RESP: COPD Flashcards
How does a patient with COPD present? divide into symptoms and signs
Symptoms: Productive cough sputum Wheeze Dyspnoea Reduced exercise tolerance
Signs : Accessory muscle use Tachypnoea Hyperinflation Reduced cricosternal distance Reduced chest expansion Hyper-resonant percussion Decreased/quiet breath sounds Wheeze Cyanosis Cor pulmonale (signs of right heart failure)
what DDx should you consider when thinking about COPD
- Lung cancer
- Heart failure
- lung fibrosis
- asthma
- bronchiecstasis
What might you see on examination of a pt with COPD?
Tacchypnoea Resp distress accessory muscle use intercostal retraction barrel chest wheezing coarse crackles cyanosis Right sided heart failure (+ neck veins, heptatomegaly, LL oedema) Asterexis -hypercapnia
What are the most common bacterial organisms that cause infection exacerbations of COPD?
Haemophilus influenzae (most common cause)
Streptococcus pneumoniae
Moraxella catarrhalis
What would you see on CXR with a patient with COPD?
- Airway central
- Breathing - hyperinflated lung fields with more than 6 anterior ribs seen on radiograph
- bullae may be seen, almost mimicing a pneumothorax
- cardiomegaly may be present
- flattened hemidiaphragm
What is type 1 respiratory failure?
Pa02<8kPa; PaC02 Normal
Causes of type 1 respiratory failure?
Asthma Congestive HF Pulmonary Embolism Pneumonia Pneumothorax
What is type 2 respiratory failure?
Pa02<8kPa; PaC02 > 6kPa
Causes of type 2 respiratory failure?
- Obstructive lung disease e.g. COPD
- Restrictive lung disease e.g. IDL
- Depression of respiratory centre e.g. opiates
- NMJ disease e.g. Guillan barre syndrome, MND
- Thoracic wall disease- rib fracture
- Severe asthma
- myasthenia gravis
- Obsesity
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What is pathophysiology of COPD?
Eemphysema and chronic bronchitis
Mucous gland (goblet cells) hyperplasia
Loss of cilial function
Emphysema – alveolar wall destruction causing
irreversible enlargement of air spaces distal to the
terminal bronchiole
Chronic inflammation (macrophages and neutrophils) and fibrosis / remodelling of small airways
What is the definition of COPD?
COPD is characterised by airflow obstruction. Airflow obstruction is progressive, not fully reversible and does not change markedly over several months.
The disease is predominantly caused by smoking
What are the cuases of COPD?
Smoking
Inherited - α-1-antitrypsin deficiency
Industrial exposure - e.g. soot from coal or dust
What is outpatient COPD Management?
- ‘COPD Care Bundle’
- SMOKING CESSATION
- Pulmonary Rehabilitation
- Bronchodilators
- Antimuscarinics
- Steroids
- Mucolytics
- Diet
- LTOT if appropriate
- Lung Volume reduction if appropriate
What does the ‘COPD care Bundle’ involve?
Assessment of inhaler technique
Provision of a written patient self-management action plan
(where appropriate) an emergency drug pack
The offer of referral for support to stop smoking
Access to a treatment programme that can help people with a lung condition stay active (pulmonary rehabilitation)
Appropriate follow-up arrangements.
Who is in the multidisciplinary team for COPD patient care?
Physicians GPs specialist nurses Physiotherapists pharmacists Occupational therapsits Dieticians.
What are the indications for long term oxygen therapy for a patient with COPD?
pO2 below 7.3 kPa, or 8 kPa (cor pulmonale)
Non-smokers
Balance loss of
independence/ reduced activity
Note: 02 not a treatment for breathlessness; to prevent organ hypoxia
Why is long term oxygen therapy good for COPD patients?
Hypoxia can causes renal and cardiac damage - LTOT reduces this
How long do COPD pts need to use long term oxygen therapy for a day to get a survival benefit ? (LTOT)
at least 16 hours a day
What is pulmonary rehabilitation?
MDT 6-12 week programme:
- supervised exercise
- unsupervised home exercise
- nutritional advice
- disease education
Why is pulmonary rehabilitation good for COPD pts?
COPD pts avoid exercise / physical activity as breathless.
Leads to vicious cycle of increasing social isolation, depression, muscle weakness and inactivity making symptoms worse
How would you judge a pt with COPD to be in the midst of an infective exacerbation ?
Change in sputum volume / colour
Fever
Raised WCC +/- CRP
How would you manage a pt with COPD who is having an exacerbation?
ABCDE approach
O2- aim for 94-98% but if evidence of (raised pCO2 on ABG) or Type 2 Resp Failure, then target SaO2 88-92%
NEBs – Salbutamol and Ipratropium
Steroids – Prednisolone 30mg STAT and OD for 7
days
Antibiotics if raised CRP / WCC or purulent sputum
CXR
Consider IV aminophylline
Non invasive ventilation if Type 2 respiratory failure and pH
7.25-7.35
pH <7.25 consider ITU referral
Indication for LTOTs?
paO2<7.3
paO2<8 in cor pulmonale
Not smoking
What is a restrictive pattern on spirometry?
FEV1:FVC ratio the same >0.7 but the FEV1:FVC values have decreased
Which oxygen delivery device is commonly used in patients with COPD, and why?
Venturi masks are calibrated to deliver Fio2 between 24% and 50%, allowing Po2 to be titrated.
minimising the risk of CO2 retention (hypercarbia) associated with uncontrolled oxygen therapy
How should beta-2 agonists be delivered in patients with hypercapnia, in the context of acute COPD exacerbation?
Use a nebuliser driven by compressed air rather than oxygen (to avoid worsening hypercapnia).
Describe the management of acute COPD exacerbation if there is no response to an initial dose of a bronchodilator
Repeat doses of salbutamol at 15-30 minute intervals
Give continuous nebulised salbutamol at 5-10 mg/hour
When are oral corticosteroids indicated in an acute exacerbation of COPD and what is the recommended prescription?
Consider oral corticosteroids for people with a significant increase in breathlessness that interferes with daily activities.
Offer 30mg oral prednisolone once daily for 5 days
Describe the management of patients with acute COPD exacerbation that do not respond to first or second-line drug treatments
Escalate the patient’s care to senior medical staff to consider further management, including:
Non-invasive ventilation (NIV) for persistent hypercapnic respiratory failure.
Respiratory stimulants and intravenous theophylline.
Describe the GOLD staging criteria
Used for staging COPD
4 categories based on the FEV1
Stage 1 is classed as an FEV1 >80%
Stage 2 50-79%,
Stage 3 30-49%
Stage 4 <30%.
see Geeky medics - COPD
Name four complications of COPD
Cor pulmonale
Pneumothorax
Secondary polycythemia
Hypercapnic respiratory failure
Cor pulmonale is right-sided heart failure due to high pressure in the p
Name three clinical signs associated with cor pulmonale
- Distended neck veins
- Hepatomegaly
- Peripheral oedema
