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CR > COPD > Flashcards

COPD Flashcards

1
Q

Symptoms of COPD

A 
Dyspnoea (exertional)
Chronic productive cough
Recurrent chest infections
Weight loss
Fatigue
Exercise intolerance
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2
Q

Signs of COPD

A 
Wheeze or quiet breath sounds
Peripheral oedema and raised JVP (right heart failure)
Cyanosis
Cachexia
Hyperinflated chest
Use of accessory muscles
Pursed lip breathing
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3
Q

Pathophys of emphysema

A

Smoking inactivates alpha-1 antitrypsin (or hereditary deficiency) so that this can’t inhibit serum elastase
–> elastic tissues destroyed
–> Loss of elastic fibres of the alveoli and a decreased surface area –> can lead to collapsed alveoli
Can get air trapping as you exhale as the recoil mechanism isn’t working, causing bulla formation

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4
Q

Pathophys of bronchitis

A

Problem in bronchioles

Smooth muscle hypertrophy and mucus hypersecretion

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5
Q

Risk factors of COPD

A

Smoking
Genetic factors
Air pollution
Occupational exposure to dust, chemicals, noxious gases etc.

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6
Q

CXR findings in COPD

A

Flattened diaphragm

Hyperinflation

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7
Q

Describe the airflow obstruction in COPD

A

Progressive
Not fully reversible
Does not change markedly over several months

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8
Q

How to calculate pack years?

A

Number of packs per day x number of years smoked

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9
Q

Complications of COPD

A

Disability and impaired quality of life
Depression and anxiety
Cor pulmonale (right heart failure secondary to lung disease) — caused by pulmonary hypertension as a consequence of hypoxia
Frequent chest infections
Secondary polycythaemia due to hypoxia
Type 2 respiratory failure — caused by increased airway resistance
Lung cancer — COPD may increase the risk of lung cancer

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10
Q

Investigations

A

Post-bronchodilator spirometry
CXR to exclude other pathology
FBC — to identify anaemia or secondary polycythaemia due to hypoxia
Pulse oximetry
ECG and echo if features of cor pulmonale
Sputum culture
ABG if acutely unwell, FEV1 <35% predicted, sats <92%, or signs of resp failure = shows decreased pa02 +/- hypercapnoea, may see resp acidosis
CT may be done if symptoms disproportionate to spirometry, if any abnormalities on CXR, before surgery etc.
Alpha-1 anti-trypsin if young, minimal smoking, family history

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11
Q

Features of cor pulmonale

A

Peripheral oedema
Raised jugular venous pressure
Systolic parasternal heave
A loud pulmonary second heart sound (over the second left intercostal space)
Widening of the descending pulmonary artery on chest X-ray
Right ventricular hypertrophy on ECG

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12
Q

Define airflow obstruction using FEV1/FVC

A

FEV1/FVC ratio of less than 0.7

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13
Q

Grade severity of airflow obstruction using FEV1

A

Stage 1, mild — FEV1 80% of predicted value or higher
Stage 2, moderate — 50–79%
Stage 3, severe — 30–49%
Stage 4, very severe — <30%

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14
Q

MRC dyspnoea scale

A

Grades 1-5
Prognostic
1 = not troubled by breathlessness except during strenuous exercise
2 = SOB when walking up slight hill or hurrying
3 = walks slower on the level or has to stop for breath when walking at own pace
4 = stops for breath after walking about 100m or after a few minutes on the level
5 = too breathless to leave house, breathless when dressing/undressing

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15
Q

Differentials for COPD

A 
Asthma
Bronchiectasis
Heart failure
Lung cancer
Interstitial lung disease
Anaemia
Tuberculosis
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16
Q

What is an acute exacerbation of COPD?

A

Sustained worsening of person’s symptoms from their usual stable state, which is beyond normal day-to-day variations and is acute in onset

17
Q

Symptoms of acute exacerbation

A

Increased breathlessness, cough, sputum production, wheeze, chest tightness, fatigue
Change in sputum colour
Upper respiratory tract symptoms (e.g. cold or sore throat)
Reduced exercise tolerance
Ankle swelling
Acute confusion
Fever

18
Q

Differentials for acute exacerbation of COPD

A 
Pneumonia
Recurrent aspiration
Pneumothorax
Acute heart failure
Pulmonary embolism 
Lung cancer
Pleural effusion
Upper airway obstruction
19
Q

When to refer for pulmonary rehabilitation?

A

If functionally disabled by COPD e.g. MRC dyspnoea scale grade 3 or above
OR have had a recent hospitalization for an acute exacerbation

20
Q

Benefits of pulmonary rehab

A

Improve QOL, increase exercise capacity, reduce breathlessness

21
Q

When to refer to physio

A

If excessive sputum, to learn the use of positive expiratory pressure masks and the ‘active cycle of breathing’ technique.

