CSI - COPD Flashcards
What are the two broad causes of breathlessness?
- respiratory
- cardiovascular/systemic
Why is considering breathlessness important?
- Breathlessness is a symptom, not a condition itself
- There’s often more than one cause of breathlessness
- Conditions that cause long-term breathlessness can often be treated, but some cannot be fully reversed
- It’s important to learn how to manage long-term breathlessness
Why can lung conditions cause breathlessness?
- lung disease can cause breathlessness for many reasons
can cause the airways to become inflamed and narrowed,
or filled with - phlegm, so it’s harder for air to move in and out of the lungs
- can make the lungs stiff and less elastic so it’s harder for
them to expand and fill with air
What lung conditions cause long-term chronic breathlessness?
chronic obstructive pulmonary disease (COPD)
interstitial lung disease (ILD), including
pulmonary fibrosis and sarcoidosis
bronchiectasis
industrial or occupational lung diseases such as
asbestosis, which is caused by being exposed to
asbestos
lung cancer
What are lung conditions that cause short-term (acute)
breathlessness?
flare-up of asthma or COPD
pulmonary embolism or blood clot on the lung
lung infection such as pneumonia or
tuberculosis
pneumothorax or collapsed lung
build-up of fluid in your lungs or the lining of
your lungs – this might be because your heart is
failing to pump efficiently or may be because of
liver disease, cancer or an infection
Why can heart conditions cause breathlessness?
can cause long-term breathlessness
can be due to problems with the rhythm, valves or
cardiac muscles of the heart
heart can’t increase its pumping strength in
response to exercise, or the lungs become congested
and filled with fluid
often worse when supine (so when sleeping)
Which heart conditions cause acute breathlessness?
a heart attack
an abnormal heart rhythm - you might feel your heart misses beats or you might
experience palpitations
Why is anxiety and breathlessness be interlinked?
feeling short of breath when anxious or afraid is a normal response to stressful situations; the body is preparing for action
as you get more anxious, you may start to breathe faster and tense your breathing muscles
physical health can also impact mental health, especially if living with a lung condition
you might get anxious if you don’t feel in control of your
condition
if you have a lung condition, you may have symptoms that make you feel anxious
sometimes the symptoms of lung conditions e.g.
breathlessness, tightness in your chest or getting tired very easily are similar to feelings of anxiety
What happens to the heart and muscles during panic attacks?
when body’s normal response is exaggerated, you get a rapid build-up of physical responses; breathing quickens and your body also releases hormones so your heart
beats faster and your muscles tense
What are some symptoms of panic attacks?
During a panic attack, you might feel you can’t breathe and:
have a pounding heart
feel faint
sweat
feel sick
have shaky limbs
feel that you’re not connected to your body
What is the link between anxiety and hyperventilation?
- If you start to breathe too quickly in response to a panic attack, you may breathe in more
oxygen than your body needs. - This is called hyperventilation or over-breathing.
- When you do this, the delicate balance of the gases in your lungs is upset.
- An amount of carbon dioxide normally stays in the blood. If you breathe in too much air too
often, the carbon dioxide is pushed out through the lungs and this affects the messages the
brain receives to tell you to breathe
Why does being unfit cause breathlessness?
When we are unfit, our muscles (including respiratory
muscles) get weaker.
Weaker muscles need more oxygen to work, so the
weaker our muscles, the more breathless we feel.
It’s really important to keep active to manage
breathlessness bett
Why does being an unhealthy weight cause breathlessness?
If you’re underweight, your respiratory muscles will be weaker.
If you’re overweight, it takes more effort to breathe and move around.
Having more weight around the chest and stomach restricts how much your lungs can
move.
People who are a BMI of 25 or more are more likely to get breathless compared to people with a healthy weight.
People who are severely overweight can develop obesity hypoventilation syndrome; when poor breathing leads to lower oxygen levels and higher carbon dioxide levels in
their blood.
