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Flashcards in 14. Management of COPD Deck (75):

What are main features of COPD?

- airflow obstruction(chronic bronchitis) and hyperinflation (emphysema)
-not fully reversible
- progressive
-repeating chest infections and inflammation cause obstruction


What are the 2 main symptoms of COPD which patients always present with?

1. breathlessness
2. cough and recurrent chest infections


What causes the cough in COPD?

airway inflammation


What causes the breathlessness in COPD? (2)

1. airflow obstruction (impaired gas exchange/oxygenation)
2. hyperinflated chest which pushes diaphragm down causing breathing difficulty


What percentage of COPD patients are smokers?

85-95% (very high)


What do "free radical" species found in tobacco do to anti-elastase (anti-protease) enzyme? What happens as a result?

- Inactivates it (people with alpha-1-antitrypsin more prone to it)
- As a result, neutrophil elastase increases and (along with alpha-1-antitrypsin deficiency for people who have it), can cause tissue damage


In emphysema, what occurs to elastase enzyme production?

it increases (leading to tissue damage)


What are some of the systemic symptoms of COPD? (5)

1. loss of muscle mass (protein separation occurs; human necrosis factor)
2. weight loss and loss of appetite
3. cardiac disease risk increases
4. depression/anxiety etc
5. lacking energy (more energy put into breathing which causes extreme tiredness)


How many people are there diagnosed and undiagnosed with COPD in the UK?

diagnosed; ~ 1 million
undiagnosed: ~2 million and on the increase


How many people does COPD kill in the UK?

over 30,000


Will COPD be the 3rd leading cause of death by 2020?



How to diagnose a patient with COPD?

1. relevant history (symptoms)
2. look for clinical signs+examination
3. confirmation of diagnosis and assessment
4. other relevant tests


What age should you expect COPD?

35-40 + years


What are the most common signs of COPD seen in patients? (6)

1. current or former smokers
2. chronic cough
3. exertional breathlessness
4. sputum production
5. frequent winter bronchitis (or other chest infections)
6. wheeze/ chest tightness


Is there a diagnostic test for COPD?

No (tests only support the diagnosis)


What are 2 common tests done to confirm COPD diagnosis?

1. spirometry
2. ECG


What is the clinical difference between age of COPD and asthma patients? (comparison)

-COPD: 35+ years
- asthma: any age


What is the clinical difference between cough in COPD and asthma patients? (comparison)

-COPD: cough is persistent and productive
-asthma: intermittent and non-productive


What is the clinical difference between smoking in COPD and asthma patients? (comparison)

-COPD: almost invariable/almost always
- asthma: possible


What is the clinical difference between breathlessness in COPD and asthma patients? (comparison)

-COPD: progressive and persistent
-asthma: intermittent and variable


What is the clinical difference between nocturnal symptoms in COPD and asthma patients?

-COPD: uncommon unless in severe disease
-asthma: common


What is the clinical significance between family history in COPD and asthma patients?

-COPD: uncommon unless family members also smoke
-asthma: common (can have a genetic connection)


What is the clinical significance between concomitant eczema or allergic rhinitis?

- COPD: possible
-asthma: common (can have an allergic connection)


What are the common features of COPD on examination? (5)

1. reduced chest expansion
2. prolonged expiration/ wheeze
3. hyperinflated chest
4. respiratory failure
5. may be normal in early stages


What 5 signs signs suggest respiratory failure?

1. tachypneoa (abnormally fast breathing)
2. cyanosis
3. use of accessory muscles
4. pursed lip breathing
5. peripheral oedema


What happens to anterior and posterior chest dimensions in COPD patients?

they are bigger in relation to lateral dimensions


What causes peripheral oedema?

Right side of the heart has pressure put on it due to excessive breathing, abnormal gas exchange etc, so inadequate pumping leads to oedema.


Which features may be identified in COPD patient clinical history?

cough, breathlessness, chest infections (winter bronchitis), sputum,


What features may be identified in COPD patient examination?

- may appear normal (if early stages)
- tachypneoa, wheeze, hyperinflated chest


What does spirometry reading (FEV1/FVC) <70% suggest?

obstructive condition


What does spirometry reading (FEV1/FVC) > 70% with FEV1>80% suggest?



What does spirometry reading (FEV1/FVC)> 70% with FEV1<80%

restrictive condition


What must FEV1 value be for COPD to be considered "mild"?

FEV1>80% predicted


What must FEV1 value be for COPD to be considered "moderate"?

FEV1 50-79% predicted


What must FEV1 value be for COPD to be considered "severe"?

FEV1 30-49% predicted


What must FEV1 value be for COPD to be considered very severe?

FEV1 <30% predicted


What is the RBC count in COPD patients?

High as bone marrow produces more RBCs during hypoxic situations


What are the COPD baseline tests? (5)

1. spirometry
2. chest x ray
3. ECG
4. full blood count (anaemic/polycythaemic, eosinophilia)
5. BMI (weight and height) +nutritional assessment


Are prescriptions key to solving chronic medical problems?

No, management is key.


Why is patient's psychological well being important in COPD management?

