Obstructive Diseases Flashcards
Definition of COPD
Chronic Obstructive Progressive Disease (COPD) is characterised by airflow obstruction that is progressive in severity, not fully reversible and does not change markedly over several months COPD is the umbrella term for: • Chronic bronchitis • Emphysema • Chronic Asthma
Causes of COPD
COPD is caused by:
•Cigarette smoking (90%) – those with significant smoking history (20 pack years +); Pack years = no of packs smoked per day x years of smoking
•Occupational exposure – Coal miners, lead painting, car mechanics
•Alpha-1 Antitrypsin deficiency - strong genetic link
•Social deprivation
Pathology of COPD
- Airways become irritable and inflamed
- Inflamed and irritated airways lead to narrowing of airways
- Narrowing of airways leads to difficulty moving air in and out of lungs
- Difficulty of moving air leads to trapping of air in airways
- Trapping of air in airways leads to SOB plus an increase in sputum contributes to SOB and risk of infection
Increase in sputum is caused by:
- Excess mucus is produced
- Mucus is thicker and stickier
- The cilia are trapped by mucus and unable to beat
- Smoking paralyses the cilia
- Therefore:
a. Dust and bacteria stay trapped in the airways
b. Mucus build-up and provides warm moist environment for bacteria to grow
c. Recurrent infections can develop
Medical Diagnosis of COPD
If COPD is suspected it will be diagnosed using the following:
- Detailed patient History – from MDTs = practice nurses, GPs, Physios, consultants all to ensure correct diagnosis
- Clinical signs:
a. Breathlessness on exertion
b. Cough
c. Increased sputum
d. Risk factors – smoking, occupation, family history
e. Rule out other causes - Spirometry
a. Diagnosis – gold standard for obstructive diseases
b. Categorise severity
c. Monitor progression - CXR - looking for clear clinical signs; may be done yearly to see changes
Classification of COPD
Once diagnosed COPD will be classified according to severity:
Early disease = often few symptoms. Morning cough (smokers cough), chest infections in the winter, breathlessness when exercising vigorously (not at rest). Clinical examination may be normal although spirometry may be reduced
Moderate disease = a range of respiratory symptoms. Cough, wheeze, SOB with moderate exertion. Clinical examination may reveal wheeze, barrel chest, flattened diaphragm on CXR
Severe Disease = severe symptoms, cyanosis. Weight loss, raised JVP, peripheral oedema, overuse of accessory muscles
Types of COPD
Chronic bronchitis, emphysema and chronic asthma
Define Bronchitis
• A chronic disease of the lungs where the bronchi become inflamed.
What are the 3 main clinical S&S of bronchitis
- Inflammation causes more mucus to be produced, which narrows the airway and makes breathing more difficult.
- Increased sputum production – over production of mucus in the airways which becomes difficult to clear
- Wheezing is very common especially after coughing. This is because the inflamed airways may narrow for short periods of time. This also reduces the amount of air that enters the lungs.
Define Emphysema
A condition where the alveoli of the lungs become inflamed and lose their natural elasticity
Pathology of Emphysema
- Alveoli over expand and lose their ability to fill up and contract properly
- As air fills up in these sacs, some rupture and become one sac (bullae) reducing the surface area for the exchange of oxygen and carbon dioxide
- When you breathe out, the trapped air cannot be released and breathing becomes more and more difficult
Define Asthma
•Asthma is an episodic increase in airway obstruction caused by various stimuli (allergies, dust, pollen) resulting in increased airway resistance (seen in PFTs)
•Inflammation + Bronchoconstriction
•Reversible
Hypertrophy of mucous glands may lead to mucous plugging, airway obstruction, which may become chronic & severe
Define chronic asthma
Asthma is often a reversible airway disease, but it can become chronic with some fixed airway damage and therefore comes under COPD umbrella.
