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Craven Flashcards

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1
Q

What does Mr Craven’s patient profile tell us?

A

Has a 30-pack year smoking history
Grew up in Glasgow, both parents were smokers
Works as a British Gas plumber, work has reduced hours these days
A huge fan of the Glasgow rangers
Had a chest infection recently and took amoxicillin
Took his wife to the cinema for their wedding anniversary
Enjoys fly fishing accompanied by his wife

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2
Q

What does Mr Craven talk about in the Case video?

A 
Breathing gotten a lot worse over the last few days
Can't get enough air in
Chest feels tired, achy
Having difficulty sleeping at night 
Last night had to get blue puffer out at least 4x during the night
Coughing up more phlegm and sputum than normal - a few egg cup fulls a day
Yellow green coloured sputum
No blood in sputum
No wheezing, 'rattling'
No chest tightness
No chest pain
Diagnosed with COPD 3 years ago 
On a good day - 15 mins to shop 
Stairs - can manage a flight but but of breath getting to the top
Claims he hasn't taken antibiotics or oral steroids from the GP in the last year
No other medical problems
Off food for last few days - soups 
Just him and his wife
He's gonna be a grandpa (has a daughter)
Swelling in both ankles
Feeling flushed
Waterworks and bowel movements okay
No recent faints / unconsciousness
Quit smoking when he got the COPD diagnosis
Used to smoke a pack a day for 40 years
On blue puffer and special combo inhaler
No drug allergies
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3
Q

What does the doctor think Mr Craven has after taking his history?

A

Effective exacerbation of your COPD

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4
Q

What does the doctor want to do next?

A

Examine Mr Craven, listen to his chest, run some blood tests, get a chest x-ray (CXR), get an ECG, sputum analysis

Arterial blood gas test - O2 sats low at 87

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5
Q

What is Chronic Obstructive Pulmonary Disease (COPD)?

A

Name for a group of lung conditions that cause breathing difficulties:

Emphysema – damage to the air sacs in the lungs
Chronic bronchitis – long-term inflammation of the airways

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6
Q

What are the main symptoms of COPD?

A

Increasing breathlessness, particularly when active

Persistent chesty cough with phlegm – some people may dismiss this as just a “smoker’s cough”

Frequent chest infections

Persistent wheezing

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7
Q

When is it good to get medical advice?

A

Persistent COPD symptoms, esp. if 35+ and smoke / used to smoke

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8
Q

Why is it important not to ignore COPD symptoms?

A

Best to start treatment ASAP before lungs get significantly damaged

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9
Q

What are the causes of COPD?

A

Long term exposure to dust or harmful fumes
Smoking
Rare genetic problem = lungs more vulnerable to damage

All lead to inflamed, damaged and narrowed lungs (aKA COPD)

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10
Q

What are the treatments for COPD? Why are they important / useful?

A

Damage to lungs caused by COPD is permanent but treatment can help slow down the progression of the condition

Treatments include:
Stop smoking
Inhalers and medications - help breathing
Pulmonary rehabilitation - specialised exercise and education programme
Surgery / lung transplant

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11
Q

What else may be required by someone with COPD?

A

Social care and support
Need help for daily tasks
Or they may be a carer

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12
Q

How can you reduce the chance of developing COPD?

A

Avoid smoking

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13
Q

What did COPD used to be known as?

A

Chronic bronchitis and emphysema

Affects lung tubes, air tubes and the lung tissue itself

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14
Q

How is COPD defined clinically?

A

Coughing up mucus every day, for 3 months of the year, typically in the winter

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15
Q

What is the progression of COPD?

A

Persistent smoker’s cough
Coughing up phlegm / sputum / mucus
Breatlessness on exertion

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16
Q

How to diagnose suspected COPD?

A

CXR (chest x-ray)

Blow test - measures lung function compared to average

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17
Q

What are the typical treatments prescribed by the GP for COPD patients?

A

Inhaler to to open up air passages during spasms / coughing

Inhaler to reduce inflammation

Emergency supply of antibiotics = do not need to wait for prescription if they develop a chest infection

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18
Q

What are some other less common symptoms of COPD?

