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Leicester Year 3 GP > GP/ Medicine - COPD > Flashcards

GP/ Medicine - COPD Flashcards

1
Q

What is COPD?

A

Persistent respiratory symptoms + airflow obstruction that is progressive and irreversible

Limited reversibility after bronchodilators

An umbrella term for emphysema + chronic bronchitis

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2
Q

Give 5 risk factors/ causes for COPD

A

Smoking

Air pollution

Occupational exposure to coal, dusts, fumes, and chemicals

Alpha-1 antitrypsin deficiency

Developmental problems i.e. prematurity or low birth weight

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3
Q

What is the MOST COMMON CAUSE of COPD?

A

Smoking

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4
Q

What is the pathopathysiology of COPD?

A
  • Emphysema - Destruction of alveolar wall leading to abnormal enlargement of air sacs –> reduced surface area for gaseous exchange; Loss of elastin causes reduced elastic recoil of the lungs and increased lung compliance
  • Chronic bronchitis - Mucous gland hyperplasia –> mucus hypersecretion; Loss of ciliary function –> impaired mucus clearance
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5
Q

Give 3 complications of COPD

A

Cor pulmonale (COPD –> hypoxia –> hypoxic vasoconstriction of pulmonary capillaries –> pulmonary hypertension –> Cor pulmonale)

Type 2 respiratory failure

Lung cancer (think about smoking of the BIG CAUSE)

Frequent respiratory infections (e.g. pneumonia)

Secondaru pneumothorax

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6
Q

How do you diagnose COPD?

A

Clincal features + post-bronchodilator spirometry

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7
Q

What symptoms would a patient with COPD present with?

A

Symptoms:

  • Chronic productive cough with sputum
  • Dyspnoea - progressive and worse on exertion
  • Wheeze
  • Reduced exercise tolerance
  • Weight loss, fatigue
  • Frequent lower respiratory tract infections
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8
Q

What signs would a patient with COPD present with?

A

Hyperinflated lungs (barrel chest) - anteroposterior: lateral diameter = 1:1

Hyperresonant percussion (due to air being trapped inside lungs)

Reduced lung expansion

Decreased cricosternal distance

Purse lip breathing

Use of accessory muscles of respiration

Central and peripheral cyanosis

Flapping tremour suggestive of CO2 retention - Type 2 resp failure

Raised JVP, ankle swelling, hepatomegaly, parasternal heave suggestive of Cor Pulmonale

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9
Q

What score do you we use to grade the severity of SOB in COPD?

A

MRC dyspnoea score

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10
Q

What are the different categories in MRC dyspnoea score?

A

Grade Level of activity

1 Breathlessness only on strenuous exercises

2 Breathlessness when hurrying or walking up a slight hill

3 Walks slower than normal on level ground due to breathlessness, or has to

stop for breath when walking at own pace

4 Stops for breath after walking 100 m or after a few minutes on level ground

5 Too breathless to leave the house; breathless when dressing or undressing

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11
Q

What examinations would you carry out in a GP practice?

A
  • Respiratory and Cardiovascular examinations
    • Including checking for signs of cor pulmonale - raised JVP, ankle swelling, hepatomegaly, parasternal heave

Basic obs:

  • HR, BP, SaO2 (pulse oximetry), Temperature
  • Check BMI (can compare this with previous readings to determine the amount of weight loss)
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12
Q

What findings on a spirometry would help confirm a diagnosis of COPD?

A

Post-bronchodilator spirometry:

FEV1 < 80% predicted, OR

FEV1/ FVC < 0.7

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13
Q

Other than FEV1 and FEV1/ FVC readings, what other measurements on a spirometry will reinforce the diagnosis of COPD?

A

Increased FRC, RV, TLC, but decreased IRV

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14
Q

In SHx, the impact of symptoms on daily life and occupation is often asked. What is a more objective way of assessing this?

A

COPD assessment test (CAT)

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15
Q

What differential diagnosis must you consider if a young patient presents with symptoms of COPD?

A

Alpha-1 antitrypsin deficiency

Pneumonia

Asthma

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16
Q

What questions would you ask about cough and sputum production?

A

Onset, duration, frequency, diurnal variation of cough

Colour and volume of sputum

Any blood in it?

