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Year 3 > COPD (RESP) > Flashcards

COPD (RESP) Flashcards

1
Q

Define chronic obstructive pulmonary disease.

A

Heterogeneous progressive lung disease characterised by chronic respiratory symptoms and airflow limitation that is not fully reversible

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2
Q

What does COPD encompass? (3)

A
  • chronic bronchitis - chronic narrowing of airways defined clinically as a productive cough on most days for at least 3 months per year for 2 consecutive years
  • emphysema - permanent destructive enlargement of air spaces distal to the terminal bronchioles
  • bronchiolitis (small airways disease)
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3
Q

Define chronic bronchitis (COPD).

A

Chronic narrowing of airways defined clinically as a productive cough on most days for at least 3 months per year for 2 consecutive years

(Exposure to irritants –> hypertrophy and hyperplasia + increased mucus production –> obstruction)

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4
Q

Define emphysema (COPD).

A

Permanent destructive enlargement of air spaces distal to the terminal bronchioles

(Inflammatory reaction to irritants –> enzymes break down collagen and elastin –> alveoli enlarge and lose recoil elasticity that keeps them open)

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5
Q

What is the bronchial and alveolar damage in COPD caused by?

A

Environmental toxins (cigarette smoke, dust, NO2) –> activates innate and adaptive immune responses to long term exposure to noxious particles and gases

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6
Q

Describe compliance and resistance of the lungs in COPD.

A
  • increased resistance to airflow in small conducting airways
  • increased compliance of lungs
  • progressive airflow obstruction
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7
Q

Describe the epidemiology of COPD. (3)

A
  • M>F
  • age >65
  • smokers
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8
Q

What are the main causes of COPD? (3)

A
  • smoking - most common
  • exposure to air pollution
  • alpha-1-antitrypsin deficiency (in younger non-smoker patients)
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9
Q

How can alpha-1-antitrypsin deficiency cause COPD?

A
  • inhibited action of neutrophil elastase –> emphysema
  • may be accompanied by symptoms of cirrhosis
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10
Q

What condition, other than COPD, is alpha-1-antitrypsin deficiency a risk factor for?

A

Hepatocellular carcinoma

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11
Q

What management can be done in late stage alpha-1-antitrypsin deficiency?

A

Lung volume reduction surgery

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12
Q

What are some signs and symptoms of COPD?

A
  • progressive SOB
  • wheeze
  • chronic cough
    • productive, white/clear sputum (yellow = exacerbation/infection)
  • sputum production
  • reduced exercise tolerance
  • dyspnoea and tachypnoea
  • cyanosis
  • low oxygen sats <92%
  • late stage - raised JVP, peripheral oedema
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13
Q

What are some clinical findings on inspection of a COPD patient? (6)

A
  • respiratory distress
  • use of accessory muscles (tripod position)
  • pursed lip breathing
  • barrel-shaped, over-inflated chest
  • decreased cricosternal distance
  • cyanosis
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14
Q

What are some clinical findings on palpation of a COPD patient?

A

Reduced chest expansion bilaterally

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15
Q

What are some clinical findings on percussion of a COPD patient? (2)

A
  • hyper-resonant chest
  • loss of liver and cardiac dullness
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16
Q

What are some clinical findings on auscultation of a COPD patient? (6)

A
  • distant (quiet) breath sounds
  • prolonged expiration
  • wheeze
  • rhonchi - rattling, continuous and low-pitched breath sounds (like snoring) due to secretions/obstructions
  • crepitations
  • coarse crackles
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17
Q

What are some signs of CO2 retention in COPD? (3)

A
  • bounding pulse
  • warm peripheries
  • asterixis (hand flap)
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18
Q

What are some signs of late stage COPD (Cor Pulmonale)? (3)

A
  • right ventricular haeve
  • raised JVP
  • ankle oedema
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19
Q

What are some non-modifiable risk factors for COPD? (4)

A
  • male sex
  • advanced age
  • white ancestry
  • genetic factors / developmentally abnormal lung
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20
Q

What are some modifiable risk factors for COPD? (4)

A
  • smoking - makes cilia short and less mobile
  • occupational exposure (dust, chemicals, vapours, fumes, gases)
  • environmental (tobacco smoke, air pollution, indoor solid fuel burning)
  • Fx or PMHx of chronic lung disease
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21
Q

What are the gold standard investigations for COPD?

A

Spirometry and pulmonary function tests

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22
Q

What are the first-line investigations for COPD?

