COPD II Flashcards
What is COPD?
Chronic obstructive pulmonary disease (COPD) is the name for a group of lung conditions that cause breathing difficulties.
What does COPD include?
emphysema – damage to the air sacs in the lungs
chronic bronchitis – long-term inflammation of the airways
Who does COPD normally affect?
middle-aged or older adults who smoke
What are the main symptoms of COPD?
increasing breathlessness, particularly when you’re active
a persistent chesty cough with phlegm – some people may dismiss this as just a “smoker’s cough”
frequent chest infections
persistent wheezing
When does COPD occur?
when the lungs become inflamed, damaged and narrowed
What causes COPD?
Smoking
Likelihood of developing COPD increases the more you smoke and the longer you’ve smoked
Air pollution
Genetics
What are the treatments for COPD?
Smoking cessation Inhalers and medicines Pulmonary rehabilitation Surgery Lung transplant
What are less common symptoms of COPD?
Weight loss Tiredness Swollen ankles Chest pain Coughing up blood
What fume substances have been linked to COPD?
cadmium dust and fumes grain and flour dust silica dust welding fumes isocyanates coal dust
What are the genetics implicated in COPD?
Alpha-1-antitrypsin deficiency
A substance that protects your lungs
How can COPD be diagnosed?
Spirometry
Chest X-Ray
Blood tests
What further test might be needed for COPD?
ECG Echocardiogram Peak flow test Blood oxygen test CT Scan Phlegm sample
What inhalers will most people use?
Short-acting bronchodilators
- beta-2 agonists e.g. salbutamol and terbutaline
- antimuscarinic inhalers e.g. ipratropium
can be used up to 4 times a day
What inhalers should you use if you experience symptoms regularly throughout the day?
Long-acting bronchodilators
beta-2 agonist inhalers – such as salmeterol, formoterol and indacaterol
antimuscarinic inhalers – such as tiotropium, glycopyronium and aclidinium
When are steroid inhalers prescribed?
If you’re still becoming breathless when using a long-acting inhaler, or you have frequent flare-ups
What tablets are used in COPD?
Theophylline tablets
Bronchodilator
What are the side effects of theophylline?
feeling and being sick
headaches
difficulty sleeping (insomnia)
noticeable pounding, fluttering or irregular heartbeats (palpitations)
What are mucolytics?
Mucolytic medicines make the phlegm in your throat thinner and easier to cough up.
e.g. carbocisteine 3-4 times a day
What could you be prescribed if you have a particularly bad flare up?
Short course of steroid tablets
When might you be prescribed antibiotics?
Signs of a chest infection, such as:
becoming more breathless
coughing more
noticing a change in the colour (such as becoming brown, green or yellow) and/or consistency of your phlegm (such as becoming thicker)
What is pulmonary rehabilitation?
specialised programme of exercise and education designed to help people with lung problems such as COPD
What does a typical pulmonary rehabilitation programme consist of?
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
What other form of treatments are available for bad cases/flare ups?
Nebuliser Roflumilast Long-term oxygen therapy Ambulatory oxygen therapy Non-invasive ventilation Surgery
What are the three surgical options?
Bullectomy
Lung volume reduction durgery
Lung transplant
What is key when living with COPD?
Take your medicine Stop smoking Exercise regularly Maintain a healthy weight Get vaccinated Check the weather Watch what you breathe
What symptoms do Mr Craven present with?
Phlegm and sputum (2 egg cups a day) SOB on going up stairs Chesty cough Low appetite Swelling in ankles Temp - 37.9
What medication does Mr Craven take for his COPD?
Combo inhlaer
What does the Doctor diagnose Mr Craven with?
Infective exacerbation of his COPD
What are the next investigations the doctor suggests?
Examine Bloods COPD ABG test ECG
What are the co-morbidities of COPD that could be contributing to Mr Craven’s SOB?
Infection Cardiovascular disease e.g. hypertension, coronary artery disease Anxiety Depression Cancer Diabetes
What are the knock on effects of a COPD exacerbation?
Decreased lung function Decreased physical activity Decreased mental health Decreased QoL Increased further COPD exacerbations Mortality?