A

Weight loss
Tiredness
Swollen ankles from a build-up of fluid (oedema)
Chest pain and coughing up blood – although these are usually signs of another condition, such as a chest infection or possibly lung cancer

Only tend to happen with COPD reaches advanced stage

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19
Q

What other conditions cause similar symptoms to COPD?

How can you differentiate between them?

A

Asthma, bronchiectasis, anaemia, heart failure

Breathing test can help determine if you have COPD

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20
Q

What are the causes of COPD?

A

Smoking - 9 out of 10 cases: harmful chemicals damage lining of lungs and airways
Passive smoking

Fumes and dust at work - damage lungs:
    cadmium dust and fumes
    grain and flour dust
    silica dust
    welding fumes
    isocyanates
    coal dust

Air Pollution
Exposure over a long period can affect how well the lungs work (inconclusive evidence)

Genetics
1 in 100 with COPD have tendency to develop a genetic condition called Alpha-1-antitrypsin deficiency. Alpha-1-antitrypsin = substance that protects your lungs

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21
Q

What might a GP do to confirm a diagnosis of COPD?

A

Ask about symptoms
Examine chest and listen to breath sounds
Ask about smoking history
Calculate BMI
Ask about family history of lung problems
Perform tests

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22
Q

What tests can help a GP confirm a diagnosis of COPD?

A

Spirometry - breathe into spirometer after inhaling a bronchodilator, record vol of air exhaled in 1st second and total vol of air exhaled. Compare results with baseline to check if lungs are obstructed

CXR (chest x-ray) - look for problems in the lungs that can cause similar symptoms to COPD e.g. cancer, chest infections

Blood test - show other conditions that can cause similar symptoms to COPD e.g. anaemia, polycythaemia. Sometimes done to look for alpha-1-antitrypsin deficiency

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23
Q

What are some further tests to determine severity of COPD?

A

Electrocardiogram (ECG) – a test that measures the electrical activity of the heart

Echocardiogram – an ultrasound scan of the heart

Peak flow test – a breathing test that measures how fast you can blow air out of your lungs, which can help rule out asthma

Blood oxygen test – a peg-like device is attached to your finger to measure the level of oxygen in your blood

CT scan – a detailed scan that can help identify any problems in your lungs

Phlegm sample – a sample of your phlegm (sputum) may be tested to check for signs of a chest infection

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24
Q

What are the available treatments for COPD?

A

Stop smoking

Inhalers - device delivers medicine directly into lungs whilst breathing

Tablets

Antibiotics

Pulmonary rehabilitation

Nebulised medicine - machine turns liquid medicine into mist and is breathed in through a mouth piece = larger dose delivered at a time