17
Q

What in the PMHx would you ask in someone with suspected COPD?

A

Asthma

Other lung or liver diseases

Cardiovascular disease

Any previous acute hospital admissions or exacerbations

18
Q

What investigations would you do for COPD patients in a primary care setting?

A

Blood tests - FBC shows anaemia or polycythaemia, and to rule out infection

Post-bronchodilator spirometry showing FEV1 < 80% predicted, or FEV1/FVC < 0.7

Request CXR shows hyperinflated lungs (> 6 anterior ribs or > 10 posterior ribs at MCL at diaphragm level) and hyperlucent lungs (bullae), flat hemidiaphragm; it also helps to rule out complications of COPD e.g. pneumonia, secondary pneumothorax, lung cancer, and cardiomegaly in cor pulmonale

Request ECG for cor pulmonale

BMI

19
Q

What other investigations can you also do?

A

ABG - may show type 1 or 2 respiratory failure

Sputum culture

ECG, Echo, BNP - may show RV hypertrophy (Cor pulmonale)

Alpha-1 antitrypsin deficiency if young patient with early onset of COPD symptoms

20
Q

Where post-bronchodilator FEV1/FVC ratio is less than 0.7, severity of airflow obstruction is graded according to reduction in FEV1 compared to appropriate reference values (based on age, sex, height and ethnicity). What are the gradings?

A

Stage 1 (mild) - FEV1 < 80% predicted

Stage 2 (moderate) - FEV1 < 50-79% predicted

Stage 3 (severe) - FEV1 < 30-49% predicted

Stage 4 (very severe) - FEV1 < 30% predicted or FEV1 < 50% with respiratory failure

21
Q

What are the differential diagnoses?

A

Asthma

Lung cancer

Heart failure

Bronchiectasis

22
Q

Compare and contrast Asthma vs COPD

A

Asthma COPD

Good reversibility after bronchodilators Limited reversibility after bronchodilators

Dry cough Productive cough with sputum

Symptoms worse at night Symptoms constant throughout day and night

Acute onset Chronic onset and progressive

First onset usually at young age First onset usually elderly patients who smoke

Hx of atopy Hx of smoking

Spirometry shows obstructive pattern Spirometry shows mixed obstructive and

restrictive pattern

23
Q

What is the management for stable COPD?

A

Non-pharmacological management:

  • Lifestyle changes - smoking cessation (offer nicotine replacement therapy), more exercises, healthy diet
  • Pneumonoccoal and influenza vaccinations
  • Pulmonary rehabilitation- if functionally disabled by COPD or MRC grade >/= 3) or a recent acute exacerbation requiring hospitalisation
  • Optimise treatment for comorbidities e.g. asthma, other lung conditions, cardiovascular disease, diabetes, HTN

Pharmacological mangement:

  • 1st line: SABA/ SAMA
    • If patients remain breathless or have exacerbations despite using SABA/ SAMA, the next step is determined by whether the patient has ‘asthmatic features/ features suggesting steroid responsiveness’
      • If no asthmatic features/ features suggestive of steroid responsiveness:
        • Add LABA + LAMA
          • If patient already taking a SAMA, discontinue and switch to a SABA
      • If they have asthmatic features/ features suggestive of steroid responsiveness:
        • Add LABA + ICS (these two can be given as a single combination inhaler called Fostair)
          • If patients remain breathless or have exacerbations, add LAMA (triple therapy)
            • If already taking a SAMA, discontinue and switch to a SABA
  • Other add-on treatments in COPD:
    • Oral theophylline - only recommended after trials of short and long-acting bronchodilators or to people who cannot use inhalers
    • Oral prophylactic Abx (azithromycin)
      • ​Discuss with a respiratory specialist first
      • CT thorax (to exclude bronchiectasis) and sputum culture (to exclude TB and atypical infections) must be done prior to prescribing
      • An ECG is needed to exclude prolonged QT
    • Oral mucolytics - if a patient develops chronic productive cough with sputum
    • If Cor pulmonale, give loop diuretics + LTOT

(Note that Oral corticosteroids should NEVER be offered for maintenance treatment of COPD in primary care)

Long-term oxygen therapy (LTOT)

  • Need to be used for at least 15 hrs/ day
  • Offer LTOT if pO2 < 7.3 kPa, or < 8 kPa with cor pulmonale, peripheral oedema, or polycythaemia
  • Patients must be non-smokers (due to risk of fire and explosion) and do not have CO2 retention
  • NIV (BIPAP) if hypercapnic on LTOT

Lung volume reduction surgery to treat hyperinflated lungs

24
Q

What are the criteria that suggest the presence of asthmatic features or features of steroid responsiveness?

