COPD, acute exacerbation Flashcards
define COPD?
progressive and irreversible obstructive airway disease
which two diseases fall under the umbrella of COPD?
emphysema and chronic bronchitis
is asthma part of COPD?
no
is COPD progressive?
yes
is COPD reversible or irrerversible?
irreversible
if an enzyme is a protease, what exactly does it do?
proteolysis; breaks down protein
elastase is what type of enzyme?
protesase
what protein does elastase break down?
elastin
which molecule counteracts elastase?
alpha-1-antytripsin
what class of molecule is alpha-1-antytripsin?
anti-protease
Emphysema is an imbalance between what proteins?
which protein is greater?
what effect does this have on lung tissue
elastase > alpha-1-antitrypsin
elastin broken down
how does elastin broken down in emphysema change alveoli?
fewer, larger alveoli
how does elastin broken down in emphysema change the passive part of exhaling?
how will this change the shape of the lungs? and shape of ribcage?
how will this look on CXR
lung can not recoil.
lungs stay hyperinflated,
rib cage expanded
CXR: big lungs with lots of black (air)
which epithet is used to describe emphysema patients?
pink puffers
which epithet is used to describe chronic bronchitis patients?
blue bloaters
Who and why are they called pink puffers?
emphysema
pink - skin is pink early on, (blue in later stages).
puffers - pursed lip breathing
Who and why are they called blue bloaters?
chronic bronchitis
blue skin
bloaters - fat
someone has pure emphysema, what are the classical characteristics they will show?
- 4 in total
pink skin
pursed lip breathing
muscle wasting
barrel chest
what happens to cilia in chronic bronchitis?
paralysed
define chronic bronchitis?
mucus hypersecretion secondary to ciliary paralysis
what is the obstruction in chronic bronchitis?
mucus in airways
in chronic bronchitis how will the histology look of the goblet cells,
what is the function of the goblet cells?
goblet cell hypertrophy and hyperplasia
make mucus
how exactly does smoking cause emphysema
smoking –>macrophage + neutrophils activated –> these make ↑elastase –> destroys alveoli (emphysema)
what does smoking do to mucus production?
mucus hypersecretion
Risk factors for COPD
- 5 things
Age Smoking Air pollution Occupation exposure A1AT deficiency – younger diagnosis
why is it that anything causing chronic inflammation of lungs can give you COPD and not just smoking?
aside from smoking what else can cause chronic lung inflammation?
- 2 things
lung inflammation –> macrophages + neutrophils activated –> these cells make proteases –> protease destroys harmful stuff & also healthy tissue.
but if chronically inflamed you will get chronic ↑ proteases –> chronic damage of healthy tissue –> COPD
air pollution occupation exposure (asbestos)
Complications of COPD?
- 5 things
Acute exacerbation Cor pulmonale Type 1 or 2 resp failure Secondary polycythaemia Pneumothorax
what is essentially the underlying cause of COPD
chronic inflammation of lungs
what is the pathway for how COPD causes cor pulmonale?
Severe COPD –> Pulmonary HTN –> R. Sided heart failure, i.e. cor pulmonale.
define cor pulmonale?
right sided haeart failure due to lung disease
how does COPD cause pulmonary HTN?
- give step by step pathway
COPD –> hypoxia in lungs –> vasculature remodels + lose capillaries in emphysema –> pulmonary HTN
what effect does emphysema have on capillaries in lungs?
lose capillaries
define polycythaemia?
↑[RBC] in blood
why is there secondary polycythaemia in COPD?
compensation for chronic hypoxia
someone has COPD,
on auscultation what do you classically hear?
and why?
wheeze
narrowed airways (mucus filled) & fewer alveoli.
symptoms of COPD
- 3 things
SOB
Productive cough
Wheeze
signs of COPD
-6 things
explain why you get each one?
Tachypnoea – SOB
Barrel chest – air in lungs, rib cage expanded
Hyperresonance on percussion – air in lungs
Wheeze – narrow airway
Tar staining – smoking
Peripheral cyanosis – chronic hypoxia
GOLD.S IX for COPD?
What is a positive result?
Spirometry and bronchodilator reversibility
FEV1/FVC < 0.70 and no reversibility post-bronchodilator is +ive result
what is the FEV1/FVC ratio for obstructive lung disease?
FEV1/FVC < 0.70
what is GOLD.S IX for COPD?
asides from the gold.S Ix what other Ix will you do for a pt suspected of COPD and what are you looking for/why do you do this?
- 3 IX
Spirometry and bronchodilator reversibility
CXR – flat diaphragm, hyperinflation and bullae.
check lung cancer
FBC – polycythaemia
BMI - weight changes in COPD
what does Serum A1AT look for?
when would this be indicated in a pt with COPD, what are you looking for?
alpha-1-antytripsin
if symptoms are early onset, or no smoking history, alpha-1-antytripsin
inherited disorder
alpha-1-antytripsin deficiency is a non-inherited disorder.
true or false?
false
very young pt who has never smoked has COPD symptoms, grandfather had the same problem
what could be the cause of their COPD?
which Ix will help diagnose this?
alpha-1-antytripsin deficiency
Serum A1AT
a doctor does an ECG on someone with COPD, what condition is he looking for?