Roflumilast - new medication for flare ups to reduce inflammation

Long-term O2 therapy - >16hrs/day

Ambulatory oxygen therapy = blood O2 normal at rest, but falls on exertion

Non invasive ventilation = portable machine connected to mask to support lungs

Surgery

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25
What are the different types of inhalers prescribed for COPD?
Short-acting bronchodilator inhalers - first treatment use: Beta-2 agonist inhalers - e.g. salbutamol and terbutaline Antimuscarinic inhalers e.g. ipratropium Used up to 4x a day, only when feeling breathless Long-acting bronchodilator inhalers - if symptoms persist throughout the day, use: Beta-2 agonist inhalers e.g. salmeterol, formoterol and indacaterol Antimuscarinic inhalers e.g. tiotropium, glycopyronium and aclidinium Last up to 12 hours, should only be used 1-2x a day Steroid inhalers - if still breathless or frequent exacerbations use: corticosteroid medicines to reduce Inflammation in the airways
26
What so combination inhalers often include?
Steroid inhalers | Long-acting medicine
27
What are the different tablets prescribes for COPD?
Theophylline tablets - bronchodilator, reduces inflammation in the airways and relaxes the muscles lining them Mucolytics - e.g. carbocisteine 3-4x a day = makes phlegm in the throat thinner and easier to cough up Steroid tablet - for bad exacerbations to reduce inflammation = 5 day course though long term use = weight gain, mood swings, weakened bones (osteoporosis)
28
What is pulmonary rehabilitation?
Specialised programme of exercise and education: involving: Physical exercise training tailored to your needs and ability – such as walking, cycling and strength exercises Education about your condition for you and your family Dietary advice Psychological and emotional support
29
What are the side effects of Roflumilast?
Side effects of roflumilast include: ``` feeling and being sick diarrhoea reduced appetite weight loss headache ```
30
What are the surgical treatment options for COPD?
Bullectomy – remove pocket of air from one of the lungs, allowing the lungs to work better and make breathing more comfortable Lung volume reduction surgery – an operation to remove a badly damaged section of lung to allow the healthier parts to work better and make breathing more comfortable Lung transplant – an operation to remove and replace a damaged lung with a healthy lung from a donor
31
What should a patient living with COPD do?
Look after themselves Take their prescribed medication and refer to info leaflets for flare ups Stop smoking Exercise regularly Maintain a healthy weight - carrying extra weight makes breathlessness worse Get vaccinated - COPD = strain on body = vulnerable to infections Check weather - symptoms temperamental so prep in advance w/ extra medication Watch what you breath - avoid dust, fumes, smoke, air freshners, strong smelling cleaning products, hairspray, perfume Regular reviews and monitoring with care team Practice breathing techniques - slow deep breaths Talk to others - GP, local support group, counsellor, psychologist Relationships - difficulty breathing = tired and depressed Sex = strenous, sex life affected Flying with COPD = take medications in hand luggage Finance - entitled to statuatory sick day and employment & support allowance; carer entitled to carer's allowance End of life care - management plan based on your wishes (advance decisions made)
32
What are some co-morbidities (with COPD) that could contribute to Mr Craven's current shortness of breath?
CVD - chronic heart failure, CAD, PAD, atrial fibrillation Asthma Anaemia Anxiety / Depression - closely related to the risk of death Respiratory infections Cancer - oesophageal, pancreatic, breast, lung = also closely related to risk of death often due to COPD population being smokers Hypertension Diabetes Chronic Renal Failure Degenerative joint disease
33
Why are COPD exacerbations so serious?
Many patients die within 1 year of their first COPD exacerbation ``` Lung function decline Lessened physical activity Poor / declining mental Health Deterioration in quality of life Further COPD exacerbations Mortality ```
34
A chest x-ray is a mandatory investigation in anyone who presents to A&E with shortness of breath What does Mr Craven's chest x-ray show now, compared to before?
Hyperinflated lungs - clavicles raised, flat hemidiaphragm Barrel chest? Enlarged heart? White fluffy cloud stuff in the right lung - pneumonia, (congestion + fluid build up in the lungs) or pleural effusion Opacification in the lower lobe of the right lung = low bar pneumonia
35
Why does Mr Craven's x-ray show an enlarged heart?
Enlarged heart - caused by pulmonary hypertension (raised BP in the pulmonary arteries) leading to cor pulmonale (i.e. right sided heart failure) This is because the right side of the heart has to work harder to pump blood to the lungs due to the pulmonary hypertension
36
Why is there an increased RBC count in cor pulmonale?
Increased RBCs in cor pulmonale due to bone marrow compensates by producing more RBCs
37
How can you differentiate between pneumonia and pleural effusion?
