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Medical conditions > COPD (chronic and acute) > Flashcards

COPD (chronic and acute) Flashcards

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USMLE® Step 1 flashcards
1
Q

Definition of COPD

A

Progressive, irreversible airway obstruction due to a combination of small airway disease (bronchiolitis) and parenchymal destruction (emphysema).

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2
Q

What is emphysema?

A

Pathological permanent enlargement of airspaces distal to the terminal bronchioles and destruction of the alveolar walls.

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3
Q

Definition of chronic bronchitis

A

Cough with sputum production for at least 3 months a year for 2 consecutive years.

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4
Q

What causes the pathophysiological changes found in COPD?

A

Chronic inflammation (caused by inhlaed particles i.e. smoking)

Inflammatory cells (neutrophil, macrophages and lymphocytes) release inflammatory mediators. This leads to airway remodelling, mucus hypersecretion and tissue destruction.

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5
Q

What are the 3 pathophysiological changes found in COPD that causes obstructive airflow?

A
  • Airway remodelling: thickened airways due to increased smooth muscle and fibrosis
  • mucus hypersecretion: stimulated by chronic inflammation
  • tissue destruction: parenchymal destruction —emphysema. Alveoli are progressively destroyed.
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6
Q

How does COPD affect the capillary pressure in the lungs and the heart?

A

Chronic hypoxia leads to thickening of vessel walls and narrowing of pulmonary arteries.

This can increase pulmonary arterial pressure and lead to pulmonary hypertension. > R-sided ventricular hypertrophy/failure, peripheral oedema etc.

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7
Q

Apart from smoking, list 4 other risk factors for COPD?

A
  • Occupation exposure of dust, fumes, chemicals (mining, construction and manufacturing.)
  • Air pollution
  • Alpha-1-antitrypsin deficiency
  • Asthma
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8
Q

When should you suspect COPD in a patient?

A

NICE says to suspect COPD in people >35 with a risk factor and one or more of the symptoms e.g. progressive, breathlessness, worse on exertion, chronic productive cough, wheeze, frequent lower respiratory tract infections e.g. during winter.

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9
Q

List some signs of COPD upon examination (from observation etc.)

A
  • Cyanosis
  • Accessory muscle use, pursed lip breathing
  • Raised JVP
  • Peripheral oedema
  • Hyperinflation of chest
  • On percussion: hyperresonance
  • On auscultation: wheeze, crackles
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10
Q

How do you describe breathlessness that is worse on exertion?

A

Exertional breathlessness

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11
Q

How is COPD diagnosed?

A

Spirometry. FEV1/FVC < 0.7 post-bronchodilator

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12
Q

What is the role of spirometry in COPD patients?

A
  • Diagnosis
  • Monitoring disease progression/severity
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13
Q

What additional test may be performed for patients who have early-onset COPD? They may also have liver disease.

A

Serum alpha-1-antitrypsin

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14
Q

What should you explain to patients upon a diagnosis of COPD?

A
  • What it is —an irreversible and progressive lung conditions
  • Disease progression/complications and ways to manage it: conservative and medical
  • Education on how to use inhalers and what to expect e.g. side effects.
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15
Q

List 3 self-management options for COPD

A
  • Smoking cessation
  • Pulmonary rehabilitation e.g. Keeping healthy e.g. diet, weight loss, exercise, education
  • Vaccination: annual flu and pneumococcal vaccine to reduce risk of infection and exacerbation
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16
Q

What is the first-line medical treatment of COPD?

A

Short acting beta-2- agonist (salbutamol)
or
Short acting muscarinic antagonist (ipratropium bromide)

SABA or SAMA; for relief of breathlessness or exercise limitations

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17
Q

What are the second-line treatments for COPD if there are persistent symptoms after first-line treatments?

Which feature determines whether to add steroids or not?

A

Continue or switch to SABA
AND
start maintenance therapy: LABA + inhaled corticosteroid if with asthmatic features or LABA+LAMA

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18
Q

List some asthma features/steroid responsive features in COPD patients.

A
  • Previous diagnosis of asthma or atopic illness
  • FEV1 variation >400mls
  • Peak flow diurnal variability or >20%
  • Elevated blood eosinophil count
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19
Q

What is triple inhaled therapy? When is it indicated?

A

LABA + LAMA + ICS

Indicated for patients with severe COPD e.g. grade 3-4 with day-to-day symptoms and exacerbations, despite dual therapy.

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20
Q

What are some long-acting beta agonists?

A

Salmeterol, formeterol

21
Q

Give an example of a SAMA and LAMA.

A
  • SAMA: ipratropium
  • LAMA: Tiotropium, aclidinium, umeclidinium
22
Q

What is a common combination inhaler brand?

A

Ellipta (LABA+LAMA)

23
Q

How do muscarinic antagonists e.g. SAMAs/LAMAs improve COPD?

A
  • Bronchodilation: relaxes airway smooth muscle
  • Reduces inflammation
  • Decreases mucus production.

By blocking M3 mAchRs.

24
Q

What are common side effects of inhaled B2 agonists? Which electrolyte imbalance might it cause?

A

Tremors, tachycardia, palpitations, headache, and muscle cramps.

Can also cause hypokalaemia.

25
Q

How should you instruct a patient on how to use a metered-dose inhaler?

