W2 - COPD Features and Management Flashcards
Name the 6 symptoms of COPD
Weight loss
Wheeze
Chronic dyspnoea
Cough
Sputum
Chest tightness
COPD is a combination of which 2 conditions, and what are they physiologically?
Chronic bronchitis - inflammation of bronchi
Emphysema - destruction of alveoli leading to loss of elasticity
How many people in the UK have COPD? How many in the world?
1.2m in UK (more in Scotland than England)
80m worldwide have moderate to severe COPD
Name 3 modifiable aetiological factors of COPD
Smoking
Lower income country (due to biomass fuel cooking and heating)
Air pollution
Name 8 non- modifiable aetiological factors of COPD
Female
Increase in age
Lower socioeconomic status
Asthma/airway hyper-reactivity
Chronic bronchitis
Childhood infection
Smaller lungs
Alpha-1 antitrypsin deficiency
What is AAT?
Alpha-1 antitrypsin is a protease inhibitor made in the liver
Toxins from inhaled cigarettes/infection are engulphed by neutrophils which release elastase. Normally, AAT mops up elastase
What 3 signs may indicate alpha-1 antitrypsin deficiency?
Someone young with COPD features
Basal predominance to emphysema
Association with liver fibrosis or cirrhosis
What % of smokers develop COPD? Which graph shows lung function vs age in smokers, stoppers and non-smokers?
Around 50% of smokers develop COPD
The Fletcher-Peto Curve
Name 3 uncommon symptoms of COPD
Weight loss
Fatigue
Swollen ankles
Name 9 signs of COPD
Cyanosis
Raised jugular venous pressure
Cachexia
Wheeze
Pursed lip breathing
Chest wall deformities
Hyperinflated chest
Use of accessory muscles
Peripheral oedema
What’s the clinical diagnosis for chronic bronchitis, “stereotype” and 6 symptoms?
Chronic bronchitis - daily productive cough for 3+ months, in at least 2 consecutive years
“Blue bloater”
Overweight
Cyanotic
Elevated haemoglobin
Peripheral oedema
Rhonchi
Wheezing
What’s the pathological diagnosis for emphysema, “stereotype” and 6 symptoms?
Permanent enlargement and destruction of airspaces distal to terminal bronchiole
“Pink puffer”
Older
Thin
Severe dyspnea
Quiet chest
Xray shows hyperinflation with flattened diaphragm
What are the 5 clinical criteria to diagnose COPD
Typical symptoms
35+
Presence of risk factors
Absence of clinical features of asthma
Airflow obstruction confirmed by post-bronchodilator spirometry
What are the 4 (and a bit!) stages of COPD, including FEV1 compared to predicted values?
Stage 1 - Mild - 80%
Stage 2 - Moderate - 50-79%
Stage 3 - Severe - 30-49%
Stage 4 - Very Severe - less than 30%
End stage COPD - not part of classification but often used in practice
What score do we use to classify COPD?
GOLD score
What 5 signs on a chest xray indicate COPD
Vascular hila
Hyperinflation
Bulla (reduced lung markings)
Small heart
Flattened diaphragm
How many ribs can we count in an xray showing hyperinflation?
6+ anterior ribs
10+ posterior ribs
What 6 things can we ask in a clinical history of COPD?
Tell me about your cough
What about breathlessness
Did you/anyone in your family have allergies, hay-fever or eczema
Did you have any childhood chest problems
Exposure history
Name 6 pathophysiological causes of COPD
Thickening, irritation and inflammation of bronchi and bronchioles
Hypersecretion
Mucociliary dysfunction
Airflow obstruction caused by narrowing bronchi
Decrease in lung elastic recoil due to destruction of lung parenchyma causing loss of alveolar attachment
Increased physiological dead space
Describe ventilation and perfusion in COPD and what causes it
Matched - mucus reduces ventilation, emphysema destroys alveoli, reducing perfusion
Describe 7 severe COPD and complications
Hypercapnea can lead to drowsiness, flapping tremor and ventilatory failure (after becoming acidotic)
Hypoxic drive
Cor pulmonale
Secondary polycythaemia
What is cor pulmonale?
Right sided heart failure due to lung disease
Alvolar hypoxia causes compensatory vasoconstriction to shunt blood to healthy alveoli. Over a long period pressure can build up in pulmonary arteries.
Smoking damages vasculature of heart. Heart muscle thickens, increasing pressure on left slide of heart, increasing jugular venous pressure and impairing left ventricle, reducing circulating blood volume.
Kidney compensation is activated (aldosterone and angiotensin system) leading to fluid retention
What is secondary polycythaemia
Response to chronic hypoxia. Body detects low O2 and produces more RBCs, increasing erythropoietin in kidneys causing increased blood viscosity, strokes, etc.
Name 6 UK anti-smoking legislation public health measures
Raising age at which tobacco can be purchased
Picture warnings on cigarette packets
Tobacco vending machines banned
Tobacco displays banned in large stores
Ban on smoking in cars carrying children
Standardised smoking packaging
If you’re not sure if a patient has COPD, what 2 pulmonary function tests can you do, and what would the results be for COPD? What test can you do if still unsure?
Lung volume test
- Increased residual volume
- Increased total lung capacity
- RV/TLC >30%
Transfer factor
- Reduced gas transfer
- Reduced Dlco
- Reduced Kco
If still unsure, do HRCT of upper zone of lung
On HRCT, what 6 signs indicate COPD?
