Respiratory disorders and their management I

Question 1

COPD statistics?

Answer 1

3M prevalence in UK
Majority diagnosed in 50s
5yr survival

Question 2

COPD diagnosis?

Answer 2

Traditional defined as emphysema
Chronic bronchitis - Clinical diagnosis with 3/12 of productive cough for more than 2 consecutive yrs
FEV1/FVC less than 70%

Question 3

COPD symptoms?

Answer 3

Chronic:
Wheeze
Cough
Weight loss

Acute:
Fever
Sputum

Question 4

COPD signs?

Answer 4

Cachexia
Use of accessory muscles
Pursed lips
Cyanosis
CO2 flaps
Drowsiness in CO2 narcosis

Question 5

Chest signs of COPD?

Answer 5

Hyper-expanded chest
Hyperesonant
Reduced breath sounds
Wheeze
Elevated JVP and peripheral oedema

Question 6

Disease severity?

Answer 6

Different clinical parameters:

• Lung function
• Symptoms
• Exacerbation frequency
• BODE index

Question 7

Management of stable COPD?

Answer 7

Smoking cessation

• Nicotine replacement therapy
• Bupropion
• Varenicline

Oral theophylline

• Trail of therapy
• Risk of side effects

Oral mucolytic therapy
- Carbocisteine

Vaccination therapy
- Annual influenza and 5 yr pneumococcal vaccination

Pulmonary rehab

• Addresses muscle deconditioning
• Improves QoL, exercise tolerance
• May impact exacerbation frequency

Nutritional support:
- BMI of 20-25

Surgery

• Transplant
• Lung volume reduction
• Placement of endobronchial valves

Oxygen therapy

• LTOT
• Ambulatory
• Short burst oxygen therapy

LTOT
- Minimum 14hrs per day of O2 therapy = Prognostic benefit
PO2<7.3kPa persistently
PO2 7.3-8kPa &Secondary polycythaemia
Nocturnal sPO2<90 for >30%

Ambulatory oxygen

• Desaturation on exercise
• Increase in exercise with supplemental O2
• Delivered by cylinder

SBOT
- Palliative care

Question 8

How to prevent exacerbations?

Answer 8

Seasonal influenza vaccination
Inhaled steroids
Other agents - anticholinergics, mucolytics
Pulmonary rehab

Question 9

What to do when a pt has a productive cough and looks uncomfortable with breathing?
How to treat this?

Answer 9

Take a history:

• Duration of symptoms
• Change in vol and character of sputum
• Severity of chronic illness
• Smoking and occupational (cigarettes a day x no. of yrs smoked)/20 >10PYH - significant

Go to GP for assessment of infective exacerbation of COPD - antibiotics:
- Oral prednisolone 
7-10 days (30-30mg/day)
Shortens hospital discharge
Must weigh severity against side effects

Question 10

What is the significance of breathing through pursed lips?

Answer 10

Pt coping strategy to allow symptomatic improvement

Prolonged opening of distal airways to allow emptying of lungs

Question 11

Treatment - how does non-invasive ventilation (NIV) work?

Answer 11

Employed after optimum medical Rx
Cyclical non-invasive positive pressure delivered by face/nasal mask
Supplemental O2 supply
Acute use for respiratory acidosis
Usually patient trigger with back-up respiratory rate
Delivered by trained nursing/physio staff
Requires ABG/transcutaneous CO2 monitoring

Question 12

Why do pts with severe COPD have high CO2?

Answer 12

Severe COPD = brainstem has lower sensitivity to CO2 = rely on hypoxic drive to ventilate

Question 13

Types of respiratory failure and their features?

Answer 13

Type 1 = low PaCO2, usually caused by A - pneumonia, asthma
C - Fibrosing lung disease

Type 2 = >6KPa PaCO2
Common causes:
A - overdose, trauma
C = COPD, neuromuscular

Question 14

When to not provide NIV?

Answer 14

Cardiac or resp arrest
Nonresp organ failure
Facial or neurological surgery, trauma
Inability to protect airway
High risk for aspiration