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Year 3 OSCE > Case 10- COPD > Flashcards

Case 10- COPD Flashcards

1
Q

Investigations for suspected COPD

A

Post bronchodilator spirometry- FEV1/FVC less than 70%
TLCO (transfer factor of CO)- decreased for COPD.
sputum culture
FBC- secondary polycythaemia, infection, serum alpha 1 anti trypsin (only if a young person)
CXR
CT Thorax
ECG/ TOE- assess cardiac function (cor pulmonale)
Gives indication of severity of the disease

NB- if an infection: UE, CRP, sputum and blood cultures

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2
Q

MRC dyspnoea scale

A

1- breathlessness on strenuous exercise
2- breathlessness on walking up hill
3- breathlessness that slows speed of walking on flat
4- stop to catch breath after 100m walking on flat
5- unable to leave house due to breathlessness

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3
Q

When is mechanical ventilation indicated?

A

Respiratory failure with hypercapnic acidosis
Hypoxaemia
Marked dyspnoea
Respiratory muscle fatigue

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4
Q

Drugs that can cause pulmonary fibrosis

A

Amiodarone
Cyclophosphamide
Methotrexate
Nitrofurantoin

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5
Q

Sx of COPD

A

SOB, productive cough, wheeze, use of accessory muscles, signs of cor pulmonale

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6
Q

COPD differentials

A

Asthma, CCF, bronchiectasis, TB, GORD, ACE-I use, lung cancer, bronchitis

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7
Q

Acute exacerbation of COPD differentials

A

CCF, acute exacerbation asthma, pneumonia, pleural effusion, pneumothorax, PE, ACS, cardiac arrhythmia

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8
Q

Sx of IPF

A

Progressive dyspnoea on exertion, non-productive cough, end expiration basilar crackles, weight loss, fatigue, malaise, clubbing, arthralgia

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9
Q

Beta blockers

A

Careful in COPD/ asthma

NB- steroids not shown to be very helpful

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10
Q

Lung transplant

A

Rarely possible in young patients if they stop smoking

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11
Q

LAMA

A

Tiotropium

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12
Q

SAMA

A

Iprateopium

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13
Q

CXR findings for COPD

A

Flattened diaphragm
Hyper inflated lungs
Horizontal ribs
Bullae (air spaces- increased black spaces)

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14
Q

Chronic bronchitis

A

Defined clinically- productive cough for 3 months of 2 years

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15
Q

Emphysema

A

Defined histologically- large air spaces

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16
Q

Features of acute COPD exacerbation

A

Increased dyspnoea, cough, wheeze
Increase in sputum- infective cause
Hypoxia, potentially confusion

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17
Q

Most common bacterial organisms that cause infective exacerbations of COPD

A

H influenzae
S pneumoniae
Moraxella catarrhalis

NB- human rhinovirus is an important cause too

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18
Q

Management of an acute exacerbation of COPD

A

Increased bronchodilator use via a nebuliser
Prednisolone 30mg for 5 days
Antibiotics if sputum purulent or clinical signs of infection ie. fever/consolidation on Xray (amoxicillin, clarithromycin, doxycycline)

NB- can also have IECOPD in absence on CXR changes/consolidation (consolidation makes its pneumonia)

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19
Q

Alpha 1 antitrypsin features

A

Young patients (may have history of recurrent infections, smoking etc.)
Lungs- emphysema in lower lobes (upper lobes in COPD)
Liver- cirrhosis and HCC in adults (abnormal LFTs), cholestasis in children

20
Q

Management of alpha 1 anti trypsin deficiency

A

No smoking
Supportive- bronchodilator and physiotherapy, monitor for complications, symptom control
Medical- IV alpha 1 anti trypsin protein concentrates (NICE don’t recommend)
Surgery- lung volume reduction surgery, lung/ liver transplantation

21
Q

Bronchiectasis

A

Permanent dilation of the airways secondary to chronic infection or inflammation

22
Q

Causes of bronchiectasis

A

TB, measles, pneumonia
CF
Obstruction eg. Lung cancer, foreign body
ABPA
Kartageners, youngs syndrome

23
Q

Imaging signs of bronchiectasis

A

Tramlines (increased lung markings)
Signet ring sign (CT chest)

24
Q

Features of bronchiectasis

A

Chronic, productive cough
Dyspnoea, wheeze
Sputum
Haemoptysis
Recurrent chest infections

