Lower respiratory tract diseases - COPD

Question 1

what does COPD stand for?

Answer 1

chronic OBSTRUCTIVE pulmonary disease

Question 2

what is COPD?

Answer 2

= airflow limitation that is not fully reversible

• airflow limitation is progressive & associated with an abnormal inflammatory response of the lungs to noxious particles or gases

Question 3

what causes COPD?

Answer 3

long term exposure to toxic particles or gases

= SMOKING

Question 4

is COPD referring to one singular condition or is it an overarching diagnosis?

Answer 4

it is an OVERARCHING DIAGNOSIS, brining together a variety of clinical syndromes associated with airflow limitation and destruction of lung parenchyma

Question 5

what is the most consistent pathological finding in COPD?

Answer 5

• increased numbers of mucus-secreting goblet cells in bronchial mucosa

Question 6

what happens to the bronchi & lumen in more advanced cases of COPD?

Answer 6

• bronchi becomes inflamed

- pus is seen in the lumen

Question 7

what is seen microscopically to the walls of the bronchi and bronchioles?

Answer 7

• walls of bronchi & bronchioles are infiltrated with acute & chronic INFLAMMATORY CELLS; e.g. lymphoid follicles

Question 8

what follows inflammation?

IMPORTANT

Answer 8

• scarring and thickening of the walls which narrows the airways

Question 9

explain the balance between proteases and antiproteases?

Answer 9

• noxious particles increase the number of proteinases
• these are normally neutralised by anti-proteinase
• but this increase in proteinase upsets the protienase-antiprotienase balance allowing proteinases to digest the lung tissue
• effectively causing emphysema

Question 10

what are the 3 main features of COPD?

Answer 10

1) hypersecretion of mucus
2) small airway obstruction
3) alveolar destruction

Question 11

what are the 2 diseases that comprise COPD?

Answer 11

1) chronic bronchitis

2) emphysema

Question 12

what is emphysema?

Answer 12

abnormal permanent ENLARGEMENT OF AIR SPACES, accompanied by DESTRUCTION of their WALLS & without obvious fibrosis

Question 13

what is enlargement of the air spaces trough to be a secondary cause of?

Answer 13

small airway inflammation and destruction

Question 14

how is emphysema classified?

Answer 14

• classified according to the site of damage;
  1) CENTRI-ACINAR emphysema
  2) PAN-ACINAR emphysema
  3) IRREGULAR emphysema

Question 15

where is the centri-acinar emphysema located?

Answer 15

• usually involves the upper part of the lungs

- changes spreading outwards, starting from the bronchioles

Question 16

what is centri-acinar emphysema associated with?

Answer 16

substation airflow limitation

Question 17

where is pan-acinar emphysema located?

Answer 17

• usually seen in lower part of the lungs

- alveoli are completely destroyed

Question 18

in what people is pan-acinar seen in?

Answer 18

people with alpha 1 ant-itrypsin deficiency

Question 19

what is pan-acinar associated with?

Answer 19

• severe airflow limitation

- Va/Q mismatch

Question 20

what does emphysema result in?

Answer 20

• expiratory airflow limitation
• air trapping
• impaired gas exchange
• Va/Q mismatch

Question 21

how do people with COPD cope with respiratory infections?

Answer 21

• they cope badly

- the infections are often the cause of an exacerbation of COPD

Question 22

symptoms of COPD

Answer 22

• productive chronic cough, white or clear sputum
• wheeze
• breathlessness
  (could be as severe as breathless after getting dressed)
• colds settle on the chest

systemic effects;

• hypertension
• osteoporosis
• depression
• decreased muscle mass with general weakness

Question 23

who is most likely to get COPD?

Answer 23

• mainly diagnosed in middle aged-elderly

- smokers of many years

Question 24

are symptoms of COPD chronic or acute?

Answer 24

chronic

Question 25

what is an exacerbation

Answer 25

= an acute change in a patients baseline dyspnoea, cough and/or sputum

Question 26

what causes an exacerbation of COPD?

Answer 26

- changes in weather, e.g. cold or damp - viral upper resp tract infection - viral of bacterial bronchitis

Question 27

what are signs of mild COPD?

Answer 27

- there are few signs | - just quiet wheezes throughout the chest

Question 28

what are signs of severe COPD?

Answer 28

- tachypnoeic (rapid breathing) - prolonged expiration - accessory muscles of respiration are used - chest expansion is poor - lungs hyperinflated - pursing on the lips on expiration

Question 29

what are later stages of COPD associated with? How could this respiratory failure be treated?

Answer 29

respiratory failure - PaO2 < 8kPa OR - PaCO2 > 7kPa - removal of retained secretions (cough up secretions) - respiratory support (non-invasive ventilatory techniques) - respiratory stimulants (e.g. doxapram) - corticosteroids, antibiotici and bronchodilators can be used

Question 30

what is pulmonary hypertension?

Answer 30

HIGH blood pressure

Question 31

what causes pulmonary hypertension?

Answer 31

- chronic alveolar hypoxia and hypercapnia | - leads to constriction of pulmonary arterioles

Question 32

how is COPD usually diagnosed?

Answer 32

- usually clinical, based on history of breathless & sputum production in a CHRONIC SMOKER.

