COPD - Clinical Features Flashcards
What is COPD?
- Chronic Obstructive Pulmonary Disease
- characterised by its irreversibility.
- It is made up of chronic bronchitis and emphysema.
How is chronic bronchitis defined?
Cough with sputum production for at least 3 months in 2 consecutive years.
What is the pathophysiology of chronic bronchitis?
- 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
How is emphysema defined?
- permanently dilated airways distal to the terminal bronchioles with alveolar destruction and bullae formation.
- associated with alpha-1 antitrypsin and increased elastase activity.
What is the pathophysiology of emphysema?
- 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.
What are the causes of COPD?
6 points
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
What is the main cause of COPD?
Smoking
What other host factors predispose a person to COPD development?
Socio-economic status
Asthma/co-morbidities
Childhood infection
What is the term given to COPD sufferers where chronic bronchitis dominates?
Blue bloaters
What is the term given to COPD sufferers where emphysema dominates?
Pink puffers
What sort of inflammation occurs in COPD?
neutrophilic airway inflammation
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.
25%
2
30-40%
Smoking in pregnancy may affect ______________ and priming of the _________.
Foetal lung development
immune system
How do you calculate pack years?
No. smoked per day/no. per pack * No. of years smoked
How many pack years is typical of a COPD patient?
> 20
What are the initial typical symptoms presented before COPD diagnosis?
- 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.
What is important to gather from the patient history?
- Age
- Smoking history
- Recurrence of symptoms
What are the less common symptoms presented before a COPD diagnosis?
- Weight loss (calorie consumption)
- Fatigue
- Decreased exercise tolerance
- Ankle swelling (if causing heart failure)
- Cor Pulmonale
What is a typical patient with COPD?
40+ years, smoker/ex-smoker, breathless on exertion, cough
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?
COPD Asthma Lung cancer Left ventricular failure Fibrosing alveolitis Bronchiectasis Rarities: TB, recurrent pulmonary emboli
Describe the breathlessness that comes with COPD?
Occurs on exertion at first with little variation and has a gradual onset. It worsens until the patient is breathless at rest.
Describe the cough and sputum that comes with COPD?
- 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
If there is haemoptysis, is it COPD?
No, it could be lung cancer, TB or bronchiectasis.
Describe the wheeze associated with COPD.
- minor symptom (not as important as in asthma)
- it is typical on exertion
Describe the weight loss associated with COPD?
- not a common symptom
- only occurs in severe cases
What causes peripheral oedema in COPD?
- Cor pulmonale: RHF due to chronic pulmonary hypertension.
- severe disease
- respiratory failure
What is the past medical history of someone with COPD?
childhood asthma
respiratory disease
ischaemic heart disease
What in the personal and social history of a COPD patient?
- occupation
- smoking history, age started, stopped smoking, cigarettes/day, pack years
What findings may be found after conducting a respiratory examination on a patient?
- 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
What symptoms come with cor pulmonale?
- increases jugular venous pressure
- hepatomegaly (large liver)
- ascites (accumulation of fluid in the abdomen)
- oedema
- RV hypertrophy
- pulmonary hypertension
There is no single diagnostic test for COPD.
What must physicians rely on to reach a diagnosis of COPD?
3 points
Symptoms, History & Spirometry
A COPD diagnosis can be reached if what criteria is met?
5 points
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)
What investigations may be carried out to help reach a diagnosis of COPD?
5 points
- Spirometry (post bronchodilator)
- CXR: lung hyperinflation, emphysematous change and diaphragmatic flattening.
- Bloods: FBC, WCC, alpha-1 antitrypsin
- ECG: cor pulmonale
- Sputum culture
Which spirometry readings would lead to an obstructive airway diagnosis?
2 points
FEV1 value <80% predicted.
FEV1/FVC < 0.7
Post-bronchodilator, demonstrates lack of reversibility
What are the stages of the GOLD scale?
How is each stage classified?
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)
What happens to FVC in spirometry with obstructive airway disease?
Reduces, but to a lesser extent than FEV1.
How can a chest x-ray help in the diagnosis of COPD?
5 points + 1 additional point
- lung hyperinflation
- bullae
- vascular hila
- flattened diaphragm
- small heart
Excludes alternate pathology + screen for malignancy.
When testing lung volumes what happens to residual volume and total lung capacity with COPD?
They increase, indication gas trapping.
RV/TLC > 30%
When carrying out a carbon monoxide gas transfer test on a COPD patient what are the results?
Gas transfer decreases
How can you tell the difference between COPD and asthma with full pulmonary function testing?
- 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.
How can you demonstrate fixed airflow obstruction, indicating it is COPD and not asthma?
- minimal bronchodilator reversibility
- minimal response to oral corticosteroids
What is the method for bronchodilator reversibility test and what are the results for COPD?
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)
What is the method for the oral corticosteroid test and what are the results for COPD?
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)
What can cause an acute exacerbation of COPD?
(secondary care)
4 points
- viral/bacterial infection
- sedative drugs
- pneumothorax
- trauma
What are the symptoms of AECOPD?
What additional symptoms/signs may be observed in severe exacerbations?
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
What tests should be carried out for AECOPD in hospital?
CXR
ABG
FBC, U&E (urea and electrolytes)
Sputum culture
What is the treatment of an acute exacerbation of COPD in hospital?
AABCD OI
Anticholinergics (e.g. ipratropium, nebulised)
Antibiotics
Bronchodilators (e.g. salmeterol, nebulised)
Corticosteroids (oral/IV)
Diuretic
Oxygen therapy (LTOT/NIV) IV Aminophylline
How do you differentiate between asthma and COPD?
Onset - early/later life Symptoms - vary widely/worsening/time of day SH - smoker/occupation/exposure FH - atopic triad Obesity
What questions might you ask in a history that could help differentiate between possible differential diagnosis?
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?
Is night time waking with breathlessness and/or wheeze more common in asthma or COPD?
Asthma
Where is emphysema commonly located in smokers?
Upper zone
Severe ventilatory problems can lead to _______ sensitivity of _____ chemoreceptors in medulla therefore some COPD patients develop a “hypoxic drive”
reduced
CO2