Signet ring sign
Honeycombing
Traction bronchiectasis
Lung cysts
Centrilobular emphysema
Paraseptal emphysema
In primary care when managing acute COPD, what 9 symptoms can worsen?
- SOB
- Wheeze
- Chest tightness
- Cough
- Sputum
- Unable to smoke
- Systemic upset - eating, drinking, ADLs
- Temperature (if infective)
Fatigue
In primary care when managing acute COPD, what 8 signs and symptoms indicate a severe exacerbation?
- Breathless (RR>22/min)
- Accessory muscle use
- Purse lip breathing
- Cyanosis (Sats <92% o/a)
- Significant decrease in exercise tolerance
- Signs of sepsis (if infective)
- Fluid retention
- Confusion
When managing acute COPD in secondary care, what 4 triggers should we look out for?
Bacterial/viral infection
Sedative drugs
Pneumothorax
Trauma
When managing acute COPD in secondary care, what 8 signs and symptoms should we look out for?
Confusion
Cyanosis
Severe breathlessness
Flapping tremor
Drowsy
Pyrexial
Wheeze
Tripod position
When managing acute COPD in secondary care, what 6 investigations can we do?
CXR
Blood gases
FBC
U&E
Sputum culture
VTS
When managing acute COPD in secondary care, what 4 treatments could we consider? What 1 other thing can we do?
O2
Nebulised bronchodilator (B2 and anti-muscarinic)
Oral/IV corticosteroid
+/- antibiotic (IV aminophylline, respiratory stimulant, NIV)
Treat any co-existing conditions
What 2 tools can we use to assess severity of COPD?
COPD Assessment Tool (CAT)
mMRC Breathlessness Scale
When assessing severity of COPD, what 2 things can we look out for?
History of moderate and severe exacerbations and future risk (number per year, hospitalisation)
Presence of co-morbidities (heart disease, atrial fibrillation, obesity)
The COPD Assessment Test asks about what 8 things?
Cough
Mucus
Chest tightness
Breathless upon exertion
Limitation of activity
Confidence leaving home
Sleep interruption
Energy level
COPD Assessment Test scores indicate what?
0-9 Low
10-20 Medium
21-30 High
31-40 Very high
What are the grades for the mMRC breathlessness scale?
0 - breathless on exertion
1 - SOB when hurrying
2 - stop for breath
3 - stop for breath after every few mins
4 - too breathless to leave house
What can we treat for COPD?
Improve exercise tolerance
Prevent exacerbations
Nutrition/weight loss
Complications
Anxiety/depression
Co-morbidities
Dysfunctional breathing
Palliative care
What 5 non-pharmacological aspects can we manage in COPD?
Pulmonary rehabilitation
Smoking cessation
Vaccination
Nutritional assessment
Psychological support
Name 4 types of classes of drugs for managing COPD
Short-acting bronchodilators
Long-acting bronchodilators
High dose inhaled corticosteroids (ICS)
Long Term Oxygen (LTOT)
Name 2 types of short acting bronchodilators and give an example of each
SABA, e.g. salbutamol
SAMA, e.g. ipratropium
Name 2 types of long acting bronchodilators and give 2 examples of each
LAMA (long-acting anti-muscarinic agent), e.g. umeclidinium, tioptropium
LABA (long-acting anti-muscarinic agent), e.g. salmeterol, formoterol, olodaterol
Name 2 types of high dose inhaled corticosteroids give an example of each
Relvar, i.e. fluticasone, vlianterol
Fostair MDI
Which 3 methods are the cheapest ways to treat COPD?
Flu vaccination (£1000)
Stop smoking support with pharma (£2000)
Pulmonary rehabilitation (£2000-£8000)
Which 3 methods are the most expensive ways to treat COPD?
Telehealth (£32,000)
Triple therapy (£7000-£187,000)
LABA (£8000)
What 3 categories of medicines can we give to manage COPD exacerbation?
Short acting bronchodilators
Steroids
Antibiotics (if evidence of infection)
In COPD exacerbation management, consider hospital admission if any of what 5 criteria are present?
Tachypnoea
Low oxygen sats (<90-92)
Hypotension
Cyanosis
Acute confusion
In ward-based management of COPD exacerbation, what 4 treatments can we offer? What complication should we look for and how can we look for it?
O2 (only if sats are 88-92% as lower suggests hypoxic drive)
Nebulised bronchodilators
Corticosteroids
Antibiotics
Look for resp failure - clinical or arterial blood gas
What 2 complications of COPD should we look for in hospital admission and what’s the treatment?
Acute respiratory failure
Hypoxia and CO2 retension
Treat with non-invasive ventilation (NIV)
What 8 methods can we use to investigate COPD exacerbation?
- FBC
- Biochem and glucose
- Theophylline concentration (in patients using theophylline preparation)
- Arterial blood gas (documenting amount of O2 delivered and by what delivery device)
- Electrocardiograph
- Chest X-ray
- Blood cultures in febrile patients
Sputum microscopy, culture and sensitivity
Name 4 platforms of patient education in the management of COPD
My COPD
My Lungs My Life
Don’t Waste a Breath
No Delays
In what 4 ways can patients self-manage COPD on the My COPD app?
Info regarding condition
Managing symptoms
Inhaler techniques
When to seek medical advice
In what ways can we manage breathlessness and dysfunctional breathing in the palliation of COPD?
Pharmacological, e.g. morphile, lorazepam (anxiety)
Psychological support
Palliative care referral
In what 3 ways can we create an anticipatory care plan in the palliation of COPD?
Hospital admission
Ceiling of treatment
DNACPR