Question 33

if a patient has the symptoms of COPD but isn't a smoker, what is the explanation most likely to be?

Answer 33

asthma | UNLESS, there is a family history of alpha 1 antitrypsin deficiency

Question 34

what is alpha 1 antitrypsin?

Answer 34

= a proteinase inhibitor produced in the liver - secreted into the blood and diffuses into the lungs - it inhibits proteinases that are capable of destroying alveolar wall connective tissue

Question 35

what happens if there is an alpha 1 deficiency?

Answer 35

the alpha 1 anti-trypsin accumulates in the liver, leading to low levels in the lungs - so the proteinase isn't being inhibited - therefore it can destroy the alveolar walls & connective tissue - leading to symptoms of COPD

Question 36

how can the diagnosis of COPD be confirmed? | what would lung function pattern be?

Answer 36

by spirometry results that show IRREVERSIBLE AIRFLOW OBSTRUCTION - PEFR reduced - reduced FEV1 - reduced FVC - FEV1/FVC ratio REDUCED - FEV1 response to B2 agonists < 15%

Question 37

in patients with COPD, what sit the FEV1 usually?

Answer 37

< 80% | - if the FEV1 is > or equal to 80%, a diagnosis of COPD is only made if there are respiratory signs of COPD

Question 38

what is the ratio of FEV1/FVC that would show COPD?

Answer 38

< 70%

Question 39

What would a chest X-ray show in a patient with COPD?

Answer 39

- relatively normal - overinflation of lungs - low, flattened diaphragm - presence of large bullae - blood vessels may be pruned - large proximal vessels & relatively little blood visible in peripheral lung fields

Question 40

what is the single most useful measure to help manage COPD?

Answer 40

tell them to stop smoking

Question 41

give 3 examples of bronchodilators?

Answer 41

1) B-adrenoceptor agonists 2) theophylline 3) anti-muscarinic drugs

Question 42

give an example of short acting B-adrenoceptor agonists (SABA)? what do short acting B-adrenoceptor agonists do?

Answer 42

- e.g. salbutamol | - feel less breathless after inhaling one

Question 43

in more severe COPD, what sort of b-adreneoceptor should be used?

Answer 43

= a LABA | = long acting beta-2 adrenoceptor agonists

Question 44

give 3 examples of a LABA?

Answer 44

1) formoterol - 12microgram powder inhaler, twice daily 2) salmeterol - 50micrograms twice daily or 3) indacaterol - 150 to 130 mcirograms once daily

Question 45

what do theophylline do?

Answer 45

- they are of little benefit in COPD | - but they may help control symptoms of dysponae & wheeze

Question 46

what do anti-muscarinic drugs do?

Answer 46

they give more prolonged & greater bronchodilator

Question 47

give examples of 2 long acting agents?

Answer 47

1) tiotropium (18micrograms daily) | 2) aclidinium (375micrograms daily)

Question 48

what are the drugs tiotropium and aclidnium preferred over?

Answer 48

they are prefered over ipratropium or oxitropium

Question 49

what is tiotropiums effect?

Answer 49

- improves quality of life but doesn't effect decline of FEV1

Question 50

what drugs could be given to reduce sputum viscosity and reduce the number of exacerbations?

Answer 50

= ANTI-MUCOLYTIC AGENTS e.g. carbocisteine 2.25g daily

Question 51

when should corticosteroids be used?

Answer 51

- in symptomatic patients with moderate/severe COPD

Question 52

what corticosteroid drug should always initially be given?

Answer 52

PREDNISOLONE, 30mg | - with measurements of lung function before and after the treatment period

Question 53

if there is evidence of substantial improvement in airflow limitation (FEV1 increase of > 15%), what change should be made to the drugs?

Answer 53

- prednisolone should be discontinued | - replaced by INHALED CORTICOSTEROID (beclometasone, 40micrograms twice daily)

Question 54

what effect do combinations of corticosteroids and B2 agonists have?

Answer 54

- protect against lung function decline | - don't improve overall mortality

Question 55

when should antibiotics be given?

Answer 55

- promptly in an exacerbation | - should always be given in acute episodes

Question 56

why should they be given during exacerbations and acute episodes?

Answer 56

= prevent hospital admissions & further lung damage

Question 57

what PaO2 value should long term oxygen therapy be offered to?

Answer 57

patients with PaO2 < 7.3 kPa (when breathing air)

Question 58

what medical conditions allows long term oxygen therapy to given to people with a PaO2 of 7.3-8kPa?

Answer 58

people with; - pulmonary hypertension - secondary polycythaemia - nocturnal hyperaemia - peripheral oedema - evidence of pulmonary hypertension

Question 59

what value might the PaO2 drop to in patients with COPD during the night?

Answer 59

2.5kPa | = profound nocturnal hypoxaemia

Question 60

what is pulmonary rehabilitation and how can it help patients with COPD?

Answer 60

= exercise training that. can modestly increase exercise capacity - diminished sense of breathlessness - improved general wellbeing

Question 61

what other measures can be done for people with COPD?

Answer 61

1) regular vaccines 2) alpha 1 anti-trypsin replacement - (weekly or monthly infusions) 3) surgery - lung transplantaion - surgical bullectomy