COPD Exercebation Flashcards
what are the main symptoms of COPD?
what happens without treatment
- increasing breathlessness, particularly on exertion
- persistent chesty cough with phlegm – some people may dismiss this as just a “smoker’s cough”
- frequent chest infections
- persistent wheezing
Without treatment, symptoms progressively gets worse.
There can be also periods of exercebation
What are the causes of COPD?
Main cause is smoking (90% of COPD have smoked)
However it can happen in people who have never smoked before!
Long term exposure to harmful fumes or dust (at eork)
Air pollution
Rare- Genetics
what are the possible treatments for COPD and what should you recognise about this treatment
Damage is permanent but. treatment slows down progression.
Treatments:
- stopping smoking – if you have COPD and you smoke, this is the most important thing you can do
- inhalers and medicines – to help make breathing easier
- pulmonary rehabilitation – a specialised programme of exercise and education
- surgery or a lung transplant – although this is only an option for a very small number of people
what is the prognosis for COPD?
it vary slightly from person to person however IT CANNOT BE CURED/REVERSE
Treatment can help keep in under control so you can perfom ADLs
In some, COPD gets worse despite treatments- lead to lessened quality of life and life threatening problems
what is the main way of preventing COPD
Stopping smoking- the earlier the better (use nHS stop smoking services)
what is COPD and when (age) do pts normally feel symptoms
Combination of emphysema and chronic bronchitis
Develops slowly and pts do not normally feel symptoms until they are in theri 40s or 50s
What are the less common symptoms of COPD? and when does it happen. Give relevant details
- weight loss
- tiredness
- ankle oedema
- chest pain and haemotypsis– although these are usually signs of another condition, such as a chest infection or possibly lung cancer
This tend to occur when COPD is in advanced stage
when should you get medical advice? what will the GP do
if you have persistent symptoms of COPD especially if you’re over 35 and smoke/used to smoke
the GP will do multiple breathing tests on you to help determine if you have COPD or other conditions like:
- asthma
- bronchietacsis
- anaemia
- Heart failure
They have similar symptoms
How does smoking cause COPD?
The harmful chemicals in smoke can damage the lining of the lungs and airway.
Passive smoking can also increase risk
what are the substances that can linked to COPD if you’re exposed to them over a long period of time?
- cadmium dust and fumes
- grain and flour dust
- silica dust
- welding fumes
- isocyanates
- coal dust
Risk is higher if you breathe in these chemical AND you smoke
Describe and explain the evidence behind air pollution causing COPD
Expsoure to air pollution over a long time can affect how lungs works
Hence could increase risk of COPD
However the evidence suggesting this link isn’t robust enough
Explain the part genetics play in the causation of COPD
Increased risk of getting COPD if you smoke and have a close relative with COPD
Some genes make you susceptible to getting COPD: alpha- 1- antitrypsin deficiency.
A1-antitrypsin protects lung from damage
10% of people with COPD have this genes.
They also tend to develop COPD at a younger age
what are the 2 charities for peopl affected by A1-antitrypsin deficiency
Alpha-1 Awareness
Alpha-1 UK Support Group
if you go to the GP about persistent COPD symptoms, what will the GP do
Ask bout HPC, FHx
They’ll calculate BMI and assess your smoking status (pack years)
Chest examination: auscultation of chest
Investigations:
- Spirometry
- Bloodt tests
- CXR
- Further specialised tests
How will a GP conduct a spirometry test for a pt presenting with persistent COPD symptoms
Breathe into spiromoter after inhaling bronchodilator
it measures: FEV1 and FVC
Results are compared with normal for your age group
why might a GP order a CXR?
Help to exclude or find other problems like:
- Chest infections
- lung cancer
N.B. they do not always show
why do GP carry put blood tests
It helps to find out if there are other diagnosis that causes same symptoms of COPD like:
- anaemia
- polycythaemia
Can also be used to find out if you havew A1-antitrypsin deficiency
what furthert test may GP carry out to confrim diagnosis or determine severity of COPD?
ECG
Echocardiogram – an ultrasound scan of the heart
Peak flow test – a breathing test that measures how fast you can blow air out of your lungs, which can help rule out asthma
Pulse Oximetry
CT scan – a detailed scan that can help identify any problems in your lungs
Phlegm sample – a sample of your phlegm (sputum) may be tested to check for signs of a chest infection
what different bronchodilator inhaler therapies may be given to a pt with COPD.
give examples and when can it be used.
give any other relevant details
Short acting bronchodilators:
- most first line treatment
- They should be used when you feel breathless up to max of 4 times a day
- SABA- e.g salbutamol or terbutaline
- SAMA- e.g ipratropium.
