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Respiratory System > COPD - Clinical Features > Flashcards

COPD - Clinical Features Flashcards

1
Q

What is COPD?

A
  • Chronic Obstructive Pulmonary Disease
  • characterised by its irreversibility.
  • It is made up of chronic bronchitis and emphysema.
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2
Q

How is chronic bronchitis defined?

A

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

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3
Q

What is the pathophysiology of chronic bronchitis?

A
  • chronic infection results in chronic infiltration of the respiratory submucosa by inflammatory cells.
  • resulting in mucous gland hyperplasia and;
  • smooth muscle hypertrophy
  • thickening of airway wall
  • luminal occlusion by secretions of mucous and inflammatory exudate
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4
Q

How is emphysema defined?

A
  • permanently dilated airways distal to the terminal bronchioles with alveolar destruction and bullae formation.
  • associated with alpha-1 antitrypsin and increased elastase activity.
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5
Q

What is the pathophysiology of emphysema?

A
  • alveolar walls are destroyed resulting in bullae formation and the fusion of adjacent alveoli.
  • results in decreased surface area for gas exchange.
  • reduced elastic recoil with subsequent air trapping.
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6
Q

What are the causes of COPD?

6 points

A

GASHES

  • Genetics: alpha-1 antitrypsin deficiency results in loss of protection against proteases (i.e. increased elastase activity).
  • Air pollution
  • Smoking
  • Host factors
  • Exposure (e.g. occupational risk)
  • Second-hand smoke exposure
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7
Q

What is the main cause of COPD?

A

Smoking

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8
Q

What other host factors predispose a person to COPD development?

A

Socio-economic status
Asthma/co-morbidities
Childhood infection

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9
Q

What is the term given to COPD sufferers where chronic bronchitis dominates?

A

Blue bloaters

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10
Q

What is the term given to COPD sufferers where emphysema dominates?

A

Pink puffers

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11
Q

What sort of inflammation occurs in COPD?

A

neutrophilic airway inflammation

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12
Q

After 25 years of smoking, at least _____ of smokers without initial disease will have clinically significant COPD (stage ___ or worse) and ____ will have any COPD.

A

25%
2
30-40%

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13
Q

Smoking in pregnancy may affect ______________ and priming of the _________.

A

Foetal lung development

immune system

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14
Q

How do you calculate pack years?

A

No. smoked per day/no. per pack * No. of years smoked

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15
Q

How many pack years is typical of a COPD patient?

A

> 20

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16
Q

What are the initial typical symptoms presented before COPD diagnosis?

A
  • Shortness of breath
  • Productive cough/sputum
  • Ongoing cough
  • Recurring infections
  • Wheeze

Symptoms will have persisted over a long time and will gradually be getting worse.

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17
Q

What is important to gather from the patient history?

A
  • Age
  • Smoking history
  • Recurrence of symptoms
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18
Q

What are the less common symptoms presented before a COPD diagnosis?

A
  • Weight loss (calorie consumption)
  • Fatigue
  • Decreased exercise tolerance
  • Ankle swelling (if causing heart failure)
  • Cor Pulmonale
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19
Q

What is a typical patient with COPD?

A

40+ years, smoker/ex-smoker, breathless on exertion, cough

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20
Q

What would be the differential diagnosis when diagnosing a 40+ years patient who smokes or has done in the past, is breathless on exertion and has a cough?

A 
COPD
Asthma
Lung cancer
Left ventricular failure
Fibrosing alveolitis
Bronchiectasis
Rarities: TB, recurrent pulmonary emboli
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21
Q

Describe the breathlessness that comes with COPD?

A

Occurs on exertion at first with little variation and has a gradual onset. It worsens until the patient is breathless at rest.

22
Q

Describe the cough and sputum that comes with COPD?

A
  • long history of smokers cough
  • clear or mucoid sputum
  • moves from early morning in winter months to all day in winter to all day all year
23
Q

If there is haemoptysis, is it COPD?

A

No, it could be lung cancer, TB or bronchiectasis.

24
Q

Describe the wheeze associated with COPD.

A
  • minor symptom (not as important as in asthma)

- it is typical on exertion

25
Q

Describe the weight loss associated with COPD?

A
  • not a common symptom

- only occurs in severe cases

26
Q

What causes peripheral oedema in COPD?

A
  • Cor pulmonale: RHF due to chronic pulmonary hypertension.
  • severe disease
  • respiratory failure
27
Q

What is the past medical history of someone with COPD?

A

childhood asthma
respiratory disease
ischaemic heart disease

28
Q

What in the personal and social history of a COPD patient?

A
  • occupation

- smoking history, age started, stopped smoking, cigarettes/day, pack years

29
Q

What findings may be found after conducting a respiratory examination on a patient?

A
  • Cyanosis
  • Raised JVP
  • Cachexia
  • Wheeze
  • Pursed lip breathing
  • Hyper inflated chest/decreased expansion
  • Use of accessory muscles
  • Peripheral oedema
  • Flapping tremor (CO2 retention)
  • <3 finger widths between manubrium and cricoid cartilage
  • Decreased breath sounds (no crackles)
  • Breathlessness walking into clinic/undressing
30
Q

What symptoms come with cor pulmonale?

