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MBBS IV - Junior Clerkship WCS > JC19 (Medicine) - COPD > Flashcards

JC19 (Medicine) - COPD Flashcards

1
Q

Define COPD

A

Chronic obstructive pulmonary disease (COPD): disease characterized by
□ Progressive but not fully reversible airflow obstruction (unlike chronic asthma)
□ Due to inflammatory response to toxic particles or gases (especially smoking)

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2
Q

2 pathophysiological components of COPD

A

Components of COPD arise as consequence of inflammation in different parts of the lung

Airways → chronic bronchitis

Alveoli → emphysema: abnormal permanent enlargement of airspaces distal to terminal bronchioles accompanied with destruction of their walls + fibrosis

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3
Q

Define chronic bronchitis

A

Chronic inflammation of airway:
cough and sputum on most days for ≥3mo in 2 consecutive years

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4
Q

Risk factors of COPD

A

Environmental:
→ Cigarette smoking (>85%) and passive smoking
→ Air pollution
→ Indoor biomass combustion
→ Occupational exposure

Host: α1-antitrypsin deficiency (rare, only consider if young <45y+ Caucasian)

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5
Q

Explain the pathogenesis of COPD
Case
Process
Resulting abnormalities

A

Cause: inhalation of noxious materials

Processes:
1) Chronic inflammation → mucus hypersecretion, inflammatory infiltrates → airway obstruction + collapse of distal poorly supported airways

  • *2) Progressive destruction of lung tissues**
  • Small airways peribronchiolar fibrosis, airway narrowing
  • Alveoli emphysema → ↓radial traction → airway obstruction

Results:
Small airway obstruction → air trapping → hyperinflated lungs
Respiratory failure due to V/Q mismatch: destruction of alveolar capillary bed + non-uniform airflow obstruction
Severe hypoxaemia + hypercapnia → blunted central resp drive
Alveolar hypoventilation due to airway resistance + hyperinflation → ↑work of breathing

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6
Q

Symptoms of COPD

A

Chronic bronchitis:

  • chronic cough with whitish mucoid sputum for years
  • May come with haemoptysis in exacerbations

Emphysema: progressive SOB

Features of complications

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7
Q

Signs of COPD

  • Inspection
  • Palpation
  • Percussion
  • Auscultation
A

General: tar staining, NO clubbing

  • Inspection:
    Pursed lip breathing
    Barrel chest with ↓distance between suprasternal notch and cricoid cartilage
    Respiratory distress ± central cyanosis
    Intercostal indrawing during inspiration
  • Palpation:
    Decrease chest expansion bilaterally
    Hoover’s sign: inward movement of lower ribs on inspiration
  • Percussion: loss of cardiac and hepatic dullness
  • Auscultation:
    Coarse inspiratory crackles in episodes of infection
    Prolonged expiratory phase ± wheezing
    Decrease breath and heart sounds
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8
Q

Complications of COPD (5)

(Acute, chronic and extra-pulmonary)

A

Acute exacerbations:

  • Pneumothorax (↓air entry, hyperresonance)
  • Critical airflow obstruction (↑wheezing)
  • Infection (signs of consolidation)
  • Acute respiratory failure

Chronic complications:

  • Chronic respiratory failure
  • Lung Cancer

Extra-pulmonary:

  • Cor pulmonale: chronic hypoxaemia → pulmonary hypertension → RV failure
  • Heart disease: IHD, HF, Arrhythmia, CAD
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9
Q

2 classical clinical phenotypes of COPD

A

Two classical clinical phenotypes:

(2) Blue bloaters (type B): predominant chronic bronchitis with cyanosis and fluid retention (tachypnoeic compensation ineffective resulting in cyanosis and cor pulmonale)

Note that these phenotypes often overlap

(1) Pink puffers (type A): predominant emphysema with tachypnoea and little cyanosis (tachypnoeic compensation effective)

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10
Q

Clinical assessment of dyspnea severity

A
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11
Q

First-line investigation of COPD + rationale (6)

