COPD clinical features and management Flashcards
What is the definition of Chronic Pulmonary Obstructive Disease?
Lung disease characterised by chronic obstruction of the lung airflow that interferes with normal breathing and is not fully reversible.
Airflow limitation is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases
Describe prevalence and incidence of COPD
1.2 million living with diagnosis and 50% undiagnosed in the UK
Prevalence is increasing
Incidence is decreasing
More males than females but is plateauing
What are factors that can cause COPD?
Smoking
Biomass fuel cooking - areas of deprivation
Air pollution
Occupation
Increase in age and if female
What are modifiable factors that can cause COPD?
Smoking
Biomass fuel cooking
Air pollution
Occupation
What are some non-modifiable factors that can lead to COPD?
Increase risk as age increases
Increase risk in females
Lower socioeconomic status
Asthma
Chronic bronchitis
Childhood infection
Explain Alpha-1 Antitrypsin deficiency
Rare, inherited disease, presents with early onset COPD in under 45 year olds.
Alpha-1 antitrypsin (AAT) is a protease inhibitor made in liver - limits damage caused by activated neutrophils which release elastase in response to infection/
cigarette smoke
Basal predominance to emphysema, liver fibrosis and cirrhosis
What are the risks of smoking that are linked to respiratory disease?
Greater annual rate of decline in FEV1 and greater COPD mortality than non-smokers
More than 50% of smokers develop COPD
What does smoking during pregnancy cause?
May affect foetal lung growth - smaller lungs and affects priming of the immune system
What are the main symptoms of COPD?
Cough, Breathlessness, Sputum, Frequent chest infections and Wheezing
Other symptoms - weight loss, fatigue, swollen ankles, age, smokigh, onset
What examinational findings could be found in a patient with COPD?
Cyanosis, Raised JVP, Cachexia, Wheeze, Pursed lip breathing, Hyperinflated chest, Use of accessory muscles and Peripheral oedema
What is the process of diagnosing COPD?
No single diagnostic test
Symptoms, History and Spirometry
What is the criteria for diagnosing COPD?
Typical symptoms
Above 35 years
Presence of risk factor - smoking or occupational exposure
Absence of clinical features of asthma
Airflow obstruction confirmed by post-bronchodilator spirometry
How does spirometry help diagnose a patient with COPD?
It diagnoses airflow obstruction
FEV1/FVC is less 0.7 after bronchodilator - COPD
Explain the stages of COPD and the values of spirometry expected?
Mild - 80% FEV1/FVC so diagnosis of COPD off of symptoms
Moderate - 50-79%
Severe - 30-49%
Very severe - FEV1 less than 30% of predicted
End stage COPD - used in practice
How can a chest X-ray be useful in diagnosis?
Excludes other pathologies and screen for malignancy.
X-ray can show vascular hila, hyperinflation, bulla, small heart and flat diaphragm
What are the specialist features of COPD?
Onset in mid-life
Symptoms slowly progressive
History of tobacco smoking or exposure to other types of smoke
Explain some differences between COPD and asthma
Symptoms under age of 35 are rare in COPD but often in asthma
Chronic productive cough in COPD
Breathlessness is persistent and progressive in COPD and in asthma is variable
Asthma is common for night time waking and wheezing
Variability of symptoms is uncommon in COPD and common in asthma
What can a pulmonary function test show about lung volumes?
Can show emphysema
There would be an increase in residual volume so increase in total lung capacity
RV/TLC> 30%
What can a pulmonary function test show about transfer factor?
Can show COPD over asthma if reduced gas transfer
Decrease in DLco and Kco
What can radiology (HRCT) help show to help diagnose?
Can show upper zone emphysema in smokers
Lobules can show lack of lung tissue
What are the worsening symptoms which can show acute exacerbations of COPD?
SOB, wheeze, chest tightness, cough, sputum (possible colour change), unable to smoke, systemic upset, temp. and fatigue
What are the signs of a severe acute exacerbation of COPD?
RR > 25/min
Accessory muscles in use
Cyanosis - sats<92%
Purse lip breathing
Confusion, fluid retention and signs of sepsis
What can be a trigger for an acute exacerbation of COPD?