A

Previous diagnosis of asthma or atopy

High blood eosinophil count

Substantial variation in FEV1 over time (at least 400 mL)

Substantial diurnal variation in PEFR (at least 20%)

25
Q

What are the names of the drugs for SABA, SAMA, LABA, and LAMA?

A

SABA = Salbutamol

SAMA = Ipratropium bromide

LABA = Salmeterol / formoterol

LAMA = Tiotropium

ICS = Inhaled corticosteroids

26
Q

What do you want to check if a patient is on an inhaler? And What do you want to minimise in someone with 2 or more inhalers?

A

Check inhaler technique

Check patient compliance/ adherence

Minimise the number and type of inhalers used by each person as much as possible, e.g. use a combination inhaler (Fostair)

27
Q

What is Fostair inhaler?

A

LABA + ICS

It’s usually given when patients are already on 2 inhaler medications, and a third one needs to be given.

28
Q

When would you NOT refer the patient for pulmonary rehabilitation?

A

Cannot walk

Unstable angina or recent MI

29
Q

When should you refer a patient with COPD to a respiratory specialist?

A

Lung cancer is suspected

Cor pulmonale is suspected

Very severe COPD (FEV1 < 30% predicted)

Frequent chest infections

Diagnostic uncertainty

30
Q

What advice would you give to the patient with stable COPD?

A

Advice:

  • Stops smoking
  • Encourage exercises
  • Check inhaler techniques
  • Advise to carry inhalers and other appropriate medication wherever they go
  • Educate on symptoms of acute exacerbation of COPD
  • Advise them about the side effects of each medication
    • SABA - tachycardia, palpitations, hypokalaemia, tremor
    • SAMA - dry mouth, cough, constipation, N&V
  • Safety netting: If their conditions deteriorate e.g. medications no longer effective or if there is development of new symptoms, arrange to see their GP or call 999
31
Q

What are the clinical features suggestive of an acute exacerbation of COPD?

A

Worsening dyspnoea

Worsening cough with increased sputum volume and purulence

Worsening wheeze

Chest tightness, reduced exercise tolerance

Fever

URTI in the past 5 days

Increased RR or HR 20% above baseline

Acute confusion, cyanosis, peripheral oedema

32
Q

What examinations would you do for AECOPD?

A

Respiratory and cardiovascular examinations

Check BP, HR, SaO2 and Temperature

Assess for confusion

33
Q

What investigations would you do in AECOPD?

A

Blood tests

ABG

CXR

ECG, Echo

Sputum culture if purulent

Blood culture if fever

34
Q

What is the acute management for AECOPD?

A
  • ABCDE
  • Controlled oxygen via Venturi mask (24 or 28%), aim at SaO2 88-92%
  • Nebulised bronchodilators - salbutamol and ipratropium bromide
  • Steroids - oral prednisolone 30 mg STAT and then OD for 7 days
  • Antibiotics ONLY if raised CRP/ WCC or purulent sputum - give amoxicillin (if no underlying lung disease) or co-amoxiclav (if respiratory failure or cor pulmonale)
    • If penicillin allergic, give doxycycline or clarithromycin (avoid in long QT)
  • CXR
  • If not improving, consider:
    • IV aminophylline
    • NIV if type 2 respiratory failure and acidotic (pH 7.25-7.35)
    • ITU referral for invasive ventilation if pH < 7.25
35
Q

What are the two most common microorganisms that cause AECOPD?

A

Haemophilus influenza (that’s why patient have yearly influenza vaccine)

Streptococcus pneumoniae

Moraxella Catarrhalis

Rhinovirus

Leicester Year 3 GP (36 decks)

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