Chronic obstructive pulmonary disease Flashcards Preview

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Flashcards in Chronic obstructive pulmonary disease Deck (36):
1

Definition

Chronic
Progressive
Irreversible
Airway obstruction

Chronic bronchitis
Emphysema

2

Diagnosis of chronic bronchitis

Clinical
3 months. most days, two consecutive years of sputum production and cough

3

Diagnosis of emphysema

Histological diagnosis
Enlarged airway spaces distal to terminal bronchioles with destruction of alveolar walls

4

Epidemiology

>65
10-20% of all >40

5

Pathophysiology

Chronic inflammation
narrowing and remodelling of airways, increased number of goblet cells, enlargement of mucus-secreting glands of the central airways, and, finally, subsequent vascular bed changes leading to pulmonary hypertension

Decreased elastic recoil, fibrotic changes in lung parenchyma, and luminal obstruction of airways by secretions all contribute to increased airways resistance. Expiratory flow limitation promotes hyperinflation

6

Comparing pink puffers and blue bloaters

Pink puffers->+alveolar ventilation, normal 02, normal/low CO2. Breathless, not cyanosed. May progress to type 1 respiratory failure

Blue bloaters->-ve ventilation, hypoxemic and hypercapnic. Not breathless, cyanosed. May progress to cor pulmonale

7

Main symptoms

Breathless
Cough
Sputum
Wheeze

8

Signs

Tachypnoeic
Cyanosed
Use of accessory muscles
Pursed lipped breathing
Tracheal tug
Plethoric

Reduced chest wall expansion
Hyper-resonant
-ve air entry
Quiet breath sounds

Evidence of cor-pulmonale->distended neck veins, hepatojugular reflux, loud P2, edema

9

Complications

Acute exacerbation
Typer 1 respiratory failure
Cor pulmonale
Pneumothorax
Polycythemia
Lung cancer

10

Investigations and findings

Spirometry->FEV1/FVC ratio PaCO2 >50 mmHg and/or PaO2 of Flattened diaphragm, hyperinflation, large central pulmonary arteries, -ve vascular markings, bullae
FBC->+HCT, possible +WCC
ECG->RA and RV hypertrophy
Pulmonary function tests

11

Severity of COPD->mild, moderate, severe

Mild: FEV1 50-80% predicted
Moderate: FEV1 30-49% predicted
Severe: FEV1

12

Consultation checklist

SMOKES
Smoking cessation
Medications
Oxygen
Komorbidities->cardiac, sleep apnea, osteoporosis, depression, asthma

13

Pharmacotherapy options

short-acting
β2-agonists
(salbutamol, terbutaline)
short acting
anticholinergic drugs
(ipratropium bromide)
long-acting β2-agonists
(eformoterol, salmeterol);
long-acting anticholinergic drugs
(tiotropium);
and
corticosteroids.

14

Management of mild

SABA before exercise->Salbutamol 200mcg as needed
1-2 puffs/4-6 hours
Patient education->disease progress, symptoms of exacerbation
Influenza/Pneumococcal
Smoking cessation

Advice:
Avoid pollution
Cool dry areas
Avoid cold/flu
Optimise diet and lifestyle

15

Management of moderate

Regular combined LABA (salmeterol) + anticholinergic (tiotropium), +SA dilator
Salbutamol 200mcg as needed
1-2 puffs/4-6 hours
Terbutaline 500mcg as needed
Ipratropium 42 mcg Atrovent
1-2 puffs 4 X daily

Advice:
Avoid pollution
Cool dry areas
Avoid cold/flu
Optimise diet and lifestyle
Education
Smoking cessation
Pulmonary rehab

16

Management of severe

Regular LABA + anticholinergic + SABA + regular inhaled corticosteroid

budesonide+eformoterol=
Symbicort 400/12
twice daily

fluticasone propionate+salmeterol
500/50 twice daily
Seretide

Advice:
Warn risk of osteoporosis
Rinse mouth out
MDI-->use a spacer
Avoid pollution
Cool dry areas
Avoid cold/flu
Optimise diet and lifestyle
Education
Smoking cessation
Self management plan
Pulmonary rehab

