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Flashcards in COPD Deck (23):

What is meant by 'blue bloaters' and 'pink puffers'?

  • pink puffers (emphysematous): have inc alveolar ventilation, near normal PaO2 but normal/decreased PaCO--> breathless but not cyanosed (-> may prog to type I resp failure)
  • blue bloaters (bronchial): have reduced alveolar ventilation, low PaOand a high PaCO2 --> cyanosed but not beathless -> may develop cor pulmonale 


What are the symptoms of COPD?

  • dyspnoea
  • cough productive w/ sputum
  • bilateral expiratory wheeze


What are the signs of COPD?

  • tachypnoea + use of accessory muscles
  • hyperinflated lungs
  • reduced cricosternal distance (<3cm)
  • barrel chest
  • breathing through pursed lips
  • prolonged expiration on PE
  • cyanosis
  • reduced chest expansion bilaterally
  • normal percussion / hyper-resonance
  • normal/decreased tactile fremitus
  • decreased breath sounds
  • wheeze, rhonchi (rattling due to secretions)


What are the causes of COPD?

  • tobacco smoking
  • occupational exposure
  • air pollution
  • genetic susceptibility (eg. a1-antitrypsin deficiency)


How do you quantify smoking in "pack years"?

  • defines a person's life time smoking load
  • cig/day per pack of 20 x no yrs smoked
  • eg. 20 cigs per day for 52 years = 52 pack years
  • 30 cigs per day for 40 years = 60 pack years

usually need 20 pack year to cause COPD


What investigations are important for COPD?

  • spirometry -> ratio <0.7
  • pulse oximetry -> low
  • ABG -> hypercapnic, hypoxic
  • CXR
  • FBC -> raised haematocrit, poss inc WBC
  • ECG -> RVH, arrhythmia, ischaemia


What does this CXR show for COPD?

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  • this CXR shows hyperinflation, flattened diaphragm and increased intercostal spaces
  • it is often normal even when the disease is advanced but classic features include:
    • bullae
    • hyperinflation
    • flat hemidiaphragm
    • consolidation
    • collapse
    • retrosternal air space on lateral film


Describe the role of spirometry in diagnosing and determining the severity of COPD

  • FEV1: vol of air forcibly exhaled in 1 sec
  • FVC: vol of air totally exhaled
  • should be 80-120% of predicted
  • 70% of total should be inhaled in first sec 
    • ie FEV1/FVC should be ~70%
  • <0.7 indicates obstructive disease
  • bronchodilator showing >15% improvement indicates significant reversibility


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Which organisms are likely to produce acute exacerbations of COPD, that can be found in sputum culture?

  • haemophilus influenzae
  • steptococcus pneumoniae
  • ocassionally moraxella catarrhalis


What might an ECG show in advanced cor pulmonale?

  • P wave is taller (P pulmonale)
  • right bundle branch block (RSR' complex)
  • changes of right ventricular hypertrophy


What are the 7 products free on prescription for nicotine replacement therapy?

  • patch
  • gum
  • inhalator
  • microtabs
  • losenge
  • nasal spray
  • mouth spray

Practitioners advocate cutting down combined with NRT, some evidence to show that this aids abstinence. Combinging products appear to be safe and more effective. 


What is bupropion (zyban)?

  • free on prescription
  • anti-depressant (dopamine + nicotine uptake inhibitor)
  • reduces withdrawal craving
  • one of only two non-nicotine products licensed
  • start taking 1-2 weeks before quit
  • only tested w/ behavioural support
  • overall LT effect: 9%


What is varenicline (champix)?

  • varenicline tartrate: nicotine receptor partial agonist
  • maintains dopamine levels to counteract withdrawal
  • start taking 1-2 weeks before quit
  • reduces smoking cessation
  • similar effect on abstinence rates as Zyban (9%)


How do electronic cigarettes aid in smoking cessation?

  • most popular aid to smoking cessation - used in about third of quit attempts
  • two trials provide evidence
  • regular use in children rare + no evidence of gateway to smoking
  • no evidence of harm of long-term use of nicotine
  • may be some harm of additives but negligible compared w/ smoking


What other lifestyle changes apart from smoking cessation are important for COPD patients?

  • encourage exercise
  • treat poor nutrition or obesity
  • annual influenza + one-off pneumococcal vaccination


What are the medications for management of COPD?

  • inhalers - b2-agonist, anticholinergic, steroid
  • theophylline
  • diuretics
  • LTOT
  • mucolytics


What are the NICE guidelines for medical management of COPD?

  • NICE only recommends oral theophylline after trials of short + long-acting bronchodilators or to ppl who cannot used inhaled therapy
  • mucolytics - consider in pts w/ chronic productive cough and continue if symptoms improve

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Describe features of pulmonary rehabilitation

  • exercise training to improve breathlessness + general wellbeing
  • instituted at home; climbing stairs or walking fixed distances can be combined w/ reg clinic visits for encouragement
  • QoL improved by MDT approach: physio, exercise, education
  • rehab programmes should include the following:
    1. patient + family education
    2. smoking cessation
    3. physical, nutritional + occupational therapy
    4. in selected pts LTOT or CPAP


What is long-term oxygen therapy?

  • reduces mortality if given for at least 15hrs per day
  • also less polycythaemia, improved progression of pulm hypertension and improved neuropsych health
  • at a flow rate of 1-3L via nasal prongs 
  • to increase arterial oxygen sats >90%
  • prescribed to pts who:
    • no longer smoke
    • have a PaO2 <7.3kPa 
    • FEV1 <30%
  • Other indications for use of LTOT include PaO2 of 7.3-8kPa w/ one of following:
    • secondary polycythaemia
    • nocturnal hypoxaemia
    • peripheral oedema
    • pulmonary hypertension


What are surgical options for COPD?

  • bullectomy
  • lung volume reduction surgery
  • single lung transplantation

Surgery indicated when there are recurrent pneumothoraces or isolated bullous lung disease.


What are complications of COPD?

  • cor pulmonale
  • resp failure
  • acute exacerbations
  • pneumonia
  • pneumothorax
  • polycythaemia
  • lung carcinoma


What is the management of acute exacerbation of COPD?

  1. nebulised bronchodilators (salbutamol)
  2. controlled O2 if SaO2 <88% or PaO2 <7kpa
    • start at 24-28%, aim sats 88-92%
    • adjust according to ABG, aim PaO2 >8kpa
  3. steroids -> IV hydrocortisone or oral prednisolone
  4. abx -> if infection, amoxicillin or clarithromycin or doxy
  5. physiotherapy to aid sputum expectoration
  6. if no response to nebulisers + steroids -> consider IV aminophylline
  7. if no response:
    • consider NIPPV if RR >30 or pH <7.35 OR
    • consider resp stim drug eg. doxapram IV for those that mechanical ventilation not suitable 
  8. consider intubation + ventilation if pH <7.26 + PaCO2 is rising despite non-invasive ventilation only where appropriate


Why are COPD sats only aimed at 88-92%?

  • great danger of hypoxia - accounts for more deaths than hypercapnia
  • however, in some pts who rely on their hypoxic drive to breathe, too much oxygen may lead to a reduced respiratory rate + hypercapnia, with a consequent fall in conscious level
  • always prescribe O2 as if it were a drug
  • esp if there is evidence of CO2 retention, start with 24-28% O2 in such patients