This occurs when patients have recurrent asthma exacerbations that are not treated quickly leading to scarring and chronic inflammation so in turn leads to permanent narrowing
Symptoms of asthma
Breathlessness, Wheeze, Tightness in the chest
Medical treatment of COPD
- Inhalers
- Rescue Steroids and Antibiotics - for exacerbation (infective or non-infective)
- Other medication
- Flu and Pneumonia vaccines - prevent life-threatening complications
Physiotherapy treatment of COPD
Smoking Cessation:
•Educate effects of smoking - by using Fletcher-Peto Diagram
•4x more likely to quit with help, advice and nicotine replacement
•Stop smoking services (every contact counts) are widely available in the community
•Stopping smoking will help to slow the progression of the disease
•We can refer as physios at any time
Pulmonary Rehabilitation As important as medication - Will help to reduce admissions and aid recovery time post exacerbation 1.Exercise 2.Education 3.Self-management 4.Diet 5.Lifestyle modifications
How do bronchodilators work
Decrease spasm by relaxing the smooth muscle and empty the lungs of trapped air
How do anti-inflammatory drugs work
In asthma they reduce inflammation
In COPD they reduce ‘flare ups’ or exacerbations
What is correct inhaler technique
- Aerosol inhaler or canisters, should be a ‘slow and steady’ internal sigh
- Dry powder inhalers should be taken ‘Quick and deep’
- Inhalers should be prescribed only after patients have received training and the final decision is based on patient preference and assessment of correct use
Importance of correct inhaler technique
One of the biggest causes in increase in exacerbation rate is poor technique hence Inhaler technique must be checked regularly by a trained person (nurse, doctor, physio, pharmacist)
Benefits of using spacers
- Easy to use, no coordination needed, allow time for medication to be inhaled
- Single or multiple breath techniques
- Improves lung deposition
- Reduces side effects
Considerations when using spacers
- Important to teach care and cleaning of device to patient
- should be replaced yearly
Common short-acting bronchodilators
Salbutamol – Ventolin,Airmir, Salamol
Terbutaline (Bricanyl)
Salmeterol (serevent)/ Formoterol (oxis)
Common side effects of short-acting bronchodilators
Shaky hands Cramp in hands and feet Racing heart or palpitations Flushing Headache
Common examples of long-acting bronchodilators
Tiotropium (Spiriva) Aclidinum Bromide (Eklira Genuair)
Common side effects of long-acting bronchodilators
Dry mouth Blurred vision Racing heart or palpitations Constipation Difficulty urinating
Common combination inhalers
Duaklir – contains both aclidinum (long acting) and formoterol (short acting) to take one puff twice a day
Stiolto – contains both tiotropium (long acting) and olodaterol (Short acting) to take two puffs once a day
Bronchodilator + anti-inflammatory (steroid): Symbicort, Seretide, Fostair
How are corticosteroids delivered
inhalers, nebules, tablets, and injection. The inhaled route is preferred
Common types of corticosteroids
beclomethasone
budesonide
fluticasone
prednisolone
Side effects of corticosteroids
osteoporosis, hypertension, dermal thinning, and reduced growth rate in children
Inhaled: mouth infection (thrush) and hoarseness (husky voice)
How to reduce inhaled corticosteroid side effects
Using a spacer
Rinsing mouth after taking it
Using correct inhaler technique
Effects of corticosteroids in asthma
Reduce the number and activity of mucosal mast cells and eosinophils
Reduce inflammatory reactions such as oedema and mucus secretion
Suppress late phase inflammatory reactions
Effects of corticosteroids in COPD
Do not affect the rate of decline in FEV1
Have a beneficial effect on exacerbation rate in severe disease
Reduce the rate of decline in health status
Improve long term survival
How to improve compliance with medication
- Improve patient understanding
- Tailor treatment to suit the patient
- Use treatments where patients rapidly perceive the effect of medication
- Reduce the complexity of treatments
- Reduce the cost to the patient
Other medication available in COPD
Theophyllines possess both bronchodilator and anti-inflammatory properties. They can be taken in tablet form but require blood test monitoring to make sure they are in the body in the appropriate level as they can be dangerous in very high levels.
Mucolytics: carbocisteine can be used to reduce the thickness of sputum and therefore aid sputum clearance. Patients are given a loading dose when they first start it and it is gradually reduced to the maintenance dose.- Normally a maintenance dose is 2 x 375mg tablets morning and evening after food.
Nebulisers: Bronchodilators, steroids and antibiotic treatments can all be nebulised. However, large does carry greater side effects with them and this is not routinely recommended. They also carry potential infection control risks.
