COPD Flashcards
1
Q
What does COPD stand for?
A
Chronic obstructive pulmonary disease
2
Q
What is COPD?
A
Chronic, slowly progressive disorder characterised by airflow obstruction that does not change markedly over several months
3
Q
Which gender gets COPD?
A
Male
4
Q
Causes of COPD
A
Smoking (85%) Chronic asthma Passive smoking Maternal smoking Air pollution Occupation (15-20%)
5
Q
Examples of occupations causing COPD
A
Coal mining Hard rock mining Tunnel working Concrete manufacturing Construction Farming Foundry working Plastics Textiles Rubber Leather
6
Q
What does a1-antitrypsin do?
A
Neutralises enzymes released by neutrophils
7
Q
Genotypes of a1-antitrypsin deficiency
A
Normal genotype - PiMM (86%)
Troublesome genotype PiZZ (10-20%)
8
Q
What can happen in a1-antitrypsin deficiency?
A
Bad emphysema can develop very quickly as nothing to neutralise the neutrophils
People tend to develop COPD at younger age
9
Q
What is the most important cause of COPD?
A
Smoking
10
Q
What % of smokers develop significant COPD?
A
20%
11
Q
When would COPD tend to develop in non smokers?
A
Asthma
a1-antitrypsin
12
Q
What is 1 pack year?
A
1 pack a day for a year
13
Q
How many pack years does it usually take to develop COPD?
A
20 pack years
14
Q
What is COPD defined by?
A
Airflow obstruction
15
Q
Pathology of COPD
A
Luminal obstruction due to small airway narrowing and can be worsened by inflammation and mucus, leading to progressive breathlessness on exertion, along with coughing and wheezing
Breakage of alveolar cell membranes
16
Q
What is a prime feature of COPD?
A
Mucus secretion
17
Q
What is chronic bronchitis?
A
Sputum produced every day for at least 2 years
18
Q
What is ACOS?
A
Asthma/COPD overlap syndrome
19
Q
What conditions overlap to make up COPD?
A
Chronic bronchitis
Emphysema
20
Q
Type of airflow obstruction in asthma
A
Reversible
21
Q
Type of airflow obstruction in COPD
A
Fixed airflow obstruction
22
Q
Presentation of COPD
A
SOB - gradual onset - little variation - progressively getting worse Cough - long history of 'smokers cough' - clear of mucoid sputum Wheeze - typically on exertion Progressive difficulty in performing ADLs Weight loss (severe disease,
23
Q
Typical COPD patient
A
Patient >40+ years
Smoker / ex smoker
SOB on exertion
Cough
24
Q
Differential diagnosis of COPD
A
Asthma Lung cancer LVF Fibrosing alveolitis Bronchiectasis TB Recurrent PE
25
If the patient has symptoms of COPD with haemoptysis, what conditions must be looked into?
Lung cancer
TB
Bronchiectasis
26
Examples of causes of peripheral oedema
Cor pulmonale
Severe disease
Respiratory failure
27
Signs of COPD
```
SOB walking into clinic, undressing
Pursed lips
Accessory muscles
Cyanosis
CO2 flap, tremor (B-agonists)
Effects of steroids
Hyperexpanded (barrel) chest
Decreased expansion
Less than 3 finger spaces between manubrium and larynx
Laryngeal descent
Paradoxical movement of ribs and abdomen
Decrease in cardiac dullness to percussion
Decreased breath sounds
Prolonged expiration with wheeze
Palpable liver
Cor pulmonale
```
28
Why does pursed lips help in COPD?
Generates a bit more of a positive pressure which causes the airways to open up a bit more
29
Signs of steroid use
Thin skin
Bruising
Cushingoid
30
Do crackles occur in COPD?
NO
31
Signs of cor pulmonale
Increased JVP
Hepatomegaly
Ascites
Oedema
32
What are acute exacerbations of COPD caused by?
Viral/bacterial infection
33
Causes of acute exacerbation of COPD
Viral/bacterial infection
Sedative drugs
Pneumothorax
Trauma
34
Symptoms of acute exacerbation of COPD
```
Increased cough
Increased sputum
Increased SOB
increased wheeze
Unable to sleep
Increased oedema, confusion, drowsiness
```
35
Investigations for acute exacerbations of COPD
```
CXR
Blood gases
FBC
U and Es
Sputum culture
```
36
What does spirometry rule out if the FEV1 is normal?
COPD
37
What is a normal FEV1?
> 80% predicted
38
What spirometry result would be abnormal?
FEV1 < 80% predicted with FEV1/FVC ratio < 70%
39
What is emphysema?
Damaged alveoli and so reduced gas transfer
40
In asthma, is the gas transfer affected?
No
41
How is fixed airflow obstruction demonstrated by spirometry?
Minimal bronchodilator reversibility
- Baseline, 15 mins post neb 2.5-5mg salbutamol, baseline 30 mins post neb 2.5-5mg salbutamol + 500ug ipratropium
Minimal response to oral corticosteriods
- 30 - 40mg prednisolone daily for 2 weeks
- measure baseline and final FEV1
42
What would a significant bronchodilator/steroid response suggest?
