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Year 2 - CSI > CSI 4 - Breathlessness > Flashcards

CSI 4 - Breathlessness Flashcards

1
Q

What is chronic obstructive pulmonary disease? (COPD)

A

COPD is a name for a group of lung conditions that cause breathing difficulties, including emphysema and chronic bronchitis

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2
Q

Give brief descriptions of emphysema and chronic bronchitis.

A
  • emphysema - damage to the air sacs in the lungs
  • chronic bronchitis - long-term inflammation of the airways
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3
Q

What are the main symptoms of COPD? (4)

A
  • shortness of breath, particularly when active
  • persistent chesty cough with phlegm - some may dismiss this as just a ‘smoker’s cough’
  • frequent chest infections
  • persistent wheezing
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4
Q

What are COPD flare-ups/exacerbations?

A

Periods when symptoms get suddenly worse

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5
Q

When should you get medical advice for COPD?

A

See a GP if you have persistent symptoms of COPD, particularly if you are over 35 and smoke/used to smoke

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6
Q

What can the GP do after asking about your symptoms and whether you smoke or have smoked in the past?

A

Organise a breathing test to help diagnose COPD and rule out other lung conditions such as asthma

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7
Q

What is the main cause of COPD, and some other causes? (3)

A
  • main - smoking
  • long-term exposure to harmful fumes or dust
  • rare genetic problem (alpha1 antitrypsin deficiency) that makes lungs more vulnerable to damage
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8
Q

What happens to the lungs in COPD?

A

COPD happens when the lungs become inflamed, damaged and narrows

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9
Q

Is damage to the lungs caused by COPD temporary or permanent?

A

Permanent - but treatment can help slow down the progression of the condition

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10
Q

What are some treatments for COPD? (4)

A
  • 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 lung transplant - only an option for a very small number of people
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11
Q

When is social care and support needed for COPD?

A
  • if you need help with day-to-day living because of illness or disability
  • if you care for someone regularly because they are ill, elderly or disabled (including family members)
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12
Q

How do you go about preventing COPD?

A

Avoid smoking / stop smoking if you already do

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13
Q

What are some less common symptoms of COPD (often at advanced stage)? (4)

A
  • weight loss
  • tiredness
  • swollen ankles from build-up of fluid (oedema)
  • chest pain and coughing up blood - although these are usually signs of another condition e.g. chest infection/lung cancer
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14
Q

What tests are used to diagnose COPD? (4)

A
  • spirometry
  • chest X-ray (rule out other conditions)
  • blood tests (rule out other conditions/look for A1AT deficiency)
  • further tests e.g. ECG, echocardiogram, peak flow test, blood oxygen test, CT scan, phlegm sample
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15
Q

What are three types of inhalers used to manage COPD (in order of severity)?

A
  • short-acting bronchodilator inhalers
  • long-acting bronchodilator inhalers
  • steroid inhalers
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16
Q

What are the two types of short-acting bronchodilators?

A
  • beta-2 agonist inhalers - salbutamol and terbutaline
  • antimuscarinic inhalers - ipratropium
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17
Q

What are the two types of long-acting bronchodilators?

A
  • beta-2 agonist inhalers - salmeterol, formoterol and indacaterol
  • antimuscarinic inhalers - tiotropium, glycopyronium and aclidinium
  • some new inhalers contain a combination of a long-acting beta-2 agonist and antimuscarinic
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18
Q

What are the types of tablets used to manage COPD? (4)

A
  • theophylline tablets - bronchodilator
  • mucolytics (carbocisteine) - makes phlegm thinner
  • steroid tablets
  • antibiotics
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19
Q

What other treatment options are there? (5)

A
  • nebulised medicine
  • Roflumilast
  • long-term oxygen therapy
  • ambulatory oxygen therapy
  • non-invasive ventilation
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20
Q

Describe the COPD exacerbation and how this could lead to mortality.

A
  • COPD exacerbation
  • decreased lung function
  • decreased physical activity
  • decreased mental health
  • decreased QoL
  • further COPD exacerbations
  • mortality
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21
Q

What are some of the comorbidities associated with COPD?

A
  • hypertension
  • hyperlipidaemia
  • atrial fibrillation
  • CAD
  • breast cancer, anxiety
  • CHF, CVA, PAD
  • lung cancer, pulmonary fibrosis, pulmonary hypertension, OSA
  • diabetes, erectile dysfunction, BPH, CRF, DJD, GERD, gastric duodenal ulcer, diabetes with neuropathy, liver cirrhosis, oesophageal cancer
  • depression, substance abuse
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22
Q

How does the severity of COPD change with number of comorbidities?