On examination; crepitations and expiratory wheeze

25
FEV1 staging of COPD
Post bronchodilator FEV1/FVC is less than <0.7 for all Stage 1- mild (>80%)- if no symptoms, COPD can’t be diagnosed Stage 2- moderate (50-79%) Stage 3- severe (30-49%) Stage 4- very severe (<30%)
26
Assess any of the following for potential LTOT in COPD
Stage 4 very severe (FEV1 less than 30%) (consider for stage 3 severe (FEV1 30-49%)) Cyanosis Polycythaemia Peripheral oedema Raised JVP Oxygen sats less than 92% pO2<7.3 NB- Assessment is done by measuring arterial blood gases on 2 occasions at least 3 weeks apart in patients with stable COPD on optimal management.
27
General supportive management of COPD
Smoking cessation advice Annual influenza vaccination One off pneumococcal Pulmonary rehabilitation (MRC grade 3)
28
Medical management of COPD
1. SABA or SAMA 2. Asthmatic/steroid responsive features- LABA+ICS, then triple therapy LAMA LABA + ICS (SAMA or SABA) 2. No asthmatic/ steroid responsive features- LABA+LAMA (Switch SAMA to a SABA)
29
Asthma/steroid responsiveness features
Previous diagnoses of asthma or atopy, high blood eosinophils, FEV1 variation, diurnal variation of PEFR (20%)
30
Prophylactic antibiotic therapy in COPD
azithromycin prophylaxis is recommended in select patients patients should not smoke, have optimised standard treatments and continue to have exacerbations other prerequisites include a CT thorax (to exclude bronchiectasis) and sputum culture (to exclude atypical infections and tuberculosis) LFTs and an ECG to exclude QT prolongation should also be done as azithromycin can prolong the QT interval
31
Investigations for IPF
Spirometry- restrictive picture (FEV1 normal/decreased, FVC decreased, FEV1/FVC normal or increased), reduced TLCO Bloods- FBC UE LFT (infection?) Imaging- bilateral interstitial shadowing on CXR, but CT scan is investigation of choice ANA positive in 30 cases
32
Management of IPF
Refer to respiratory physician Supportive management- smoking, substances, exercise, support with work diet etc. Supplementary oxygen and if possible a lung transplant Pirfenidone nintedanib may help (say "antifibrotics")
33
Nicotine replacement therapy
N and v headache and flu like symptoms Offer 2 forms if high dependency
34
Varenicline
Nicotine receptor agonist 1 week before stopping 12 weeks total Nausea, headache, insomnia, abnormal dreams Not in pregnancy, breast feeding, depression, self harm
35
Burporpion
Nicotine agonist and a norepinephrine and dopamine reputable inhibitor 1-2 weeks before stopping Risk of seizure (b for bad) Contraindicated in epilepsy, pregnancy breast feeding, eating disorder
36
Pregnancy and smoking cessation
CBT NRT- remove patches before bed
37
CO2 and COPD
Acute retainers- low pH with a raised pCO2 Chronic retainers- raised bicarbonate. Over time kidneys have increased bicarbonate levels to balance acidic CO2 and maintain a normal pH.
38
Polycythaemia and COPD
When a patient has been referred to hospital; If new- refer to respiratory If long standing or already been seen by respiratory- repeat FBC in 2 months as outpatient (target 0.54)
39
Acute bronchitis
Cough- white clear productive sputum Exclude pneumonia with a CXR ESR below 100- conservative ESR- above 100, systemically unwell, or co morbidities- doxycycline 5 days
40
Investigations for alpha 1 antitrypsin
Low serum-alpha 1-antitrypsin (screening test of choice) Liver biopsy shows cirrhosis and acid-Schiff-positive staining globules (this stain highlights the mutant alpha-1-antitrypsin proteins) in hepatocytes Genetic testing for the A1AT gene High resolution CT thorax diagnoses bronchiectasis and emphysema
41
Management of bronchiectasis
Conservative- immunisations, exercise, postural drainage Medical- ABX for exacerbations, long-term/prophylactic in severe cases, bronchodilators in selected cases Surgery- surgery in selected cases
42
When to offer LTOT COPD in COPD
pO2 <7.3 or pO2 7.3-8 and one of the following; Secondary polycythaemia Peripheral oedema Pulmonary HTN NB- don't offer to people if they continue to smoke NB- Assessment is done by measuring arterial blood gases on 2 occasions at least 3 weeks apart in patients with stable COPD on optimal management.
43
Non invasive ventilation
BiPAP or CPAP- involves forcing air into lungs (in between basic oxygen and intubation) BiPAP- type 2 respiratory failure eg. COPD CPAP- where airway is prone to collapse (Obstructive sleep apnoea, Congestive cardiac failure, Acute pulmonary oedema) NB- BTS suggest NIV works best in COPD with respiratory acidosis pH 7.25-7.35, but it can be used in more acidotic patients (closer monitoring/HDU)
44
Immediate management of critically ill CO2 patient with very low sats
Reservoir mask at 15 litres/min (hypoxia kills)
45
glycopyrronium
LAMA

Year 3 OSCE (61 decks)

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