A
  1. CBC for anaemia and polycythaemia (chronic SOB), eosinophilia for overlap with asthma
  2. Lung fx tests: Spirometry: post-bronchodilator FEV1/FVC <70% → diagnostic
  3. CXR for lung hyperinflation
  4. High resolution CT for emphysema and bullae
  5. Arterial blood gas: T2RF (if decompensated with chronic hypercapnea), T1RF (if well-compensated)
  6. Sputum C/ST for secondary infection
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12
Q

Typical CXR features of COPD

A

Hyperinflation:

  • Elongated heart
  • Flattened diaphragm
  • Hyperlucency of lung fields

Bullae
Cor pulmonale: cardiomegaly, prominent pulmonary trunk

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13
Q

Ddx of COPD

A
  1. Chronic asthma - distinguished by bronchodilator reversibility
  2. Bronchiectasis - Diagnosed by CXR/HRCT demonstrating airway dilatation
  3. Central airway obstruction - Spirometry also shows obstructive pattern but flow volume loop is characteristic for upper airway obstruction (expiratory plateau)
  4. Left heart failure - presence of fine basilar crackles and cardiomegaly/pulmonary oedema on CXR
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14
Q

Staging of COPD (airflow limitation, symptom severity and risk of exacerbation)

A

Assessment of airflow limitation by % predicted FEV1 (spirometric grade, in numbers)
→ Grading: ≥80% (GOLD1), 50-79% (GOLD2), 30-49 (GOLD3), <30 (GOLD4)

Assessment of symptoms and risk of exacerbations: (ABCD groups, in letters)
→ Symptoms by modified MRC scale (mMRC) or COPD assessment tool (CAT)
→ Risk of exacerbation by frequency of episodes

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15
Q

First line management of Stable COPD

A
  1. Remove risk factors - Stop smoking
  2. Bronchodilator: inhaled anticholinergics, β2-agonist
    Anti-inflammatory: ICS, roflumilast
  3. Long term oxygen therapy (LTOT)
  4. Pulmonary rehabilitation + flu vaccination
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16
Q

Management of acute exacerbations of COPD (4)

A
  1. Control oxygen therapy
  2. Antibiotics if dyspnea and purulent sputum: Amoxycillin, augmentin, macrolide, cephalosporin
  3. Inhaled Bronchodilators (inhaled SABA + SAMA)
  4. Inhaled corticosteroids
  5. NIV or mechanical ventilation
17
Q

Outline the GOLD ABCD groups of COPD patients

A

Class D = >2 exacerbation + lots of symptoms

Class A = no exacerbation + little symptom

A = 0/1 outpatient exacerbation + 0/1 MRC dyspnea scale
B = 0/1 outpatient exacerbation + 2+ MRC dyspnea scale
C = 2+ outpatient exacerbation or 1+ inpatient episode + 0/1 MRC dyspnea scale
D = 2+ outpatient exacerbation or 1+ inpatient episode + 2+ MRC dyspnea scale

18
Q

Treatment of GOLD A COPD

A

Initial: any bronchodilator (short- or long-acting, based on symptomatic relief)

Subsequent: continue if good symptomatic relief

19
Q

Treatment of GOLD B COPD

A

Initial: LABA or LAMA

Subsequent: LABA + LAMA → step down if no effect

20
Q

Treatment of GOLD C COPD

A

Initial: LAMA monotherapy (superior to LABA)
Subsequent: LABA/LAMA or LABA/ICS (a/w ↑pneumonia)

21
Q

Treatment of GOLD D COPD

A

Initial: LABA/LAMA (superior to LABA/ICS)

Subsequent: triple therapy or switch to LABA/ICS

Further: add roflumilast, macrolide or stop ICS

22
Q

List examples of bronchodilators for COPD

A

Short-acting agents: as needed for symptomatic relief in group A only
→ SABA: terbutaline (Bricanyl), salbutamol (Ventolin)
→ SAMA: ipratropium (Atrovent)

Long-acting agents: for regular use for symptomatic relief and prevent exacerbation
→ LABA: salmeterol (Serevent), formoterol (Oxis), indacaterol (ultra-long acting, not used in asthma)
→ LAMA: tiotropium (Spiriva)