Long acting bronchodilators:
- used if they’re experiencing symptoms throughout the day. it lasts 12 hrs
- use only 1 or 2 times a day
- LABA: e.g salmeterol, formeterol and idacaterol
- LAMA- e.g tiotropium, glycopyronium and acidinium
Some inhlaers contain LABA and LAMA
when is steroid inhaler therapy used and give relevant details
used when:
- you’re still breahtless despite long-acting inhaler or
- frequent exercebation
inhaled Steroid- reduce inflammation in airways
Steroid inhalers are normally prescribed as part of a combination inhaler that also contains long-acting medicine
when would a doctor prescribe tablets for COPD and give examples of tablets that could nbe used?
if symptoms aren’t controlled by inhalers
Tablets could be:
- Theophyline tablets
- mucolytics
- Steroid tablets
- Antibiotics
how does theophyline work and what are the side efffects?
what will the doctor do whilst you’re on theophyline
A type of bronchodilator- uncelar how ti works but it reduces inlammation of airways and relaxes smooth muscle
Exists as tablet or capsules and taken 2 times a day
Need regular bloodt test to monitor drug blood levels- help doctor to first best therapeutic dose
S/E:
- Nausea and vomiting
- headaches
- difficulty sleeping (insomnia)
- palpitations
what is the name of the similar medicine to theophyline that may be used
Aminophyline
When do doctor use mucolytics and give examples of mucolytics and give any relevant details.
what is the main type of mucolytic?
If you have chesty cough with thick phlegms, doctor may prescribe carbocisteine.
They make break down phelgm and make them easier to cough up
Carbocisteine exists as tablet or capsule and u take it 3 or 4 times a day
what is the name of the other type of mucolytic prescribed if carbocisteine is contraindicated or doesn’t help.
Give relevant details
Acetylcisteine
Exist as powder and you mix with water
powder has unpleasant smell- rotten eggs but smell goes away when mixed with water
when are steroid tablets prescirbed and give S/Es and dosage.
Give relevant details, how long is the course of treatment
When you have a very bads exercebation
5 day short course treatment of steorid tablet given
Long term use give S/Es like:
- weight gain
- mood swings
- weakened bones (osteoporosis)
Doctor may give you a supply to help when you have an exercebation
when and how are long term steroid tablets prescribed
Longer courses of steroid tablets must be prescribed by a COPD specialist.
You’ll be given the lowest effective dose and monitored closely for side effects.
when are antibiotics prescribed
if you present with signs of chest infections like:
- becoming more breathless
- coughing more
- change in the colour (such as becoming brown, green or yellow) and/or consistency of your phlegm (such as becoming thicker)
Doctor can give you a supply just incase you experience symptoms of infection
what are the features of pulmonary rehabilitation
program of exericse and education to help those with COPD
it helps improves how much exercise you do before you feel out breath, it improves symptoms, self confidence and wellbeing
Program- 2 or more a group session a week for atleast 6 weeks
it involves:
- physical exercise training tailored to your needs and ability – such as walking, cycling and strength exercises
- education about your condition for you and your family
- dietary advice
- psychological and emotional support
Program provided by physios, nurse specialists and dieticians
Some people with vert severe symptoms or exercebations may need additional specialised reatments.
what are they
Nebulised medicine
Roflumilast
Long term oxygen therapy
Ambulatory oxygen therapy
Non-invasive ventilation
when is nebulised medicine given and what does it involve
May be given in severe cases of COPD if inhalers have not worked
A machine turns the liquid medicine into a fine mist that you breathe through a moutpiece or facemask
it allows a large dose to be taken at once
what is roflumilast and who is it recommeded for. what are the S/Es
New med used to used treat flare up- it is tablet and can help reduce inflammation in lungs and airways
Recommended for people whose symptoms have suddenly become worse atleast 2 times over past 12 months AND already on inhaler.
S/Es:
- nausea
- diarrhoea
- reduced appetite
- weight loss
- headache
Describe the features of Long term oxygen and give any precaution
COPD causes hypoxia
long term O2 helps with hypoxia but not breathlessness (hypercapnic drive to breathe)
Should be used for atleast 16 hrs a day.
Tubes are long so you can move around the house when connected and there are portable O2 tanks if you want to go outside
Don’t smoke whilst on oxygen: combustion
Give features of Ambulatory oxygen and who is it recommended for
Help COPD pts when they walk or active in other ways
if blood O2 levels are normal at rest but low on exercise then ambulatory O2 therapy is better than long-term for u
when are Non-invasive ventilation used? give features
if you have a bad flare and taken to the hospital
Where portable machine supports lungs to breathe- make it easier
when is surgery used and what are the different types of surgery
Small number of pts with severe COPD whose symptoms can’t be controlled by medicine.