Asthma/asthmatic component
43
What bronchodilator response would be consistent with COPD?
Insignificant bronchodilator / steroid response
44
Investigations for COPD
```
Spirometry
Full pulmonary testing
- Lung volumes
- carbon monoxide gas transfer
CXR
ECG
Blood gases
FBC
ECG
Sputum sample
```
45
What may be seen on a CXR in COPD?
Hyperinflated lung fields (>10 posterior ribs)
Flattened diaphragms
Lucent lung fields
Bullae
46
Decreased PaO2 on blood gas indicates what?
Type 1 respiratory failure
47
Decreased Pa02 and increased PaCO2 indicates what?
Type 2 respiratory failure
48
What would be seen on a FBC in COPD?
Secondary polycythaemia (hct > 0.52)
49
What may be seen on an ECG in COPD?
Right axis deviation
P pulmonale
T wave insertion
50
Inflammation type in COPD
Neutrophilic
51
How to prevent disease progression in COPD?
Smoking cessation
52
How to relieve breathlessness in COPD?
Inhalers
53
How to prevent exacerbations of COPD?
Inhalers
Vaccines
Pulmonary rehabilitation
54
How to manage complications of COPD
Long term oxygen therapy
55
Non pharmacological management of COPD
```
Smoking cessation
Vaccines (flu, pneumococcal)
Pulmonary rehabilitation
Nutritional assessment
Psychological support
```
56
Inhaled therapy for COPD
```
Short acting bronchodilators
- SABA (Salbutamol)
- SAMA (ipratropium)
Long term bronchodilators
- LAMA
- LABA
High dose ICS and LABA
- relvar
- fostair
```
57
As there is more symptoms/exacerbations - staging of T for COPD
1. SABA
2. LAMA or LABA
3. Further bronchodilator (LAMA and LABA)
4. Triple therapy (ICS, LAMA, LABA)
58
What does LTOT stand for?
Long term oxygen therapy
59
What Pa02 should LTOT be used at?
< 7.3 kPa
7. 3 - 8 kPa if
- polycythaemia
- nocturnal hypoxia
- peripheral oedema
- Pulmonary HTN
60
Presentation of COPD exacerbation
```
Increasing SOB
Cough
Sputum volume
Sputum purulence
Wheeze
Chest tightness
```
61
Management of acute exacerbation of COPD
SABA
Steroids
- prednisolone 40mg per day for 5 - 7 days
Antibiotics (if evidence of infection)
62
When should hospital admission be considered if unwell?
Tachypnoea
Low oxygen sats (<90-92%)
Hypotension etc
63
Ward based management of acute exacerbation of COPD
Oxygen target sats 88 - 92%
Nebulised bronchodilators
Corticosteriods
Antibiotics
64
How can evidence of bronchodilators be assessed/
Clinical
| ABG
65
What should be done in acute respiratory failure?
Non invasive ventilation (NIV)
66
Management of COPD
```
Nebulised bronchodilator B2 and antimuscarinic
O2 oral / IV corticosteriods
Antibiotics
Diuretic
IV aminophylline
Respiratory stimulant
NIV
```
67
An organism causing pneumoniae in a COPD patient is most likely to be what?
Haemophilus influenzae
68
Treatment for COPD (steps)
1st line
- SABA or SAMA
Next step is determined to do with whether there is asthmatic features/responsiveness
No asthmatic features
2. Add LABA or LAMA. Also if already taking a SAMA, switch to a SABA
Asthmatic features / responsiveness
2. LABA + ICS
3. Triple therapy i.e. LAMA + LABA + ICS. If already taking a SAMA, switch to a SABA
69
What NICE criteria would suggest that a patient has asthmatic features/responsiveness in COPD?
Any previous secure diagnosis of asthma or atopy
A higher eosinophil blood count
Substantial variation in FEV1 over time (at least 400ml)
Substantial diurnal variation in PEFR (at least 20%)
70
What prophylaxis may be done in select patients with COPD?
Azithromycin
71
Monitoring of azithromycin
LFTs
| ECG to exclude QT prolongation
72
Who with COPD should be considered to get mucolytics?
Chronic productive cough and continued if symptoms improve
73
Treatment of cor pulmonale
Loop diuretic
| Oxygen long term
74
What vaccinations should a COPD patient get?
Annual flu
| One off pneumococcal
75
What pH does NIV show most benefit?
7.25 - 7.35
76
What pH should invasive ventilation be carried out?
< 7.25
77
What can large bullae in COPD mimic?
A pneumothorax
78
What is the severity of COPD judged by?
FEV1
79
1st line antibiotics for an infective exacerbation of COPD
Amoxicillin or clarithromycin or doxycycline
80
In alpha-1-antitrypsin deficiency, where is empysema more prominent in the lungs and how does this compare to in COPD?
Lower lobes in A1ATD
| Upper lobes in COPD
81
1st line pharmacological management of COPD
SABA or SAMA
82
What criteria should be used to determine if patients having an exacerbation of COPD should require antibiotics?
Those with purulent sputum or clinical signs of pneumonia
83
From the NICE guidelines, it is recommended that patients who have had frequent exacerbations of their COPD should be given what?
A home supply of prednisolone and antibiotics
