COPD with Emphysema case Flashcards
What are the key features in the history that would suggest COPD exacerbation
What are the other signs and symptoms
Productive cough, white sputum
SOB
Barrel chest, hyperresonance Poor air movement Reduced chest expansion Accessory muscle use Cyanosis Cor pulmonale
What would spirometry and peak flow show before and after BD
-use the algorithm
Peak flow
-low, limited reversibility
FEV1, FVC, FER
-low, limited reversibility, obstructive pattern
TLC, RV
-increased, some decrease => symptomatic relief
TLCO, KCO
-Low => diffusion membrane SA lost in emphysema
What results could you get from the ABG
How would you be able to tell if someone is on air/on O2 from the ABG
Hypoxemia
Hypercapnia due to CO2 retention
If CO2 retention is chronic, bicarbonate will be raised
too
High PO2 and PCO2 with a sum of over 20kPa => on O2
What examinations would you order and why
Resp
- Barrel chest, hyper resonance
- Poor air movement
- equal but reduced chest expansion <= hyperinflation
- wheeze, crackles may also be heard
- use of accessory muscles
- cyanosed
CV
- rule out CV causes
- difficulty locating apex beat <= hyperinflation
- establish cardiac strain
GI
-rule out other pathologies
MSK
-rule out MSK pathologies
Urinalysis
-rule out infection, kidney issues
Reticulendothelial
-rule out malignancy
What investigations would you order and why
FBC, electrolytes, U&E
- establish severity of exacerbation
- anaemia, polycythemia
- high WBC => infection
- hypokalaemia => SE of salbutamol
- high urea, hyponatremia => pneumonia?
CXR
-rule out other causes
ECG
-rule exclude comorbidities
MCS
-identify cause of purulent sputum
How would you manage this case?
What are the signs of deterioration?
What would you do in this scenario?
When would you consider invasive ventilation?
SABA, SAMA (nebulised with air if CO2 retainer
ICS (prednisolone or hydrocortisone)
O2 (lower sats for CO2 retainers)
Abx if there is evidence of infection (doxycycline, amoxicillin, clarythromycin)
Type 2 resp failure despite treatment => NIV
NIV not successful/tolerated Reduced consciousness Arrested Haemodynamic instability/arrythmias Cannot maintain airway
If there is a family history of COPD, what would you suspect?
How does this alternative cause result in COPD
What are these groups predisposed to?
Alpha1-antitrypsin deficiency
- autosomal codominant
- alpha1-antitrypsin protects against proteases (eg neutrophil elastase), preventing alveolar destruction
-normally produced in the liver but cannot be released => alveolar damage, accumulation in liver => hepatocyte destruction
How would you differentiate between COPD and asthma from the history
- smoker status?
- under 35
- chronic productive cough
- SOB patterns
- night time waking with SOB, wheeze
- significant diurnal symptom variability
COPD
- most are current/ex smokers
- rare in under 35
- common to have a productive cough
- uncommon night time waking with SOB, wheeze
- uncommon to have variability in symptoms
- SOB, persistent, progressive
Asthma
- possible current/ex smoker
- often under 35
- uncommon to have a productive cough
- common night time waking with SOB, wheeze
- common to have significant variation in symptoms
- SOB, variable
What measures could you use to grade the severity of obstructive airflow
What measures could you use to grade the severity of her breathlessness?
Obstructive flow, GOLD in patients with FER < 0.7
- GOLD I (mild) FEV1 > 80%
- GOLD II (moderate) FEV1 50-79
- GOLD III (severe) FEV1 30-49
- GOLD IV (very severe) FEV1 under 30
MMRC Dyspnoea Scale
- 0, strenuous exercise only
- 1, hurrying, walking on an incline
- 2, walks slower than people of the same age due to SOB/stops due to SOB on level plane
- 3, stops for breath after 100m/few mins on level plane
- 4, too breathers to leave house/SOB when dressing, undressing
How would you manage COPD in the long term
Smoking cessation
Flu, pneumococcal vaccinations
Pulmonary rehab
SABA, SAMA
Long term O2 therapy
Prophylactic ABx