17

Self management plan

Should have dose of steroids and antibiotics at home
If breathless-->adjust bronchoD dose
If sputum +-->start antibiotics
If breathless affects activities-->use inhaled corticosteroids

18

Advice to give to recognise acute exacerbation

increasing dyspnoea including
use of accessory
muscles at rest
reduced effort tolerance
tachypnoea (>25 breaths/min)
increased fatigue
increased cough and sputum
increased wheezing

19

When is inpatient management appropriate

rapid rate of onset of
acute exacerbation with
increased dyspnoea, cough or sputum
inability to cope at home
inability to walk between rooms when previously mobile
severe breathlessness → inability to eat or sleep
inadequate response to ambulatory treatment
altered mental status suggestive of hypercapnia
significant comorbidity (e.g. cardiac disease)
new arrhythmia
cyanosis

20

Followup requirements for mild/moderate

12 monthly
Smoking status
Symptom control
Pulmonary rehabilitation
Complications of medications
Effects of treatment
Inhaler techniques
Action plan

21

Followup requirements for severe

6 monthly
Smoking status
Symptom control
Pulmonary rehabilitation
Complications of medications
Effects of treatment
Inhaler techniques
Action plan

EOL discussion
Presence of cor pulmonale, heart failure, psychiatric
Long term oxygen
Nutrition
Surgery
Measure ABG

22

Management of acute COPD exacerbation

ABC
Assess patient->vitals, GCS, RR

Controlled oxygen therapy->24-28% depending on BAG
Nebulised salbutamol 5mg / 4h and iproatropium 600ug
Steroids->IV hydrocortison and oral prednisilone
Antibiotics->use if evidence of infection
Physiotherapy

If no response->repeat nebulised, nasal intermittent positive pressure ventilation if RR >30, ph

23

Guide to non-invasive ventilation

Patients should be considered for NIV with acute acidotic exacerbations
(pH 6.0 kPa).
Use a full fitting face mask.
Start NIV at EPAP þ 4 cm and IPAP þ10 cm Increase IPAP by 2 over the
next 1 hour to maximum of þ20 cm or whatever is best tolerated.
Set ventilator to timed.
Aim for 1–2 L O2 with sats 85–90%.
Repeat ABGs after 1 hour
If ABGs worsen, consider for ITU and invasive ventilation

24

Is sputum culture generally recommended

Sputum culture+in 50% but most consistently colonised with Haemo, Klebsiella, Strep-->so culture not recommended unless suggestive bacterial multiples
recently

25

Purpose of antibiotic use

Hasten recovery rather than eliminate

26

Choice of antibiotics

amoxycillin 500 mg orally,
8-hourly for 5 days
OR
doxycycline 200 mg orally, for the first dose,
then 100 mg daily for a total treatment duration of 5 days.

27

How is reversibility defined

+in FEV1 of >12% or 200ml

28

When is oxygen therapy indicated

hypoxemia (PaO2 ≤55 mm Hg or SaO2 ≤88% at rest) or where the PaO2 is less
than or equal to 60 mm Hg and there is polycythemia, pulmonary hypertension,
or peripheral edema suggesting heart failure. Oxygen therapy is the only
intervention that has been shown to decrease mortality and must be worn
for at least 15 h/d.

29

Benefit of smoking cessation

By quitting, his current pulmonary function will be unchanged, but the rate of pulmonary function decline will slow

30

By the time symptoms of COPD develop, how much as lung function reduced by

50%

31

When do patients lose their hypoxic drive

When they lose their hypoxia

32

How is +pCO2 followed clinically

Drowsiness
Vasodilation
Bounding pulses
Asterixis

33

How is alveolar ventilation monitored

pCO2

34

How long is the course of steroids following acute exacerbation

Taper over 2 weeks

35

Does the absence of crepitations exclude cardiogenic pulmonary congestion

No.
Those with low tidal volumes may not have prominent
crepitations or wheeze, due to the low
volumes of gas reaching the alveoli and low air
flows.

36

Letter to GP following D/C

What has happened
Steroid tapering
Need to pulmonary function tests
Optimise lung function
Smoking cessation
Pulmonary rehab
Other lifestyle modifications