E.g
- Bullectomy- remvoe bullae and make it easier to breathe
- lung volume reduction surgery- remove bad part of lung and allow healthier parts to work better
- Lung transplant
Done under general anaesthetic
what are the general advice you can give to pts living with COPD
Take your prescribed medicine-
- read med info leaflet about medicine and check with care team if you plan to take over the counter meds.
- talk to doctor about side effects
Stop smoking, Exercise regularly and maintain healthy wieght
Get vaccinated
Check the weather
Explain rationale behind the following advice and give any additional details
- exercise regularly
- maintain healthy wieght
Exercise- inprove symptoms and QoL
- exercise until you a little bit breathless (safe) but do not push yourself
- speak to GP if you want to start new exercise
- use pulmonary rehabilitation
Healthy weight
- Being too heavy worsens dyspnea
- COPD pts can unintentionally lose wieght so take food that are high in proteins and have enough calories
- use a dietician- pulmonary rehabilitation
Explain rationale behind the following advice and give any additional details
- Getting vaccinated
- Checking the weather
Vaccine
- COPD pts are more vulnerable to infections
Waether
- Cold spells and periods of hot weather and humidity can cause breathing problems in COPD pts
- Check weather forecast and make sure you have enough medicine at hand incase weather gets worse
What types of air substances should pts with COPD avoid in order to reduce flare ups
- dusty places
- fumes, such as car exhausts
- smoke
- air freshener sprays or plug-ins
- strong-smelling cleaning products (unless there’s plenty of ventilation)
- hairspray
- perfume
what breathing techniques are important for people with COPD
When short of breath use breathing control- gently breathing useing the least effort with the shoulders supported
For more active people:
- relaxed, slow, deep breathing
- breathing through pursed lips, as if whistling
- breathing out hard when doing an activity that needs a big effort
- paced breathing, using a rhythm in time with the activity, such as climbing stairs
if you have chesty cough with phlegm use active cycle breathing techniqe to help clear airways
Sometimes you need to talk to other people , why is this useful and who can you talk to
GP or nurse- education and reassurement
Talking to a trained counsellor or psychologist or specialist helpline
Talking to people with COPD online or local support group
Helps psychologically
what is the advice about relationship and sex for people with COPD
You can be tired and depressed - important to talk about your worries
Be open about what you feel and tell them when you need time to yourself
Sex life
- tell your partner and explore what you can/cannot do
- doctor, nurse or physio may suggets ways to help during sex
what should a pt do if they want to fly
Go to GP for fitness to fly assesment : uses spirometry
pack all meds in hand luggage
If your using O2 therapy, tell flight in advance and get a medical form from GP
if on LTOT- make sure u have anough O2 for the flight and time away
N.B- airlines don’t allow O2 cylinders inside flgiht- combust. however they may permit portable oxygen concentrator devices
what financial support are available for people woith COPD especially when they cannot work
If you have a job but cannot work due to illness- get Statutory sick pay
if you don’t have a job due to illness- may get Employment and support allowance
if you’re caring for someone with COPD- may get Carer’s allowance
you may get other benefits: chidlren, low income, etc
Describe the end of life care for pts with COPD.
palliative care- talking and planning end of life care
Talk to family and freinds- there’s support for them
Talk to doctor and they’ll tell you what symptoms you’ll get at that time and treatments available at that time
Establish a clear management plan with Dr. ti could include:
- whether you want to go to hospital or hospice or looked after at home
- maybe get advanced decisions like living will, DNAR or whether you want to artificila ventilation to continue
what is the physiological rationale behind proning in typical ARDS
reduce ventilation/perfusion mismatching, hypoxaemia and shunting.
Proning decreases the pleural pressure gradient between dependent and non-dependent lung regions as a result of gravitational effects and conformational shape matching of the lung to the chest cavity.
it increases recuritment of dorsal lung units due to homegenous strain distribution and lung aeration
what does proning NOT alter
DOES NOT alter regional distribution of pulmonary blood flow, with perfusion predominating towards dorsal lung aspects due to non-gravitational factors.