A
  1. Shake the inhaler
  2. Take a deep breath out before closing your lips around the mouthpiece of the inhaler
  3. Press the dose-release button and breathe in slowly and deeply.
  4. Hold your breath for about 10 seconds
  5. Breathe out slowly.
  6. Wait 30-60s if another dose is needed.

Ask patient to repeat after.

Propellent is used in the mist

26
Q

What are the differences between dry-powdered inhalers?

A

There is no need to press a dose-release button, but requires patient’s sharp and deep inhalation.

27
Q

Why is good inhaler technique important and how would you explain this to a patient?

A

Explain this before instructing patient of inhaler technique.

Good technique is essential for ensuring the medication reaches their lungs for its therapeutic effects. It also reduces the chance of side effects associated with steroids e.g. oral thrush.

28
Q

Do all patients need to rinse their mouths after inhaler use?

A

No. Only those which has steroid.

29
Q

What are infective causes of COPD exacerbations? List 3 viral and 3 bacterial causes.

A
  • Rhinovirus
  • Influenza virus
  • Respiratory syncytial virus (RSV)
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Moraxella catarrhalis
30
Q

List 4 non-infective causes of COPD.

A
  • Psychological: stress and anxiety
  • Environmental: cold weather, air pollution
  • Allergens: pollen, dust mites, animal dander
  • Medication non-adherence
31
Q

What is an important feature in a COPD patient’s history that may suggest an infective exacerbation?

A

Recent upper respiratory tract infection (past 5 days)

32
Q

What are some symptoms that suggest COPD exacerbation?

A
  • Worsened dyspnoea (reduced air entry)
  • Worsened cough and sputum - plurulence, amount
  • Wheezing
  • Fatigue, malaise
33
Q

What is the name of right-sided heart failure that originates from lung disease? How may it present?

A

Cor pulmonale

May cause raised JVP, peripheal oedema, fatigue etc.

34
Q

What are complications of COPD exacerbations i.e. which conditions are patients at risk of?

A
  • Pneumonia
  • PE
  • Cardiac disease e.g arrythmias
  • Worsening diabetes
35
Q

What are 3 important bedside investigations for COPD exacerbation patients?

A
  • Vital signs: pulse oximetry
  • ECG - to rule out comorbidities and make sure there are no cardiac complications
  • Take sputum culture
36
Q

What are some blood tests and first line imaging for investigating COPD exacerbation?

A
  • FBC, UnE - might show infection, polycythaemia
  • ABG - for respiratory failure
  • Blood culture if feverish.
  • Chest X-ray
37
Q

What blood gas results may indicate a type two respiratory failure?

3 domains

A
  1. Respiratory acidosis (pH <7.35)
  2. PaO2 < 8 kPa
  3. PaCO2 > 6 kPA
38
Q

What are 3 components of managing COPD exacerbations?

A
  1. Oxygenation - target 88-92%
  2. Bronchodilation and reduction of inflammation
  3. Treatment of underlying or presumed infection.
39
Q

How might you achieve good oxygenation in COPD patients? Give 2 ways.

A
  • Venturi mask (24% at 2-3L or 28% at 4L) - These are lowest. Blue or white masks.
  • Nasal cannula flow rate 1-2L/min

88-92%

40
Q

What five colours do venturi masks come in? What is the lowest O2 concentration and what is the highest?

A
  • Blue: Imagine a calm blue sky, representing the lowest oxygen concentration (24%).
  • White: Think of a white cloud, slightly higher up in the sky (28%).
  • Yellow: Picture a bright yellow sun, providing more energy (35%).
  • Red: Visualize a red hot air balloon, higher and more intense (40%).
  • Green: Imagine a lush green forest, representing the highest concentration (60%)
41
Q

What are adjustements to short-acting bronchodilation therapy for COPD exacerbation? I.e. changes to salbutamol.

A

Increase frequency and dose. Use nebulisation if needed.

42
Q

What additional medication is given in COPD exacerbation. What dose for how many days?

A

PO 30mg prednisolone once daily for 5 days.

43
Q

First-choice antibiotics for COPD exacerbation.

A

Amoxicillin

44
Q

What is an additional drug that can be used as an adjunct if patient is not responding to nebulisedi bronchodilators?

What is a cautionary test?

A

Theophylline.

Should monitor theophylline levels

45
Q

What should be done before discharge of a COPD exacerbation patient?

A
  • Spirometry tests
  • Optimisation of maintenance therapy.
46
Q

During a review for COPD, what key elements should be discussed?

A
  • Disease progression and effects of treatment
  • Mental health
  • Management: smoking status and motivations, rehab activities e.g. diet and exercise, vaccines, inhaler technique

https://www.nice.org.uk/guidance/ng115/resources/chronic-obstructive-pulmonary-disease-in-over-16s-diagnosis-and-management-pdf-66141600098245#page45

47
Q

What is LTOT and what is the criteria for being started on it?

A

LTOT - administration of oxygen for more than 15 hours a day, aimed at increasing life expectancy, reducing complications, and improving quality of life.

Criteria: people with advanced COPD.
ABG taken at 2 occasions, 3 weeks apart of
1. PaO2 < 7.3 or
2. PaO2 <8 with complicated features e.g. cor pulmonale (pulmonary hypertension, peripheral oedema), secondary polycythaemia

In patients with stable COPD management and are not smoking.

48
Q

What is the main risk of LTOT? What safety information should you provide?

A

Burns and fires - no smoking and neighbors smoking, including e-cigarettes.

Medical conditions (19 decks)

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