22
Q

Define chronic bronchitis

A

Presence of chronic productive cough and sputum for at least 3 months in each of two successive years.

23
Q

Pathophys of COPD

A

Chronic inflammation (i.e. due to the inhaled stimuli)

  • -> narrowing and remodelling of airways, enlargement of mucus glands
  • -> increased airway resistance due to decreased elastic recoil (smoke causes release of serine elastase which destroys elastic tissue), fibrosis, luminal obstruction of airways by secretions
  • -> hyperinflation and destruction of lung parenchyma
  • -> hypoxia
  • -> vascular smooth muscle thickening
  • -> pulmonary hypertension
24
Q

Causes of COPD

A

Smoking
Air pollution
Occupational dusts, chemicals, fumes
Alpha-1 anti-trypsin deficiency

25
Q

Fundamentals of COPD care

A 
Smoking support/cessation
Pneumococcal and flu vaccines
Pulmonary rehab if indicated
Personalised self-management plan
Optimise treatment for comorbidities
26
Q

Inhaled therapies for COPD

- if asthmatic features or features suggesting steroid responsiveness

A

1) SABA or SAMA as needed
2) LABA + ICS
3) LABA + LAMA + ICS
4) Explore further treatment e.g. theophylline, oral mucolytic therapy, long term oxygen therapy

27
Q

Inhaled therapies for COPD

- if NO asthmatic features or features suggesting steroid responsiveness

A

1) SABA or SAMA as needed
2) LABA + LAMA
3) LABA + LAMA + ICS (3 month trial unless has 1 severe or 2 moderate exacerbations within a year)
4) Explore further treatment e.g. theophylline, oral mucolytic therapy, long term oxygen therapy

28
Q

Oral prophylactic antibiotic therapy - what is used?

A

Azithromycin (usually 250 mg 3 times a week)

29
Q

When might long term oxygen therapy be needed?

= 15 HOURS A DAY

A 
FEV1 below 30% predicted
Cyanosis
Polycythaemia
Peripheral oedema
Raised JVP
Saturations <92%

–> then do 2 ABGs 3 weeks apart

If Pa02 <7.3kpa or <8kpa + polycythaemia, peripheral oedema, pulmonary hypertension

–> risk assessment (CANNOT SMOKE)

30
Q

Varenicline mechanism + contraindications

A

Selective nicotine receptor partial agonist
Avoid if Hx of mental illness as may cause suicidal thoughts. Contraindicated in pregnancy/breastfeeding, under 18 year olds, end-stage renal disease.

31
Q

Buproprion mechanism + contraindications

A

Antidepressant
Increases risk of seizures, so contraindicated in epilepsy, alcohol withdrawal, eating disorders or CNS tumours. It is also contraindicated in bipolar disorder, pregnancy/breastfeeding, under 18 year olds, and severe cirrhosis.

32
Q

Features of a severe exacerbation

A 
Acute confusion.
Marked reduction in activities of daily living.
Marked breathlessness and tachypnoea.
Pursed-lip breathing.
Use of accessory muscles at rest.
New-onset cyanosis or peripheral oedema.
33
Q

What oxygen should be given (if no alert card)?

A

28% Venturi mask at a flow rate of 4 L/min, and aim for an oxygen saturation of 88–92%

34
Q

Organisms that may cause pulmonary infection in patients with COPD

A
  • Often viral (30%) e.g human rhinovirus
  • Haemophilus influenzae (most common)
  • Moraxella catarrhalis
  • Streptococcus pneumoniae
35
Q

Investigations for acute COPD exacerbation

A

• Oxygen saturations
• ABG
• Sputum sample for microscopy and culture (if sputum is purulent)
• Blood cultures (if pyrexial)
Investigations to exclude other diagnoses:
• CXR
• ECG
• Bloods – FBC, U&E, CRP, theophylline level, cardiac enzymes
• CT/CTPA
?echo

36
Q

Treatment of COPD exacerbation

A

Increase frequency of bronchodilator use and consider giving via a nebuliser
Give prednisolone 30 mg daily for 5 days
Oral antibiotics ‘if sputum is purulent or there are clinical signs of pneumonia’

37
Q

Treatment of COPD exacerbation

A

Oxygen
Increase frequency of bronchodilator use and consider giving via a nebuliser
Give prednisolone 30 mg daily for 5 days
Oral antibiotics ‘if sputum is purulent or there are clinical signs of pneumonia’
May need non-invasive ventilation

38
Q

How to choose antibiotics for COPD exacerbation

A

First line = amoxicillin 500mg TDS for 5 days

If amoxicillin allergy = doxycycline 200mg on first day then 100mg OD for a total of 5 days

If contraindicated = clarithromycin 500mg BD for 5 days

If increased risk of resistance = co-amoxiclav 500/125 mg TDS for 5 days.

CR (19 decks)

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