A
  • spirometry
  • standardised symptoms score
  • pulse oximetry
  • ABG
  • CXR
  • FBC
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23
Q

What does (post-bronchodilator) spirometry + pulmonary function tests show for COPD?

A
  • FEV1/FVC ratio <0.7
  • no bronchodilator reversibility (unlike asthma)
  • significantly reduced FEV1 (<80% predicted), slightly reduced/normal FVC
  • TLC normal/high
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24
Q

How can COPD be classified by severity based on FEV1?
(FEV1/FVC<0.7 for all)

A
  • GOLD 1 (mild): FEV1>80% predicted + symptoms
  • GOLD 2 (moderate): 50%<FEV1<79% predicted
  • GOLD 3 (severe): 30%<FEV1<49% predicted
  • GOLD 4 (very severe): FEV1<30% predicted
25
Q

What does a chest x-ray show for COPD? (7)

A
  • hyperinflation (>6 anterior ribs seen above diaphragm)
  • flat hemidiaphragm
  • reduced peripheral lung markings
  • large central pulmonary arteries
  • bullae (if large may mimic pneumothorax)
  • hyperlucent lung fields)
  • elongated cardiac silhouette
26
Q

When do we do ECG and echocardiogram for COPD?

A

Check for Cor Pulmonale - right atrial and ventricular hypertrophy

27
Q

When do we test alpha-1-antitrypsin levels in COPD?

A

In young patients who have never smoked

28
Q

What would we see on CT for A1AT deficiency compared to COPD?

A
  • A1AT deficiency - emphysema in lower lobes
  • COPD - emphysema in upper lobes
29
Q

Why do we do FBC for COPD?

A
  • assess severity of exacerbation
  • may show: polycythaemia (haematocrit >55%), anaemia and leukocytosis
30
Q

When do we do ABG for COPD?

A
  • if acute exacerbation to check O2 and CO2 levels
  • COPD causes CO2 retention –> type 2 respiratory failure
  • PaCO2>50mmHg and/or PaO2<60mmHg = respiratory insufficiency
31
Q

What are some differential diagnoses for COPD?

A
  • asthma
  • congestive heart failure - orthopnoea, bibasilar inspiratory crackles, BNP
  • bronchiectasis - recurrent childhood infections, sputum, bronchial dilation
  • TB - fever, night sweats, weight loss
  • bronchiolitis - PFTs restrictive/mixed, younger
  • upper airway dysfunction
  • chronic sinusitis/postnasal drip - sinus pressure, rhinorrhoea, headache
  • GORD
  • ACEi induced chronic cough
  • lung cancer (do CXR)
32
Q

Describe the GOLD group method for categorising risk of exacerbations of COPD.

A
  • GOLD group A: low risk (0-1 exacerbations per year, not requiring hospitalisation) and fewer symptoms
  • GOLD group B: low risk (0-1 exacerbations per year, not requiring hospitalisation) and more symptoms
  • GOLD group E: high risk (>/=2 exacerbations per year or >/=1 requiring hospitalisation) and any level of symptoms
33
Q

What is the first step of management for any patient with COPD?

A

Smoking cessation

  • NRT (especially in pregnant women as varenicline and bupropion contraindicated)
  • varenicline
  • bupropion (contraindicated in epilepsy patients)
34
Q

What are some non-pharmacological management methods for COPD? (3)

A
  • annual influenza vaccine
  • one-off pneumococcal vaccine
  • pulmonary rehabilitation in patients who view themselves as functionally disabled by COPD
35
Q

What is an example of a SABA (COPD)?

A

Salbutamol sulfate

36
Q

What is an example of a SAMA (COPD)?

A

Ipratropium bromide

37
Q

What is an example of a LABA (COPD)?

A

Salmeterol, Olodaterol (ultra long-lasting)

38
Q

What is an example of a LAMA (COPD)?

A

Tiotropium bromide

39
Q

What are some examples of a ICS (COPD), and when do we use these?

A
  • budesonide, beclomethasone, fluticasone, mometasone
  • consider if Hx of asthma, or blood eosinophils >300
40
Q

What is the first-line treatment for GOLD group A, B and E COPD?

A
  • GOLD group A: SABA/SAMA/LABA/LAMA
  • GOLD group B: LABA+LAMA plus SABA/SAMA
  • GOLD group E: LABA+LAMA or LABA+LAMA+ICS plus SABA/SAMA
41
Q

What is the first-line treatment for GOLD group A/B/E COPD if persistent dyspnoea/exercise limitation after initial therapy?