What is the association between mortality and COPD exacerbation?
1 in 5 patients will die in 1 year after their first COPD exacerbation
What COPD co-morbidities are closely associated with death?
Anxiety
Oesophageal cancer
Breast cancer
Lung cancer
What differences are seen on Mr Cravens X-ray now?
Hyper-inflated lungs Raised clavicles Flattened diaphragm Enlarged heart Opacification - right lower zone
What is the likely diagnosis for Mr Craven?
Pneumonia
‘Opacification - right lower zone’
What are are silhouette signs?
Loss of silhouette
Less clarity
Cannot see outlines of structures e.g. hemidiaphragm and heart
What other features of a COPD exacerbation can be seen on a CXR?
Lung tumour (white mass) Pleural effusion (large area of white, suggestive of fluid in the lung)
What does Mr Craven’s ABG show?
Uncompensated respiratory acidosis with hypoxemia
Low O2 - hypoxemia
High CO2 - hypercarbia
Low pH - acidotic
Normal BE
What must you remember to do when noting down an ABG?
Say what they are breathing e.g. room air, 2L O2 etc.
What are the features of hypoxemic respiratory failure?
Type ARF
Lung Failure
O2 Low
Failure of oxygenation does not meet metabolic needs
What causes hyp
R-L shunt
V/Q mismatch
Alveolar hypoventilation
What are the features of hypercapnic respiratory failure?
Type II ARF
Failure of the lungs to eliminate adequate CO2
What causes hypercapnic resp failure?
Pump failure
R-L shunt
What are the organs doing to restores acid base balance?
Lungs respond to metabolic disorder
Kidneys respond to respiratory disorder
What conditions cause Type I respiratory failure?
Pneuomnia Pulmonary oedema Pumonary embolism Pulmonary fibrosis Aspiration Lung collapse Asthma Pnuemothorax Pulmonary contusion
Lung tissue unable to keep up
What conditions cause Type II respiratory failure?
Reduced respiratory drive e.g. drug overdose, head injury Upper airway obstructions Late severe acute asthma COPD Peripheral neuromuscular disease Flail chest injury Exhaustion
What drugs would you use in Mr Cravens initial management?
inhaled beta 2 agonists inhaled anticholinergics
antibiotics - look are previous cultures
systemic corticosteroids - IV hydrocortisone
Oxygen therapy
What non-drug treatment would you use in Mr Cravens initial managment?
Sit them upright to release pressure
Respiratory physiotherapy to remove secretions clogging up the airways
What are the two types of ventilation support?
CPAP
NIV (BiPAP)
What is CPAP?
Continuous positive airway pressure
What is BiPAP?
NIV - non invasive ventilation
Bi-level positive airway pressure
What type of ventilation would you give Mr Crave?
BiPAP
Provides ventilatory support at 2 pressures so aids with inhalation and exhalation
Reduces the work of breathing
What are the features of CPAP?
Gives a continuous positive airway pressure
Trying to force Oxygen in - overcome obstruction
What are the features of BiPAP?
Delivers differing air pressures
Inspiratory pressure is higher than expiratory pressure
Not an equally high expiratory pressure that would increased the work of breathing
Allows CO2 to be expelled
Need to balance I:E ratio
What are the key features of ventilation?
Time
Pressure
Frequency
Why are Mr Craven’s ankles swollen?
Alveolar hpoxia
Hypooxic vasoconstriction
Pulmonary vascular resistance
Pulmonary hypertension
Right ventricular afterload
Right ventricular failure
Peripheral oedema
Swelling of ankle and feet
How does COPD affect patients?
Every part of your daily living
Have to think about every breathe you take
Wake up feeling awful and as if you will not achieve anything
What can make the lives of those with COPD easier?
Blue badge Taxi card Oxygen Gentle exercise once a week BLF Helpline Family support Volunteering
What are the 4 steps to interpret a ABG?
pH - acidic, alkalotic, normal
Primary disturbance - respiratory (O2) or respiratory (CO2)?
Is there a anion gap? (Base excess)
Is there any compensation?
What causes respiratory acidosis?