What features on an ECG will be +ve for this condition?
- 2 thigns
R. Sided heart failure
right BBB or right axis deviation
pt has acute exacerbation of COPD.
You want to check their lactate and assess what type (1 or 2) resp failure they have.
Which Ix do you use?
ABG
pt has acute exacerbation of COPD. you suspect an infective cause.
What Ix do you do to confirm infection and confirm the infective organism?
Sputum culture
What are the two common options for nicotine replacement?
varenicline
bupropion
pt has COPD,
what two vaccinations should they get?
one off pneumococcal & annual influenza
pt has chronic productive cough, what is the 1st line therapy?
Oral Mucolytic therapy
pt has COPD and is on treatment for this.
but now develops cor pulmonale, what is the additional management for this?
-2 things (name drug)
Furosemide
long term O2 therapy
COPD pt cannot tolerate his inhaled medication.
What drug do you give?
class of this drug?
MOA of this drug?
Theophylline
bronchodilator
relaxes bronchial smooth muscle.
pt with COPD, but he is refractory to bronchodilator therapy.
which drug can help this?
Roflumilast
pt newly diagnosed with COPD
what is the 1st line medical MX for all patients?
1st: SABA or SAMA
pt newly diagnosed with COPD.
what is the most effective intervention to treat him?
stop smoking
pt newly diagnosed with COPD. he is asthma/steroid responsive.
his SABA and SAMA does not help.
What is the next Medical MX?
LABA + ICS
pt newly diagnosed with COPD. he is asthma/steroid irresponsive.
his SABA and SAMA does not help.
What is the next Medical MX?
LABA + LAMA
pt newly diagnosed with COPD . he is put on 1st line drug management.
What is the drug class? (2)
the drug is working, so what should his management be?
1st: SABA or SAMA
continue with SABA/SAMA
pt has COPD, he is asthma responsive.
SABA/SAMA is ineffective.
LABA + ICS also ineffective.
What is the next cocktails of drugs for him?
LABA + LAMA + ICS
define Acute Exacerbation of COPD
an acute worsening of respiratory symptoms.
what could trigger an acute exacerbation of COPD?
- 3 things
what do these triggers do to inflammation?
infection, air pollutants, allergens
↑inflammatory cells
what is the most common trigger for an acute exacerbation of COPD?
infection
As COPD worsens the acute exacerbations get worse
true or false?
true
Some exacerbations are very long and thus deteriorate lung function permanently
true or false?
true
all infective exacerbations are bacterial.
true or false?
false
why exactly does an inflammatory trigger worsen COPD symptoms
inflammatory trigger –> ↑macrophages + neutrophils –> ↑↑↑mucus, bronchoconstriction, ↑proteases –> symptoms worse
most common infective cause for acute exacerbation of COPD in smokers?
Haemophilus influenzae
most common viral cause for acute exacerbation of COPD in smokers?
Rhinovirus
someone has acute exacerbation of COPD.
what is the hallmark symptom to suggest an infective trigger?
↑sputum + changes colour
signs of acute exacerbation of COPD.
- 5 things
Hypoxic Tachypnoea Acute confusion New-onset peripheral oedema New-onset cyanosis
pt has acute exacerbation of COPD.
What is the initial assessment (1st line) comprised of?
- 4 things
Vitals
GCS – confusion
Examine chest
Check ability to cope at home
how is acute exacerbation of COPD diagnosed?
Clinical diagnosis
is a sputum culture routinely done for acute exacerbation of COPD?
no
pt has acute exacerbation of COPD, there are sputum changes?
What is line Mx?
- 3 things
↑bronchodilator
Prednisolone 30mg 7-14 days
AB
pt has acute exacerbation of COPD.
which steroid is given, dose, how long?
Prednisolone 30mg 7-14
which AB are 1st line for acute exacerbation of COPD?
what is the mnemonic for this?
amoxicillin, clarithromycin, doxycycline
abc easy as adc
pt has acute exacerbation of COPD.
what features would make you admit them to hospital?
- 6 things
Severe breathlessness O2 sats <90% Acute confusion Can’t cope at home (or living alone) Already on LTOT Changes on CXR
pt has acute exacerbation of COPD.
what feature is required for antibiotic prescription?
sputum changes
pt comes to A&E with acute exacerbation of COPD.
he is assessed and told he can go home.
which Mx is used for all of these patients who go home?
1st Line: ↑short acting bronchodilator
pt comes to A&E with acute exacerbation of COPD.
he is assessed and told he can go home. he is put on ↑short acting bronchodilator but says he struggles with daily activities.
what drug is now indicated?
Prednisolone
pt has acute exacerbation of COPD and is told he can be managed at home.
at home he struggles with daily activities because of his symptoms.
what drug is now indicated?
Prednisolone
pt has acute exacerbation of COPD, no sputum culture is done but he is on put AB.
when is a sputum culture done for acute exacerbation of COPD?
If AB have not worked – then send sputum culture
should all exacerbations be followed up.?
and is so when?
yes
after 6 weeks
emphysema etymology?
emphusan - puff up
sama stand for what?
short acting muscarinic antagonists ipratropium
sama example?
ipratropium