23
Q

Example of ICS for COPD

Indication

One risk

A

Inhaled corticosteroids (ICS), eg. beclomethasone (becloforte), budesonide (pulmicort), fluticasone (flixotide)

Use: as combination with bronchodilator therapy in those with frequent exacerbations

High risk of pneumonia → STOPPED if exacerbation while on triple therapy

24
Q

Management of COPD refractory to Bronchodilator and ICS

A

Roflumilast: newer oral non-steroid anti-inflammatory agent

Macrolide: azithromycin taken daily to reduce exacerbation

Stopping ICS: Lower risk of pneumonia

25
Q

Indication for LTOT for COPD

A

Aim: maintain PaO2 ≥8kPa (60mmHg) or SaO2 ≥90%

Continuous LTO2
→ Resting PaO2 <7.3kPa (55mmHg) or SaO2 ≤88%

Non-continuous LTO2 when
→ During exercise, PaO2 <7.3kPa (55mmHg) or SaO2 ≤88%

→ During sleep, PaO2 <7.3kPa (55mmHg) or SaO2 ≤88% with associated complications

26
Q

Non-pharmalogical management of GOLD B-D COPD

A

Pulmonary rehabilitation for group B-D:

  1. Physiotherapy, muscle and exercise training
  2. Nutritional support for cachexia
  3. Psychotherapy and education
  4. Ventilatory assistance and home care

Smoking cessation: find reason of smoking, reason for cessation, manage withdrawal symptoms

Medications: (efficacy: V>B>N)

  1. Nicotine (gum, patch, inhaler) (still w/ S/E of nicotine)
  2. Bupropion (Zyban): NE-DA reuptake inhibitor and nicotinic antagonist
  3. Varenicline (Champix): nicotinic receptor partial agonist
27
Q

Management of severe COPD (hospitalization)

A
  1. Controlled oxygen therapy
  2. Exclude and treat pneumothorax
  3. SYSTEMIC corticosteroid (only difference with outpatient frequent exacerbation)
  4. Inhaled Bronchodilation
  5. Antibiotics coverage
  6. NIV
28
Q

Management of cor pulmonale secondary to COPD

A

Diuretics

Salt and fluid restriction

29
Q

Controlled Oxygen therapy for COPD

  • Target PaO2
  • Modes of delivery
  • Monitoring methods
A

Aim: PaO2 of 8kPa, SaO2 >90%

Modes: Nasal cannula, venturi mask

Monitor:

  • Clinical (BP, Pulse, Conscious level)
  • Pulse oximetry
  • Arterial blood gas measurement
30
Q

Indication for use of antibiotics for COPD

A

Give if any 2 of:

(1) ↑dyspnoea (2) ↑sputum volume (3) purulent sputum

Choice of Abx: Amoxycillin, augmentin, macrolide, cephalosporin

31
Q

Long-term management of COPD/ end-stage COPD

A
  1. LTOT
  2. Pulmonary Rehabilitation program
  3. Yearly Flu vaccination
  4. Lung volume reduction surgery
  5. Lung transplantation
32
Q

Reasons for chronic smoking

A

overlearnt habit,

routine,

craving,

stress, social-peer pressure,

relaxation,

addiction to Nicotine

33
Q

Reasons for smoking cessation

A

save money,

more socially acceptable,

not harm other,

improve health,

clothes and home smell fresher,

↑appreciation of taste and smell,

fire hazard

34
Q

Withdrawal symptoms from smoking

A

craving,

coughing,

hunger/weight gain,

bowel disturbance,

sleep disturbance,

dizziness, paraesthesia,

mood swings,

lack of concentration and irritability

35
Q

Medication for quitting smoking

A

Nicotine (gum, patch, inhaler) (still w/ S/E of nicotine)

Bupropion (Zyban): NE-DA reuptake inhibitor and nicotinic antagonist

Varenicline (Champix): nicotinic receptor partial agonist: ↓withdrawal symptoms, ↓reinforcing effect if start smoking again

36
Q

Comorbidities of stable COPD

A

MBBS IV - Junior Clerkship WCS (131 decks)

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