Viral/bacterial infection, sedative drugs, pneumothorax and trauma
What test would you conduct if a patient is having an acute exacerbation in secondary care?
Chest X-ray, Arterial blood gases, Full blood count, U&E (kidney function test), Sputum culture and Viral throat swab
How would you measure severity in acute exacerbation of COPD?
Spirometry
Nature and magnitude of symptoms
History of exacerbations and future risk
Presence of co-morbidity - heart disease, obesity..
What could severe disease of COPD cause?
Respiratory failure - caused by reduction ventilation and perfusion
Type 1 - decreased pO2
Type 2 - decreased pO2 and increased pCO2 - causes drowsiness and shows flapping tremor
Cor pulmonale
Secondary polycythaemia
What is Cor pulmonale?
Right sided heart disease due to lung disease
Thickened muscle on right with increases pressure on left
Pulmonary vessels affected - hypoxia
Can cause tachycardia, oedematous, raised JVP and congested liver
What is secondary polycythaemia?
Raised Hb level
Body produces more more erythropoietin in response to low O2
Increased Hb and haematocrit
Increases blood velocity
What is the clinical diagnosis of chronic bronchitis?
Daily productive cough for 3 months or more, in at least 2 consecutive years
What are the signs of a blue bloater?
This is for chronic bronchitis
Overweight and cyanotic
Elevated haemoglobin
Peripheral oedema
Rhonchi and wheezing
What is the pathological diagnosis of emphysema?
Permanent enlargement and destruction of airspaces distal to the terminal bronchiole
What are the signs of a pink puffer?
This is for emphysema
Older and thin
Severe dyspnoea
Quiet chest
X-ray shows hyperinflammation with flattened diaphragms
What is the end stage of COPD?
Terminal illness
Unpredictable decline
Breathlessness and anxiety
In tripod position, frail, may need O2
What are the vaccinations needed in non-pharmacological management in COPD?
Annual flu vaccine
Pneumococcal vaccine
What are the non-pharmacological ways to manage COPD?
Smoking cessation
Vaccinations
Pulmonary rehabilitation
Nutritional assessment
Physchological support
Explain pulmonary rehabilitation
6 week course of physio
Occupational therapy
Includes dieticians
and phychological support
What are the benefits of pharmacological management?
Relieve symptoms, prevent exacerbations and improve quality of life
What are the types of inhaled therapy used in COPD?
Short acting bronchodilators - SABA and SAMA
Long acting bronchodilators - LAMA and LABA
High dose inhaled corticosteroids (ICS) and LABA - Relvar and Fostair MDI
What are the types of short acting bronchodilators?
SABA - salbutamol
SAMA - ipratropium
What are the types of long acting bronchodilators?
LAMA - Umeclidinium, Tioptropium
LABA - salmeterol
When is long term O2 given to patients with COPD?
Stop smoking for 6 months and are hypoxic
PaO2 < 7.3 kPa or PaO2 7.3-8 kPa if polycythaemia, nocturnal hypoxia, peripheral oedema and pulmonary hypertension
What are the types of management used in primary care with acute exacerbations COPD?
Short acting bronchodilators - salbutamol or/and ipra, neb if cant use inhaler
Steroids - prednisolone 40mg for 5-7days
Antibiotics - viral infection
Consider hospital admission - low O2 sat, hypertension and tachypnoea
What investigations would be required when a AECOPD patient is admitted to hospital?
Full blood count, Biochemistry and glucose, Theophylline conc., Arterial blood gases, Electrocardiograph, CXR, Blood cultures in febrile patients and sputum microscopy
What are the types of ward based managements for AECOPD?
O2 target saturation 88-92%
Nebulised bronchodilators
Corticosteroids
Antibiotics (oral or IV)
Assess for respiratory failure
What would you give a patient who has acute respiratory failure - AECOPD?
Non-invasive ventilation
What does palliative care for COPD look like?
Management of breathlessness and dysfunctional breathing - morphine, psychological support
Anticipatory care plan - DNACPR, hospital, ceiling of treatment