A

The more comorbidities, the more severe the patient’s COPD

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23
Q

How do you assess image quality in chest X-rays (RIPE)?

A
  • R - rotation
  • I - inspiration (how many ribs seen?)
  • P - projection (AP or PA? usually PA)
  • E - exposure
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24
Q

What is the ABCDE approach to chest X-rays?

A
  • A - airway (trachea central? bronchi branching?)
  • B - breathing (lung fields, lung markings - normal)
  • C - cardiac (heart size and borders) / consolidation (any white opacities, compare right and left upper, middle and lower zones)
  • D - diaphragm (costophrenic angle where it meets lung)
  • E - everything else (bones, ribs, clavicle, fractures, tubes, pacemakers)
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25
Q

What does opacification (whiteness) on a chest X-ray mean?

A
  • cloudy white area where there should not be (opacification) = something has replaced the air in the alveoli in that part of the lung
  • could be mucus, fluid, bacteria or immune cells replacing air = gas exchange in this part of the lung cannot happen
  • white parts can also be masses
  • pneumonia, infection, tumour, blood
26
Q

What does a chest X-ray of COPD show?

A
  • hyper-expansion of lungs
  • flattened diaphragm (due to hyper-expansion)
  • but sharp costophrenic angle
  • bullae (large) / blebs (small) - dark circular air pockets
  • (reduced lung markings, vertical heart)
27
Q

What does a chest X-ray of an infective exacerbation of COPD show?

A
  • general cloudiness (opacity) near lower lobe, trachea and edges
  • lack of sharp costophrenic angle
  • cannot see diaphragm
28
Q

What does a chest X-ray of a lung tumour show?

A

Opaque mass in one of the lungs

29
Q

What does a chest X-ray of pleural effusion show?

A

Part/majority of lung(s) is filled with fluid (opacity), meniscus

30
Q

How do you interpret an ABG (arterial blood gas) to determine respiratory/metabolic acidosis/alkalosis?

A
  • look at pH - is it low, normal or high?
  • if low –> acidaemia –> is there high PCO2 (respiratory acidosis) or low HCO3- (metabolic acidosis)?
  • if high –> alkalosis –> is there low PCO2 (respiratory alkalosis) or high HCO3- (metabolic alkalosis)?
  • (always check O2 as well e.g. if COPD given too much O2)
  • remember to check for compensation
31
Q

What are the features of Type I respiratory failure?

A
  • hypoxia without hypercapnia
  • PaO2 < 8kPa (normal/low PaCO2)
  • impaired oxygenation of the blood
32
Q

What are the features of Type II respiratory failure?

A
  • hypoxia WITH hypercapnia
  • PaCO2 > 6.5 Pa (O2 < 8kPa)
  • impaired excretion of CO2 from the lungs
33
Q

What are some examples of Type I respiratory failure? (10)

A
  • pneumonia
  • pulmonary oedema
  • pulmonary embolism
  • pulmonary fibrosis
  • ARDS
  • aspiration
  • asthma
  • lung collapse
  • pneumothorax
  • pulmonary contusion (blunt chest trauma)
34
Q

What are some examples of Type II respiratory failure? (7)

A
  • reduced respiratory drive e.g. drug OD, head injury
  • upper airway obstruction (oedema, infection, foreign body)
  • late severe acute asthma
  • COPD
  • peripheral neuromuscular disease (e.g. Guillain-Barre, myasthenia gravis)
  • flail chest injury
  • exhaustion
35
Q

How can the kidneys help compensate for type II respiratory failure?

A
  • lungs –> hypoventilation –> increased pCO2 –> fall in plasma pH –> respiratory acidosis
  • kidneys –> secretion of H+ (into tubular filtrate) and reabsorption of HCO3- (into blood) –> increase in plasma pH = metabolic compensation
36
Q

How can the lungs help compensate for renal failure?

A
  • kidneys –> loss of HCO3- (in urine) and retention of H+ (in blood) –> fall in plasma pH –> metabolic acidosis
  • lungs –> hyperventilation –> decrease pCO2 –> increase plasma pH –> respiratory compensation
37
Q

What is the compensatory mechanism for respiratory acidosis?

A

Metabolic alkalosis

38
Q

What is the compensatory mechanism for metabolic acidosis?

A

Respiratory alkalosis

39
Q

What is the compensatory mechanism for respiratory alkalosis?

A

Metabolic acidosis

40
Q

What is the compensatory mechanism for metabolic alkalosis?

