COPD pre work (+asthma) Flashcards
COPD pathophys
- Treatable (not curable)
- Largely preventable
- Perisstent resp symptoms- breathlessness, cough, sputum
- Airflow obstruction
- Progressive, not fully reversible
- Chronic inflam - usually caused by exposure to tobacco spoke (can also be envitonment and occupational)
Symptoms to suspect COPD
- Breathlessness - progressive, persistent, worse on exertion
- Wheeze
- Chronic/recurrent cough
- Regular sputum
- Freq LRTI
Can get:
* Weight loss, anorexia, fatigue
* Waking at night due to breathlessness
* Ankle swelling
* Chest pain
* Haemoptysis
* Reduced exercise tolerance
Examination signs of COPD
- Cyanosis
- Raised JVP +/- peripheral oedema - cor pulmonale?
- Cachexia
- Hyperinflation of chest
- Use of accessory muscles +/- pursed lips breathing
- Wheeze +/- crackles on ausc
RF for COPD
- Smoking
- Occupational/environmental exposures - dusts, fumes/chemicals
- Air pollution
- Genetics - alpha 1 antitrypsin
- Lung development problems in utero and childhoof
- Asthma
Spiro findings COPD
- post BDR of less than 0.7 FEV1/FVC
CXR findings COPD
- Enlarged lung fields
- Flattened diaphragm
- Air pockets (bullae)
FBC and COPD results
- Elevated Ht and Hb - chronic hypoxia
- Elevated RBC count
- Elevated WBC if infection/inflammation
- Can change platelet count
What is COPD and steroid responsiveness/asthmatic features?
- Higher blood eosinophil count
- Diagnosis of asthma or atopy
- Substantial variation in FEV1 over time (at least 400mls)
- Substantial diurnal variation in PEFR (at least 20%)
When can COPD with asthmatic features/steroid responsiveness occur?
- Confirmed asthma but continues to smoke
- Other atopic conditions and develops COPD
- Person with COPD has raised eosinophil count
Other tests when COPD suspected
- Alpha-1-antitrypsin
- Heart disease investigations - ECG, NT-proBNP, echo
- Other lung disease - CT thorax, sputum culture
- O2 sats
Complications of COPD
- Exacerbations
- Cor pulmonale - pulmonary HTN from hypoxia, inflammation, loss of alveolar capillaries
- T1RF/T2RF
- Psychological problems and loss of functional ability
Aims of COPD treatment
- Reduce symptoms
- Reduce exacerbations
- Improve QoL
- Prevent deterioration of lung function
General management COPD
- Holistic approach - control other resp and cardiac risk factors eg weight, diet, exercise
- Smoking cessation
Non-pharmacological advice to offer in COPD
- Healthy diet and physical activity - British Lung foundation or NHS COPD page
- Stop smoking
- Pneumococcal and flu vaccines
- Pulmonary rehab
- Personalised self management plan
- Optimise treatment of co-morbidities
Vaccinations for COPD
- Pneumococcal vaccine
- Annual influenza
What is pulmonary rehab and when should it be offered, any scenarios where not appropriate?
- Refer if functionally disabled by COPD - MRC 3 or above
- OR recent hospitalisation for exacerbation
- Do not refer if unable to walk or have unstable angina or recent MI
When should LTOT be commenced?
- Not without specialist assessment - treatment for HYPOXAEMIA and NOT breathlessness
- Can improve survival if chronic hypoxia
Refer if:
* O2 sats 92% or less breathing air
* Very severe FEV1 (less than 30% predicted) or severe (FEV30-49%) airflow obsruction
* Cyanosis
* Polycythaemia
* Peripheral oedema
* Raised JVP
* Refer for ambulatory if mobile outdoors
* Warn people not to smoke - explosion risk but do not withdraw
Pharmacotherapy for COPD - initial
- Either SABA or SAMA
Second line COPD treatment fir patients without asthmatic features/steroid responsivness
- Offer LABA and LAMA - discontinue SAMA if LAMA is given
- SABA is continued at all stages
- If symptoms persist, severe exacerbation or 2 moderate exacerbations, consider addition of ICS (trial for 3 months if just for symptoms, others review annually)
Step up treatment for those with asthmatic features/steroid responsive COPD
- LABA and ICS
- Review ICS annually
- If severe exacerbations or 2 moderate within 1 yr/daily symptoms consider adding LAMA (remove SAMA if originally started)
What is severe vs moderate COPD exacerbation?
- Severe - hospitalisation
- Moderate - systemic corticosteroids +/- antibacterial treatment
Features of acute COPD exacerbation
- Wheeze
- Cough
- Worsening breathlessness
- Increased sputum volume/purulence
- Fever without obvious source
- URTI in last 5 days
- Increased RR or HR 20% above baseline
Severe exacerbation COPD features
- Marked breathlessness and tachypnoea
- Pursed lips breathing and or use of accessory muscles at rest
- New onset cyanosis or peripheral oedema
- Acute confusion/drowsiness
- Marked reduction in ADLs
What should you do whilst waiting for emergency services in acute COPD exacerbation?
- Give O2 and monitor with pulse oximetry
- Otherwise initially give O2 via venturi 24% at 2-3L/min or 28% at 4L/min or nasal cannula at 1-2L/min (if 24% venturi not available)
- Target O2 sats 88-92% usually BUT not always - if not retainer, normal sat target
If someone does not require admission for COPD, what treatments should you offer?
- Advise to increase doses/freq of short acting bronchodilators (not exceeding max dose)
- Consider oral corticosteroids for breathlessness that is interefering with daily activity
- Consider need for abx - sputum colour change/increased thickness?
Safety netting for someone not admitted with COPD exacerbation
- Symptoms worsen (eg sputum changes/thickens)
- Systemically unwell
- Symptoms do not improve within given timeframe
Follow up for someone with COPD exacerbation
- Reassess if symptoms worsen rapidly/significantly at any time
- Send sputum sample for culture and sensitivity if not improving on given abx
- Follow up when stable (eg 6 weeks post exacerbation onset)