Psychological aspect can stimulate nervous responses, increasing heart rate and breathing rate, leading to more energy being invested in breathing and making patient weaker leading to more susceptibility to further infection (constant cycle)


Outline possible COPD complications which can arise. (8)

1. Acute exacerbation COPD
2. Pneumonia
3. Cor Pulmonale
4. Wasting (muscle atrophy)
5. Polycythemia
6. Micro-nutrient deficiency
7. Depression
8. Pneumothorax


What is the main intervention to prevent disease (COPD) prevention?

stopping smoking (smoking cessation)


What is the main intervention to relieve breathlessness in COPD?



What is the main prevention for preventing exacerbation? (3)

inhalers, vaccines, pulmonary rehabilitation (PR)


What is the main management of complications strategy?

long term oxygen therapy


What are 5 on-pharmacological management of COPD methods?

1. smoking cessation
2. vaccinations (annual flu vaccine or pneumococcal vaccine)
3. pulmonary rehabilitation
4. nutritional assessment
5. psychological support


How many times faster does lung function decline in a smoker compared to a non-smoker?

3 x faster


Can lung function be restored if a patient stops smoking at 45?

Lung function cannot be reversed but lung function stabilises and doesn't fall downhill as fast as in smokers giving the patient better chances of slowing down their lung function decline.


Where are pulmonary rehabilitation classes done and for what time period?

usually in primary care settings (half a day for once a day or week for around 6 weeks depending on patient's severity)


Why does every medical intervention needs to be evidence based?

To prove that the intervention is benefiting the patient to the maximum.


What is Evidence A intervention?

- most studies have been done
- more significant statistical backing and most likely to be true
- can be the best intervention


What can evidence based medicine range from?

can range from Evidence A-D (from most/best to least/worst evidence)


What are 3 top benefits on pharmacological management of COPD?

1. relieve symptoms
2. prevent exacerbations
3. improve quality of life


What are 3 groups of inhaled therapy drugs used to manage COPD?

1. short acting bronchodilators
2. long acting bronchodilators
3. high dose inhaled corticosteroids (ICS) and LABA


What are the 2 short acting bronchodilators used to manage COPD?

1. SABA (e.g. salbutamol) -short acting beta agonist
2. SAMA (e.g. Ipatropium) -short acting muscarininc antagonistic


What are the 2 main long acting bronchodilators used to manage COPD?

1. LAMA (long acting anti-muscarining agent e.g. umeclidinium or tioptropium)
2. LABA ( long acting B2 agonist e.g. salmeterol)


What are the 2 main high dose inhaled corticosteroids (ICS) and LABA?

1. Relvar (Fluticasone/vilanterol)
2. Fostair MDI


What is the order of prescribing drugs for COPD going from mild COPD to worsening FEV1 and worsening symptoms and exacerbations. (approach to treatment)

2. long acting bronchodilators (LAMA OR LABA)
3. Further long acting bronchodilators (LAMA AND LABA
4. Triple therapy (ICS, LABA and LAMA)


What are the cheapest two COPD management methods?

-flu vaccinations
- stop smoking support with pharmacotherapy


What are the most expensive two COPD management methods?

- telehealth for chronic disease (telecommunication)
- triple therapy (ICS, LABA, LAMA)


What must oxygen pressure fall below for Long Term Oxygen (LTOT) to be used? (in kPa)



What 4 conditions can be diagnosed if PaO2 is within the range of PaO2 7.3-8kPa

1. polycythaemia
2. nocturnal hypoxia
3. peripheral oedema
4. pulmonary hypertension


What is the best management for people who are "at risk" for COPD?

smoking cessation


What is the best treatment option for people who are symptomatic for COPD?

disease management


What is the best treatment option for people who are exacerbated for COPD?

pulmonary rehabilitation


What is the best treatment option for people who are in respiratory failure?

other options as disease has progressed too much


What is the main cause for exacerbations?

chest infections


What are the 6 main COPD exacerbation signs?

1. increasing breathlessness
2. cough
3. sputum volume
4. sputum purulence (pus containing)
5. wheezing
6. chest tightness


What are 4 main treatment options for managing acute exacerbating COPD? (AECOPD)

1. short acting bronchodilators
2. steroids
3. antibiotics
4. consider hospital admission if not well


What 2 short acting bronchodilators are used in AECOPD?

-salbutamol and/or
- ipratropium
(Nebulisers if cannot use inhalers)


What steroid is used to manage AECOPD and what is its dose and time period?

Prednisolone, 40mg per day for 5-7 days


When are antibiotics used in AECOPD?

If there is evidence of infection (fever or increase in volume/ purulence of sputum)


When would you consider hospital admission in AECOPD? (3)

1. tachypnea
2. low oxygen saturation (<90-92%)
3. hypotension etc


What investigations are required for patients admitted to hospital with AECOPD? (8)

1. full blood count
2. biochemistry and glucose
3. theophylline concentration
4. arterial blood gas (documenting the amount of oxygen given and by what delivery device)
5. electrocardiograph
6. chest x ray
7. blood cultures in febrile patients
8. sputum microscopy, culture and sensitivity


What are the 4 steps for ward management of patients with AECOPD?

1. oxygen- target saturation is 88-92%
2. nebulised bronchodilators
3. corticosteroids
4. antibiotics (oral vs IV)
5. assess for evidence of respiratory failure (clinical and arterial blood gas (ABG))