Evaluate the use of PEEP via -NIV or CPAP in management of ARDS
how do you mitigate this
Good- prevent alveolar derecruitment
Bad-
- Overdistension of well perfused alveoli
- Lung injury in Type 1 pts who can spontaenously breathe
Contrast the evidence available in using proning for ARDS/ severe Type 1 pts under IMV and awake pts
IMV- high evidence reduces 28 mortality by half
awake - evidence not robust enough
Proning is niormally used for severe COVID pts under IMV (Invasive mechanical ventilation)
why isnt proning used universally fro all COVID pts?
In early stage of COVID pneumonitis: lung compliance is high and hence there is minimal recruitbaility- proning isnt useful.
- Hypoxemia driven by pulmonary perfusion patterns
As it progresses; it looks more like ARDS and complicance reduces and become more recuritable; proning is more useful
You can tell the difference from early to late stage (according to the paper) using CT scan of lung weight, gas Vol and proportion of non-aerated lung tissue
what is the normal duration of proning time neccessary for ARDS pts under IMV?
wbu awake proning
12-16hrs a day
Awake- not specified yet, but longest recorded was 8 hrs
what are the downsides of proning an awake pt with COVID
Firstly need more personnel; costly
Contamination of pts environment due to:
- Increased coughing in proned postion
- Increased lung secretion drainage under G forces
what are the main causes of COPD in the poorer countries (developing world)
Environmental polliutants from biofuel
Biofuel contains: dung cakes, residues from agricultural crop and firewood 🪵 ( 1or all)
Toxic fumes are:
- CO,
- polyaromatic and polyorganic hydrocarbons
- formaldehyde
What is the target pulse oximetry for COPD pts and explain why
88-92%
HIgh alveolar dead space lead to V/Q msimatch lead to hypercapnia eventually (due to vasoconstriction)
Overtime due to chronic hypercpania, chemoreceptors (both central and peripheral ) get tolerance to CO2 and hence you develop hypoxic drive to breathe
Giving them too much O2 will stop them breathing
what is the equation linking pH to HCO3- and pCO2
what is the overall aim of compensation
Hasselbach equation
pH = 6.1 + log − HCO3/0.03pCO2
Aim of compensation: keep the HCO3/pCO2 ratio constant
what is the compensatory mechanism for acute respiratory acidosis
1 mEq of bicarbonate increases with every 10 mm Hg increase in pCO2.
H+ ions buffering in the acute phase takes place by proteins (primarily hemoglobin) and other buffers (non-bicarbonate).
H2CO3+ −Hb => HHb + −HCO3
what is the compensatory mechanism for chronic resp acidosis?
What must you be aware of?
Kidney- takes 3-5 days. The body is much better at this.
it retains HCO3- and secrete H+ ; hence prevents pH from becoming too low.
this only occurs in the blood and not the brain. Therefore long term resp acidosis causes CNS symptoms:
- drowsiness, anxiety, headaches and sleep disturbances
what is the prognosis of COPD pts with renal failure
Can’t compensate
Hence overtime there is mixed resp and metabolic acidosis leading to very very low pH
hence higher mortality as low PH can:
- cause rythm dysfunction leading to arrythmias
- hypotension
Why should you be cautiois of using suppelemental O2 to prevent hypercapnia?
i.e. how can hypercapnia occur if you give too much supplemental O2 (more than 92%) to a pt with COPD
this can lead to very high levels of hypercapnia due to:
- The failure of the hypoxic drive
- Haldane effect: The increased PaO2 displaces the CO2 from hemoglobin and thereby increasing the PaCO2
- The increased partial pressure of oxygen reverses the hypoxic vasoconstriction at the pulmonary artery level which leads to V/Q mismatching; . Increasing dead space and thus increasing acidosis.
- The increased amount of oxygen displaces nitrogen, which leads to atelectasis.
COPD pts with Low pH and or renal failure are more likely to be in ICU and have higher mortality rates
How can we prevent hypercarbia related complication in COPD pts
- Careful monitoring and proper management of COPD
- Smoking cessation
- Healthy lifestyle and regular exercise help prevent diseases that can worsen respiration
- Use pt centered approach and MDT to reduce morbidity
what should you do with a COPD exercebation pt who has renal fialure
Spirometry, ABG, pulse oximetry can be used to determine severity of disease especially during exercebation
For these pts ther are to be treated in ICU by a a different subspecialty physicians
Describe the homeostasis of HCO3- ions in detail
Where does it occur and how, what is the normal HCO3- level
In PCT- regulate reabsorption of HCO3- mainly through PCT (around 90%)
Also at PCT- can form HCO3- through excretion of NH3 and PO43-
Intercalated cells in DCT- can also increase and decrease HCO3- and H+ antagonistically
Normal- 22-28mmol/l
what can cause metabolic acidosis
Either increase in H+ or decrease in HCO3-
Reverse for alkalosis
how can you tell whether metabolic acidosis is caused by increase in H+ or decrease in HCO3-
Find the anion gap (normal is 8-16 mmol/l)
Main cation blood conc (Na+) minus the all anions
Howvever when K+ is added as a cation in the equation then normal anion gap level is (12-20mmol/l).