A

Respiratory acidosis

41
Q

What are some treatment options for acute exacerbation of COPD? (6)

A
  • 1st line - short-acting bronchodilator
  • systemic corticosteroid
  • oxygen (only saturate to 88-92% as too high can cause oxygen-induced hypercapnia)
  • ventilation
  • antibiotic therapy (infective exacerbation)
  • supplemental treatment
42
Q

How do the treatment options change if there are comorbidities of diabetes, depression and hypertension?

A
  • avoid systemic corticosteroids - corticosteroids elevate cortisol which is associated with depression, also elevate glucose in diabetes, and can cause psychosis
  • plus: review diabetes medication
  • plus: monitor comorbidities during hospital stay
43
Q

How do the treatment options change if there is also chronic kidney disease?

A
  • kidney needed to compensate for lungs
  • avoid ventilation (kidneys unable to compensate for increased CO2 –> reduced pH)
  • avoid supplemental treatment
  • plus: monitor comorbidity during hospital stay
44
Q

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

A

Haemophilus influenzae infection (bacterial)

45
Q

Why can COPD (acute exacerbation) cause swollen ankles?

A
  1. alveolar hypoxia (decreased gas exchange)
  2. hypoxic pulmonary vasoconstriction (response of pulmonary circuit to increase SA for gas exchange)
  3. pulmonary vascular resistance (due to vasoconstriction)
  4. pulmonary hypertension
  5. right ventricular afterload (heart has to pump harder on right side to overcome increased pressure in pulmonary circuit)
  6. right ventricular failure
  7. peripheral oedema (blood backed up in veins throughout body, oedema develops as fluid leaks into surrounding tissues)
  8. swelling of ankles and feet (due to effects of gravity, fluid pools in lowest parts of body making them swell)
46
Q

How do you interpret an ABG report?

A
  • determine whether the pH is acidic, alkalotic or normal
  • is the primary disturbance respiratory or metabolic? look at pCO2 relating to respiratory causes, look at cHCO3- for metabolic causes
47
Q

When is respiratory acidosis caused?

A

When there is too much CO2 in the blood leading to increased H+ (/HCO3-), decreasing the pH

48
Q

When is respiratory alkalosis caused?

A

When there is too little CO2 in the blood leading to reduced H+(/HCO3-), increasing the pH

49
Q

Where does reabsorption of bicarbonate ions mainly occur?

A

Proximal renal tubule (PCT)

50
Q

The excretion of what molecules allows the reabsorption of bicarbonate ions?

A

Ammonia and monophosphate ions, and also hydrogen ions

51
Q

Between what concentrations is the bicarbonate ion a marker of homeostasis?

A

22-28mmol/L

52
Q

How does metabolic acidosis occur?

A
  • decreased HCO3- (not related to H2CO3/H+ as that is from ventilation) = decreased pH
  • increased acid formation (more H+) in blood or insufficient synthesis of HCO3- in kidneys
53
Q

How does metabolic alkalosis occur?

A
  • increased HCO3- (not related to H2CO3/H+ as that is from ventilation) = increased pH
  • decreased acid formation (less H+) in blood or too much synthesis of HCO3- in kidneys
54
Q

How do you calculate the anion gap in metabolic acidosis?

A
  • sodium ion - bicarbonate ion - chloride ion = 8-16mmol/L
  • if potassium included (Na+ + K+ - HCO3 - Cl) then the gap is 12-20mmol/L
55
Q

What is a high anion gap caused by?

A
  • increase in unmeasured ions
  • H+ reacting with HCO3-
56
Q

What are common causes of high anion gap metabolic acidosis? (4)

A
  • lactic acidosis
  • ketoacidosis
  • toxins
  • renal failure
57
Q

Why might there be a normal anion gap metabolic acidosis?

A

Lost bicarbonate ions are replaced with chloride ions

58
Q

What are the most common causes of normal anion gap metabolic acidosis? (2)

A
  • diarrhoea
  • renal tubular acidosis
59
Q

What is the respiratory compensation in metabolic acidosis?

A

decreased pH due to (decreased?) HCO3- –> increased ventilation –> decreased CO2 –> decreased carbonic acid –> increased pH

60
Q

When does the respiratory compensation usually begin?

A

In the first hour

61
Q

How is hypoventilation in metabolic alkalosis usually presented?

A
  • less pronounced
  • rarely retains CO2 beyond 7.5kPa
62
Q

If a patient has respiratory acidosis, what is the response of the kidneys?

A

Kidneys retain more bicarbonate and excrete more H+ to raise the pH and takes several days to complete

Year 2 - CSI (6 decks)

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