pO2 of < 7.3 kPa or
- pO2 of 7.3 - 8 kPa and
- secondary polycythaemia
peripheral oedema
pulmonary hypertension
What factors may improve survival in patients with stable COPD?
- smoking cessation - the single most important intervention in patients who are still smoking
- long term oxygen therapy in patients who fit criteria
- lung volume reduction surgery in selected patients
What advices would you give for pt needing LTOT?
- Pt should be on suplemental O2 for min 15hrs/day
- Warn about risk of fire explosion if they smoke or someone around them smoke
- Offer smoking cessation
- Use oxygen concentrators to provide fixed supply of O2 at home
What is the reasoning for LTOT in COPD?
- Pt c COPD have polycythaemia
- Polycythaemia increases blood viscosity > increases resistance to flow
- High risk of thrombosis