A
  • LABA+LAMA
  • plus SABA/SAMA
  • consider O2 therapy/ventilatory support
  • consider mucolytic (e.g. acetylcysteine if chronic bronchitis)
  • consider theophylline
  • consider bronchoscopic intervention/surgery
  • supportive care + pulmonary rehabilitation + palliative care
42
Q

What is the first-line treatment for GOLD group A/B/E COPD if persistent exacerbations after initial therapy?

A
  • LABA+LAMA or LABA+LAMA+ICS
  • plus SABA/SAMA
  • consider O2 therapy/ventilatory support
  • consider roflumilast (oral phosphodiesterase-4 inhibitor if FEV1<50% and chronic bronchitis)
  • consider azithromycin
  • consider mucolytic
43
Q

What are the 4 asthmatic features of COPD?

A
  • Hx of asthma or atopy
  • eosinophilia
  • FEV1 variability min. 400ml
  • diurnal variation in peak flow min. 20%
44
Q

Describe the general first-line treatment algorithm for COPD.

A
  • 1st line: bronchodilators - SABA or SAMA
  • next if no asthmatic features/steroid responsiveness: add LABA+LAMA (if on SAMA, change to SABA)
  • next if asthmatic features/steroid responsiveness: add LABA+ICS, have SABA/SAMA as required
  • final step: LABA+LAMA+ICS triple therapy if patients remain breathless/exacerbations (if already taking SAMA, discontinue and switch to SABA)
45
Q

How do we manage an acute exacerbation of COPD?

A
  • controlled O2 therapy: 24% Venturi mask
    • aim for sats 88-92% for hypercapnia, 94-98% if pCO2 normal, PaO2>8kPa
  • nebulised bronchodilators (salbutamol + ipratropium bromide)
  • corticosteroids (oral prednisolone for 5 days or IV hydrocortisone if clinically unstable)
  • IV theophylline
  • Abx - if evidence of infection e.g. green sputum, signs of pneumonia –> amoxicillin, doxycycline or clarithromycin
  • NIV (BiPAP) - if respiratory acidosis with high CO2 despite maximum medical treatment, pH 7.25-7.35
46
Q

When is clarithromycin contraindicated?

A

Prolonged QT interval

47
Q

What oral prophylactic Abx therapy is there for COPD and when do we use this?

A

Azithromycin, if they meet criteria for recurrent infections:

  • patient should not smoke
  • have optimised standard treatments
  • continue to have exacerbations
  • (CT thorax - exclude bronchiectasis)
  • (sputum culture - exclude atypical infections and TB)
48
Q

What should you be careful of when giving azithromycin?

A

Can cause QT interval prolongation –> request ECG

49
Q

What is the most common cause of an acute exacerbation of COPD?

A

Haemophilus influenzae

50
Q

What do you give to critically ill (including CO2 retaining) COPD patients?

A

High flow oxygen –> reservoir mask at 15L/min

51
Q

Who do we offer long term oxygen therapy to (LTOT) for COPD?

A
  • assess ABG on two occasions at least 3 weeks apart to show:
  • pO2 <7.3kPa
  • OR pO2 7.3-8kPa AND secondary polycythaemia/peripheral oedema/pulmonary hypertension
52
Q

Why can supplemental oxygen be harmful to COPD patients?

A
  • reduces respiratory drive –> hypoventilation –> CO2 retention
  • patient will often already have chronic respiratory acidosis indicated by raised HCO3-
53
Q

When is oral theophylline recommended for COPD and what should we check first?

A
  • NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy
  • check U&Es and LFTs before starting
  • dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed
54
Q

When should mucolytics be considered for COPD?

A

In patients with a chronic productive cough and continued if symptoms improve

55
Q

What do we give COPD patients with frequent exacerbations to take home? (2)

A
  • antibiotics
  • prednisolone
56
Q

What are some complications of COPD?

A
  • Cor Pulmonale (right-sided heart failure)
  • recurrent pneumonia
  • depression
  • lung cancer
  • pneumothorax (secondary to bullae rupture)
  • respiratory failure
  • anaemia
  • polycythaemia
  • receiving too much O2 –> acute respiratory acidosis on top of chronic acidosis with compensatory metabolic alkalosis (= elevated HCO3-)
57
Q

How do we manage Cor Pulmonale (right-sided heart failure) due to COPD? (2)

A
  • loop diuretic for oedema
  • consider long-term oxygen therapy
  • NOT recommended: ACEi, calcium channel blockers, alpha blockers
58
Q

What is the reported prognosis of COPD based on?

A

FEV1 - significant correlation between increased FEV1 and lower risk of COPD exacerbation

Year 3 (22 decks)

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