Maintaining a healthy weight may help you to manage your breathlessness better and be more active
What are other causes of long term breathlessness?
smoking
conditions that affect how your muscles work, such as muscular dystrophy, myasthenia
gravis or motor neurone disease
postural conditions that alter the shape of your spine, and affect how your ribs and
lungs expand - for example scoliosis and kyphosis
anaemia, when a lack of iron in the body leads to fewer red blood cells
kidney disease
thyroid disease
What are patient barriers to diagnosing COPD?
Patients may:
think breathlessness is as a normal part of
ageing, so don’t tell their doctor
feel responsible for causing their illness and
don’t feel they deserve help
not realise they can get any help for their
breathlessness
not actually feel out of breath when they see
their doctor (would be sitting down and may
have only walked a short distance), so may
forget what their breathlessness feels like
and find it hard to describe
What tools should patients use to diagnose COPD?
Patients should:
Use an online breath test to find out if your
breathlessness is something to get checked out
with your doctor.
bring someone with them who can help
describe their breathlessness
think about how they will be describing their
breathlessness in advance of seeing a doctor e.g.
what they used to be able to do but can’t any
more
what people of their age around them do that
they find difficult
what their personal goals are for their day-today activity
use local landmarks such as bus stops, shops
and hills to help you describe these thing
record the sort of activities that make them out
of breath to show their doctor what it looks or
sounds like
What tools will doctors use to investigate breathlessness?
Doctors will:
Use the MRC breathlessness scale
Ask questions about breathlessness
Do some tests to help diagnose what’s causing
the breathlessness
What is the MRC?
MRC = Medical Research Council
The scale health care professionals usually use to
measure breathlessness
This does not recognise other aspects of breathlessness – such as how you think or feel about getting out of breath.
The MRC scale shows what your breathlessness stops you doing.
Your grade is the one that describes you when you’re at
your best
What are the grades on the MRC breathlessness scale?
1 = not troubled by breathlessness except on strenuous exercise
2 = short of breath when hurrying on the level or walking up a slight hill
3 = Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace
4 = Stops for breath after walking about 100 yards or after a few minutes on level ground
5 = Too breathless to leave the house, or breathless when undressing
What questions doctors might ask about breathlessness?
duration
onset
frequency
pattern
time
relieving factors e.g. lying flat
exacerbating factors e.g. pollen, pets, medication
smoking
coughing/phlegm
chest pain, palpitations, ankle swelling
normal activity levels
occupation
whether breathlessness is related to certain times at work
history of heart, lung or thyroid disease, or of anaemia
family history of breathlessness
lifestyle changes made due to breathlessness (if any)
feeling worried, frightened, depressed or hopeless
coping mechanisms
What physical tests doctors may carry out to diagnose cause of breathlessness?
breathing and lung function tests
Respiration rate (breaths per min)
Chest auscultation (listening)
Look and feel how chest moves during breathes
heart rate and rhythm
check if fluid is building up in ankles or lungs
blood pressure and temperature
check height, weight, waist and BMI
examine head, neck and armpits to see if lymph glands are swollen
inspect eyes, nails, skin and joints
check blood sats with a pulse oximeter
if there are signs that patient is anxious/depressed, a short questionnaire
Diagnosing breathlessness: What are additional possible tests at GP surgery, local testing centre or hospital?
chest X-ray
spirometry test
electrocardiogram or ECG - if breathlessness is intermittent, wear a portable recorder for
24 hours or 7 days to record heart’s electrical activity
echocardiogram - this is a non-invasive ultrasound of heart which can tell how well it’s
working
blood tests to detect anaemia, allergies or any thyroid, liver, kidney or heart problems
What is meant by shortness of breath on exertion?
Shortness of breath on exertion: when you have additional requirements on top of your baseline
needs, and do not acquire enough oxygen to meet the needs
What are the respiratory differential diagnoses that can present with shortness of breath on exertion?