Anion gap could be high or normal
what is the signifcance of a high anion gap in metabolic acidosis. give causes
Caused by increased in unmeasure anions as the hydrogen ions react with bicarbonate ions
Hence H+ is ioncreased
common causes of high anion gap metabolic acidsosis are are:
- lactic acidosis
- toxic acidosis
- ketoacidosis
- renal failure
what is the signifcance of normal anion gap in metabolic acidosis
Loss of bicarbonate ions are replaced with chloride ions
Causes:
- Diarrhoea and renal tubular acidosis
Descirbe the differences according to bmj vidoes in repsiraotry compensation when there’s metabolic alkalosis or acidosis
Acidosis- Hyperventialtion is very fast ( within 1 hr)
Alkalosis- hypoventilation- still fast
- Less pronounced
- CO2 retained doesnt get beyond 7.5 kPa
Explain the relationship between COPD exercebation and death
Exercebation can be infective or non-infective
A single COPD exercebation doubles the rate of lung function decline leading to deceased physical activity
This can affect mental health and hence QoL
this can cause further exercebation and death
20% of pts with first execerbation die within 1 yr
what are the indicators of infective exercebation
Sputum- colur change and consistency- u can culture it also
pyrexia
all pts with SOB in hospital must have CXR, what can the CXR show especially for pts woth COPD
Infective exercebation- airspace opacities and lobar conolidation and flattening of costophrenic angle.
- Mr craven had this- pneumonia
lung cancer
plueral effusion
COPD- hyperinflated lungs
what were the tests orderd for Mr craven?
Interprete these ABGs
CXR, bloods, ECG, sputum and an ABG
ABG: interpretation
what are the normal values for PaO2 and PaCO2
what are the causes of type 1 resp failure
what are the causes of type 2 resp failure
late severe acute asthma- as asthma worsens you feel incredibly tired and hence can’t ventilate
what are the features of Type 1 failure
what are the criteria and give basic causes
Hypoxaemia- less than 60mmHg
Due to failure to oxygenate- problme with lung tissue and hence cannot meet body O2 commands
CO2 is normal
Increased shunt fraction
what are the features of type 2 resp failure
give criteria and causes
Pump failiure (affect anything from brain to skeletal muscle)
Hypercapnia- more than 6.7kPa
Increase deadspace - causes
what resp failure did Mr craven have
He had Type 1 failure before coming to hospital but the pneumonia worsens the COPD and now has type 2 resp failure
if a pt comes to the hosptial with exercebation, what criteria must be met before discharging them
- No type 2 failure
- No sepsis
- No confusion and must be orientated to time and space
- Good NEWS2
- Good support at home
- Can contact you (doctor) and hosptial staff if exercebation
what were the drug and non -drug treatment that were given to Mr Craven in hospital and can be given to anyone with exercebation of COPD
Drugs
- HIGH O2 (repeat ABG, pulse oximetry then reduce as possible)
- IV hydrocortisone
- IV antibioticsa
- Nebulised bronchodilators
Non drug:
- Sit them up
- Respiratory physiotherapy
N.B May need NIV/CPAP if worsens or even progress to IMV
what are the differences between CPAP and BiPaP (NIV)
Draw out the pressures
what precautions
CPAP-
- constant pressure given and used for type 1 resp failure pts
- Positive pressue should be around 12cmH2O
BiPAP- has too pressures. IPAP is higher than EPAP. This is used for type 2 resp failure; helps to recurit more lung units.
Precautions:
- Don’t use too much FiO2 (cap at 35%)
- Dont use too much pressure- damage lungs
- increase pressure gradually with high frequency at the start
how can COPD lead to ankle oedema
Cor-Pulmonale
what is CPAP and biPAP (NIV)
what are the presentations of COPD
Can be acute, chronic or acute on chronic
Normally type 2 failure but can be normal or type 1
Comorbidities can exercebate COPD
Write down the 2 most common COPD comorbidites and 2 one are linked most to mortality
Common:
- Hypertension
- Hyperlipidaemia
- CAD and PAD:
mortality
- pancreatic and breast cancer
- anxiety
- other cancers- lung
notable
- polycythaemia
- HF
- diabetes