CO2 level rises and patient cannot increase respiratory drive
Increased in carbonic acid formation
Decreases pH
What causes respiratory alkalosis?
Hyperventilation
CO2 levels fall
Less carbonic acid
Increased pH
What is the buffering role of bicarbonate ions in the blood?
React with Hydrogen ions to form water
What is the role of the Kidneys in acid-base regulation?
Regulate reabsorption of bicarbonate ions esp. in PCT
Form bicarbonate ions through excretion of ammonia and monophosphate ions
Increase H+ secretion and higher pH
What is the importance of bicarbonate ions?
Marker of metabolic homeostasis
Low bicarb = metabolic acidosis
High bicarb = metabolic alkalosis
What causes a high anion gap?
Increase in unmeasured anions
Hydrogen ions reacting with the bicarbonate ions
Causes commonly by metabolic acidosis
What are common causes of high anion gap metabolic acidosis?
Lactic acidosis
Ketoacidosis
Toxins
Renal failure
What happens in a normal anion gap?
Lost bicarbonate ions are replaced with chloride ions
Commonly due to: Diarrhoea
Renal tubular acidosis
What are the two methods of compensation?
Adjustments to ventilation
Adjustments to kidney absorption and excretion
What happens metabolic acidosis to compensate?
Ventilation increases driving off CO2
Reduces carbonic acid in blood
Increase pH
What are the compensatory mechanisms in metabolic alkalosis?
Hypoventilation is less pronounced
Rarely retains CO2 beyond 7.5 kPa
What is the compensatory mechanism for respiratory acidosis?
Kidneys attempt to retain more bicarb and excrete more H+
Takes place over several days
What is ARDS?
Acute respiratory distress syndrome
What is the criteria for awake prone positioning?
In patients requiring and FiO2 > 28%
What is the rationale behind prone postitioning?
Reduce:
ventilation/perfusion mismatching
hypoxaemia
shunting
What does prone positioning do?
Decreases the pleural pressure gradients between dependent and non-dependent lung regions
How does prone positioning help?
Gravitational effects
Conformational shape matching of the lung to chst cavity
Generates more homogenous lung aeration and strain distribution
Enhances recruitments of dorsal lung units
What is further contributing to incidence of COPD?
Environmental pollutants
What increases environmental pollutants in developing countries?
Use of biomass fuel for domestic energy
e.g. dung cakes, residues from crop, firewood
What leads to inefficient gas exchange in COPD?
Alveolar dead space
What does inefficient gas exchange lead to?
Ventilation perfusion mismatch
What does the body do to retain the V/Q ratio?
localised vasoconstriction in the affected lung areas that are not oxygenated well
What causes hypercapnia in COPD patients?
patients have a reduced ability to exhale the carbon dioxide adequately
What does chronic CO2 elevation lead to?
acid-base disorders and a shift of normal respiratory drive to hypoxic drive
chemoreceptors develop tolerance to chronically elevated arterial carbon dioxide level
shifts the normal acid-base balance toward acidic
What is the target O2 sats for COPD patients?
88% to 92%
What is the hasselbach equation?
pH = 6.1 + log − HCO3/0.03pCO2
What is the significance of COPD patients with renal failure and COPD exacerbation?
kidneys are unable to reabsorb bicarbonate to compensate for chronic respiratory acidosis
Over time, mixed respiratory and metabolic acidosis sets in causing dangerously low levels of pH
The mortality rate is much higher
Why do you not want sats above 92% in COPD?
The failure of the hypoxic drive
Haldane effect: The increased partial pressure of oxygen in the blood displaces the carbon dioxide from hemoglobin and thereby increasing the CO2 level.
The increased partial pressure of oxygen reverses the hypoxic vasoconstriction at the pulmonary artery level which leads to the blood going to areas of lungs with no ventilation. Increasing dead space and thus increasing acidosis.
The increased amount of oxygen displaces nitrogen, which leads to atelectasis.
How can hypercarbia related complications be prevented?
Careful monitoring and proper management of COPD
Smoking cessation
Healthy lifestyle and regular exercise help prevent diseases that can worsen respiration