Asthma
COPD
Pulmonary fibrosis (lung tissue becomes fibrotic
and scarred)
Lung cancer
Pulmonary embolism
Pneumothorax
Lower respiratory tract infection
What are the possible cardiovascular differential diagnoses that mean you can present with shortness of breath on exertion?
Congestive heart failure (fluid builds up within
the heart and causes it to pump inefficiently)
• Pulmonary oedema (fluid collects in the
numerus air sacs in the lungs, making it difficult to
breathe -mainly caused by heart problems)
• Valvular defects
• Acute coronary syndrome
• Anaemia
• Renal or heart failure
• Deconditioning (being unfit/significant loss in
muscle mass -affects heart and respiratory muscles)
What questions could you ask Mr Craven to eliminate differential diagnoses?
how long has he had symptoms for (to differentiate acute e.g. infection, pneumothorax and chronic e.g. COPD, asthma, pulmonary fibrosis)
is he waking up at night; left heart failure results in back clog of blood in lungs (pulmonary oedema), lying down is worse as fluid remains around lungs instead of being drained away when standing
chest pain; causes acute coronary syndrome, pneumonia, heart attack, angina, pneumothorax, pulmonary embolism
cough e.g. infection
times of breathlessness (asthma symptoms are typically worse in the morning)
any change in physical activity
history of cancer
What are things to look out for on examination to help hone in differential of Mr. Craven?
specific lung sounds e.g. healthy chest=smooth/lamina flow, wheezing=turbulent flow, fluid
produces crackle
2. specific heart sounds e.g. look out for murmur
What are investigations you could carry out on Mr Craven?
spirometry
ECG
chest x-ray
bloods
What is FEV1/FVC? What is the ratios?
FVC = forced vital capacity:
is the amount of air that can be forcibly exhaled from your
lungs after taking the deepest breath possible
FEV1 = forced expiratory volume in 1 second:
is the maximum amount of air that the subject can forcibly
expel during the first-second following maximal inhalation
Normal FEV1/FVC ratio is 70-80%
What are the mechanisms of a restrictive disease?
lung capacity is restricted, so FVC is
lower
2. if airways are unaffected, FEV1 will
be normal
3. therefore FEV1/FVC ratio could be
slightly increased
4. if FEV1 is proportionally lower,
FEV1/FVC ratio could be normal
5. won’t necessarily affect rate of flow
but affects lung volume
6. can’t fully fill lungs
What are the causes of a restrictive disease?
scoliosis
interstitial lung disease e.g.
pulmonary fibrosis; alveoli are less
stretchy so can’t get as much air in
muscular dystrophy
obesity
sarcoidosis, an autoimmune disease
What are the spirometry results of a restrictive disease?
FEV1/FVC = normal/slightly higher
FVC = lower
What is the mechanism of an obstructive disease?
measure on outflow with FVC
2. FVC is normal; although airways are tighter,
they can get a normal amount of air in and
out, just takes longer
3. FEV1 is lower because they can’t get air out
quick enough
What are the causes of an obstructive disease?
COPD which includes emphysema and chronic
bronchitis
asthma
bronchiectasis
cystic fibrosis
What are the spirometry results of an obstructive disease?
FEV1/FVC = normal/lower
Confirmed if FEV1 = <80% of the predicted value and
FEV1/FVC = <70%
COPD: What is the pathophysiological process of bronchititis?
could be caused by infection
thickened airway walls
narrower lumen
overproduction of mucus due to
overactivity/increased number of goblet cells
in response to inflammation and irritants
symptoms could include phlegm cough (had for at least 3 months for 2 consecutive years
COPD: What is the pathophysiological process of emphysema?
interconnections between alveoli gets broken down and results in increased sacs
results in smaller SA:V ratio, resulting in less efficient gas exchange
no elastic recoil that helps to push air out
narrowing of airways
What are signs of hyperinflation?