A
  • increases jugular venous pressure
  • hepatomegaly (large liver)
  • ascites (accumulation of fluid in the abdomen)
  • oedema
  • RV hypertrophy
  • pulmonary hypertension
31
Q

There is no single diagnostic test for COPD.

What must physicians rely on to reach a diagnosis of COPD?

3 points

A

Symptoms, History & Spirometry

32
Q

A COPD diagnosis can be reached if what criteria is met?

5 points

A

Typical symptoms
>35 years
Presence of risk factor (smoking or occupational exposure)
Absence of clinical features of asthma

AND

Airflow obstruction confirmed by post-bronchodilator spirometry (i.e. no reversibility)

33
Q

What investigations may be carried out to help reach a diagnosis of COPD?

5 points

A
  • Spirometry (post bronchodilator)
  • CXR: lung hyperinflation, emphysematous change and diaphragmatic flattening.
  • Bloods: FBC, WCC, alpha-1 antitrypsin
  • ECG: cor pulmonale
  • Sputum culture
34
Q

Which spirometry readings would lead to an obstructive airway diagnosis?

2 points

A

FEV1 value <80% predicted.
FEV1/FVC < 0.7

Post-bronchodilator, demonstrates lack of reversibility

35
Q

What are the stages of the GOLD scale?

How is each stage classified?

A

Stage I: Mild, FEV1 = 80%

Stage II: Moderate, FEV1 = 50-79%

Stage III: Severe, FEV1 = 30-49%

Stage IV: Very severe, FEV < 30%

End Stage COPD (not in scale)

36
Q

What happens to FVC in spirometry with obstructive airway disease?

A

Reduces, but to a lesser extent than FEV1.

37
Q

How can a chest x-ray help in the diagnosis of COPD?

5 points + 1 additional point

A
  • lung hyperinflation
  • bullae
  • vascular hila
  • flattened diaphragm
  • small heart

Excludes alternate pathology + screen for malignancy.

38
Q

When testing lung volumes what happens to residual volume and total lung capacity with COPD?

A

They increase, indication gas trapping.

RV/TLC > 30%

39
Q

When carrying out a carbon monoxide gas transfer test on a COPD patient what are the results?

A

Gas transfer decreases

40
Q

How can you tell the difference between COPD and asthma with full pulmonary function testing?

A
  • In both gas trapping increases so lung volumes increase.

- However gas transfer is only compromised in COPD so results of carbon monoxide transfer will only be lower in COPD.

41
Q

How can you demonstrate fixed airflow obstruction, indicating it is COPD and not asthma?

A
  • minimal bronchodilator reversibility

- minimal response to oral corticosteroids

42
Q

What is the method for bronchodilator reversibility test and what are the results for COPD?

A

Method…
Baseline taken, then reading taken 15 mins post nebulised 2.5-5mg of salbutamol

OR

Baseline, 30 minutes post neb 2.5-5mg salbutamol + 500micrograms ipratropium

Results…
change in FEV1<200ml, change in FEV1 <15% of baseline
(insignificant change)

43
Q

What is the method for the oral corticosteroid test and what are the results for COPD?

A

30-40mg prednisolone daily for 2 weeks (0.6mg/kg)
Measure baseline and final FEV1

Results…
change in FEV1<200ml, change in FEV1 <15% of baseline
(insignificant change)

44
Q

What can cause an acute exacerbation of COPD?

(secondary care)

4 points

A
  • viral/bacterial infection
  • sedative drugs
  • pneumothorax
  • trauma
45
Q

What are the symptoms of AECOPD?

What additional symptoms/signs may be observed in severe exacerbations?

A

Increase in:

  • cough
  • sputum - purulence/volume
  • shortness of breath/chest tightness
  • wheeze
  • oedema
  • pyrexia

Severe:

  • breathless (RR>25bpm)
  • accessory muscles at rest
  • purse lip breathing
  • cyanosis (Sats <92% o/a)
  • fluid retention
  • flapping tremor
46
Q

What tests should be carried out for AECOPD in hospital?

A

CXR
ABG
FBC, U&E (urea and electrolytes)
Sputum culture

47
Q

What is the treatment of an acute exacerbation of COPD in hospital?

A

AABCD OI

Anticholinergics (e.g. ipratropium, nebulised)
Antibiotics
Bronchodilators (e.g. salmeterol, nebulised)
Corticosteroids (oral/IV)
Diuretic

Oxygen therapy (LTOT/NIV)
IV Aminophylline
48
Q

How do you differentiate between asthma and COPD?

A 
Onset - early/later life
Symptoms - vary widely/worsening/time of day
SH - smoker/occupation/exposure
FH - atopic triad
Obesity
49
Q

What questions might you ask in a history that could help differentiate between possible differential diagnosis?

A

Tell me about your cough…
Does it get worse at night…
What about your breathlessness…
Gradually worsening…
Do you or anyone in your family have any allergies, hay fever or eczema?
Tell me about any childhood chest problems?
Tell me about your work?

50
Q

Is night time waking with breathlessness and/or wheeze more common in asthma or COPD?

A

Asthma

51
Q

Where is emphysema commonly located in smokers?

A

Upper zone

52
Q

Severe ventilatory problems can lead to _______ sensitivity of _____ chemoreceptors in medulla therefore some COPD patients develop a “hypoxic drive”

A

reduced

CO2

Respiratory System (26 decks)

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