22. COPD Flashcards
A 64-year-old man presents to A & E extremely short of breath,
initially unable to give a history. He is recognised by one of the nursing staff as a
man known to have chronic obstructive pulmonary disease and was ventilated on ICU during his last admission.
How can we classify this disease?
- Chronic bronchitis
Defined as daily cough with sputum production for at
least 3 months a year for at least 2 consecutive years.
‘Blue bloater’
This clinically represents the bronchitic group.
They are typically hypoxaemic and cyanosed
with cor pulmonale
(peripheral oedema, raised JVP, hepatomegaly)
but with little dyspnoea.
- Emphysema
A histological diagnosis defined as enlargement of
the air spaces distal to the terminal bronchioles with
destructive changes in the alveolar wall.
Pink puffers
Representing the emphysematous group. These
patients have severe dyspnoea but relatively normal
gas exchange.
Can you tell me a little about the pathophysiology?
There is a combination of:
Mucosal inflammation
Excessive secretions
Bronchoconstriction.
There is a reduction in lung elasticity with a .
consequent fall in the maximum expiratory flow rate.
With increasing alveolar destruction,
the pulmonary vasculature may be damaged which,
along with hypoxic pulmonary vasoconstriction,
contributes to pulmonary hypertension.
The overall effect is that of V/Q mismatch.
Lung function tests show an obstructive picture:
obstructive picture
Reduced FEV1
Reduced FVC
Reduced FEV1/FVC ratio
Increased residual volume
Increased FRC
Increased total lung capacity
Reduced diffusing capacity
What signs might you elicit in this man?
- Tachypnoea
- Cyanosis
- Accessory muscle use
- Intercostal recession
- Hyperinflated lungs
- Pulsus paradoxus
- Wheeze
- Prolonged expiratory time
Cor pulmonale
Raised JVP, peripheral oedema, loud P2
Signs of hypercapnia
Warm peripheries, bounding pulse,
confusion, tremor, convulsions
What would be your initial management of this man?
Sit the patient up
Oxygen
Bronchodilators
Methylxanthines
Steroids
Antibiotics
NIV
Physiotherapy
Regular monitoring
Heart failure Rx
O2
Oxygen therapy should be used to prevent hypoxia
but should not worsen acidosis.
Oxygen should be started at ∼40% and titrated up
if O2 saturation <90% and down if sats >93% or
patient drowsy.
ABGs should be done to assess pH and PCO2
Bronchodilators
A proportion of these patients will have an element of reversibility to their bronchoconstriction.
Use a β-agonist (salbutamol or terbutaline)
with an anticholinergic (ipratropium bromide).
Methylxanthines
Intravenous theophylline may be considered if inadequate response to inhaled bronchodilators.
Caution should be taken with patients on oral theophylline and levels should be taken in all
patients.
Steroids
Prednisolone 30mg should be prescribed for 7–14 days.
Antibiotics
.NIV
Physiotherapy
Regular monitoring
Aminopenicillin or marcolide if increased purulent sputum
NIV should be considered in patients with pH <7.35.
Should be considered in some patients.
Clinical state and blood gases
BTS advocate the use of antibiotics if two or more of:
Increased breathlessness
Increased sputum volume
Development of purulent sputum
This man deteriorates despite all this treatment. What further
interventions are available to you?
Non-invasive ventilation
Needs specialist equipment.
Needs co-operation from the patient.
Most valuable when used early.
Reduces requirement for IPPV and length of hospital stay.
IPPV
Ventilatory support considered in patients:
With a pH <7.26
A rising PaCO2
Failing to respond to supportive treatment
IPPV:
Favourable
Remediable cause for acute decline
First episode
Good quality of life
Less favourable factors:
Documented severe COPD unresponsive to therapy
Poor quality of life, e.g. housebound on maximal therapy
Severe co-morbidities