Signs of hyperinflation
more than 7 anterior ribs visible at the mid-clavicular line (although this is not particularly sensitive)
flattening of the diaphragm (may be a more sensitive sign)
heart may appear small and narrow, sometimes with air visible below the inferior border (floating heart sign)
emphysema on CXR can be seen as hyperinflation, there may also be a bullae present (not seen here)
What is different about Mr Craven’s chest x-ray?
Mr C:
smaller heart
smaller + flattening of
diaphragm
gastric bubble
hyperexpansion (more air in
spaces than you would expect)
What is bullae? How does it appear on a chest x-ray?
Look for bullae:
Areas of low density
(black = lots of air!)
May be outlined,
resembling bubbles
Bullae:
Air-filled spaces with
thin walls, bordered only
by remnants of alveolar
septae or pleura
Often caused by
emphysema
What are factors that can help for COPD treatment?
COPD treatment
Factors that can help:
stop smoking
eating well and maintaining a healthy weight
keeping well in the cold
take prescribed medications
control breathing
keeping active
looking after mental health
pulmonary rehabilitation (PR); exercise and
education programme to help people with
COPD cope with getting out of breath
What is the advice for patients with COPD? (3)
Smoking cessation
Nutrition
Keeping warm
Smoking cessation:
nicotine replacement therapy
-stop smoking medication
nutrition:
-maintain healthy weight
obesity; heart and lungs work harder, can add restrictive disorder
limit simple carbohydrates
more fibre
Keeping warm
-avoid catching cold
-GP may give care pack; antibiotics and
steroids to take if they think they’re becoming unwell
Pros and cons of inhaler devices: spacers
spacers (or holding chambers) are large, empty
devices (or tubes) that are usually made out of
plastic
help get the best from asthma medicine if you use a
metered dose inhaler (MDI)
makes it easier to get the right amount of medicine
straight to your lungs, where it’s needed
can reduce the risk of side effects from your
medicine
Pros and cons of inhaler devices: MDIs
Metered dose inhalers (MDIs):
deliver a dose of medicine in a fine spray (aerosol) form
can be difficult to use them correctly as you need to breathe in at exactly the same time as you
press down on your inhaler to release the medicine
also need to breathe in very slowly and deeply
Why is a spacer good? (3)
How spacers help manage airway disease better
make it easier to get the right amount of medicine
using a spacer helps the medicine get straight to your lung
inhaler is fixed on one end of the spacer and the mouthpiece at the other
when you press on your inhaler, the medicine collects in the chamber of the spacer, so you can
breathe it in without needing to get the timing and speed exactly right
an asthma inhaler with a spacer can also help if you’re having an asthma attack
Means you can use less medicine
a spacer slows the medicine down as it comes out of the inhaler, so more gets taken down into
the lungs
makes the medicine more efficient, so may need to use less
Reduces the risk of side effects
spacers reduce the small risk of side effects if you’re taking preventer (steroid) medicine
more of the medicine gets into your lungs, less medicine is absorbed into the rest of your body,
lowering the risk of side effects
this also reduces the risk of voice changes and oral thrush: a fungal infection that can be a side
effect of asthma inhalers, particularly in children
How do you use your inhaler?
How to use
your doctor, asthma nurse or pharmacist should show you and check your technique at your
annual asthma review
Correct inhaler technique
there are two breathing techniques you can use with your spacer:
1) the ‘tidal or multiple breathing’ technique
2) the ‘single breath and hold’ technique
Spacer cleaning
keeping the spacer clean will help get the full benefits of the asthma medicines
follow the manufacturer’s instructions
if it’s a new spacer, clean it before you use it for the first time, then once a month afterwards
What are the types of inhalers?
1- Metered Dose Inhalers
(With or W/O Spacer)
2- Dry Powder Inhalers
(Single/ Multiple Dose)
3- Nebulizers
(Jet/Ultrasonic/Mesh)