Costophrenic angle up to the pleura outlining distinctive border, literally the bottom half of the lung is opaque Loss of right hemidiaphragm in pneumonia and less distinct border in opacification - all over the lung especially at the borders (doesn't collect at the bottom like pleural effusion)
38
What is Mr Craven's diagnosis based on his x-ray and arterial blood gas?
Low pH - acidosis Low O2 High CO2 - hypoxemia Normal HCO3- / BE Uncompensated respiratory acidosis with moderate hypoxemia
39
What is wrong with the ABG slip?
Doctor has not written FIO2 (fraction of inspired oxygen) Write FIO2 = room air or being given oxygen?
40
What happens in hypoxemic respiratory failure?
Type I Lack of oxygenation of the lung tissue Lung tissue failure - oxygenation failure = V/Q mismatch - blood being delivered without oxygen in it Inadequate O2 to meet matabolic needs
41
What happens in hypercapnic respiratory failure?
Type II Pump failure - leading to increased CO2 Failure of lungs to eliminate CO2 Anything affecting the muscles - nerves, neuromuscular, cervical trauma, stroke at the PONS etc.
42
What are some possible causes of hypoxemic respiratory failure?
``` Pneumonia Pulmonary oedema Pulmonary fibrosis Pulmonary embolism 'ARDS Aspiration Lung collapse - retained secretions Asthma Pneumothorax ```
43
What are some possible causes of Type II respiratory failure?
``` Late severe acute asthma Neuromuscular diseases Flail chest injury Exhaustion Reduced respiratory drive - drug overdose, head injury COPD ```
44
What type of respiratory failure is Mr Craven in?
Type II pH - low, = acidaemia High PCO2 = respiratory acidosis
45
What organ tries to compensate for the respiratory failure in the lungs?
Kidneys try to compensate for the lungs Metabolic alkalosis - increase blood pH to stabilise blood pH - regain blood pH balance Response is a partial compensation (with liver or kidney failure, lungs tend to try an compensate)
46
What is the initial management for Mr Craven's shortness of breath? Drug and non-drug
IV antibiotics - treat infection causing the pneumonia, look at previous cultures to deliver more specific antibiotic rather than broadspectrum IV cortisone VS Systemic corticosteroids - improve inflammation Anticholinergics - inhibit parasympathetic nerves, reduce airway tone and improve expiratory flow Beta-2 agonists - smooth muscle relaxation, open up the airways e.g. IV salbutamol Ventilation and oxygen - improve RR and hypoxemia Sit up - release pressure against diaphragm Respiratory physiotherapy - remove secretions clogging up the airways
47
Which ventilation method is to be used with Mr Craven? | CPAP or BIPAP?
CPAP - continuous positive airways pressure NIV - non invasive ventilation AKA BiPAP - bi-level positive airway pressure BiPAP suitable for Mr Craven - has 2 pressure settings, one for inhalation and one for exhalation (compared to CPAP which only has one pressure) This lessens the work for Mr Craven to breathe
48
Why is CPAP inappropriate for Mr Craven?
Continuous flow Controlled flow - low, medium, high Increases work required for exhalation to overcome continuous positive pressure
49
Why is BiPAP more suitable for Mr Craven?
Mr Craven has Type II = Pump failure NIV - differing pressures depending on inspiratory and expiratory pressures Higher pressure for inhalation than inhalation Reduces the work of breathing
50
Mr Craven has an issue with his lungs. So why does he have swollen ankles?
Lack of O2 in blood = Alveolar hypoxia Hypoxic pulmonary vasoconstriction (high CO2 tension with elevated H+ concentration in the blood increases the extracellular Ca2+ influx, which is thought to be the main cause of vasoconstriction in the pulmonary circulation) Increased pulmonary vascular resistance Pulmonary hypertension Right ventricular afterload is greater - needs to pump harder to compensate for pulmonary hypertension Leads to right ventricular failure Right heart muscle becomes enlarged and thickened and loses its ability to contract normally Because of this, blood backs up in the veins of your body and fluid can leak into the surrounding tissues Back flow of oedema into the peripheral system Gravity causes the oedema to pool at the ankles and feet
51
How do you interpret an arterial blood gas (ABG) report?
1. Look at pH and determine whether it is acidic, alkalotic, or normal 2. Identify primary disturbance - respiratory or metabolic cause? Review pCO2 (respiratory) and HCO3- (metabolic) 3. Is there a anion gap? (Base excess) 4. Is there any compensation?
52
What causes respiratory acidosis?
Rise in CO2 level but patient cannot increase respiratory drive Increased carbonic acid formation Decreased pH
53
What causes respiratory alkalosis?
Hyperventilation CO2 levels fall Less carbonic acid formation Increased pH
54
What is the buffering role of bicarbonate ions in the blood?
React with Hydrogen ions to form water and CO2
55
What is the role of the Kidneys in acid-base regulation?
Regulate reabsorption of bicarbonate ions esp. in PCT - to achieve bicarbonate homeostasis Form bicarbonate ions through excretion of ammonia and monophosphate ions Increase H+ excretion = higher pH
56
Bicarbonate ions (HCO3-) are kept within which range?
22-28 mmol/L
57
What is the importance of bicarbonate ions?
Marker of metabolic homeostasis Low bicarb = metabolic acidosis High bicarb = metabolic alkalosis
58
A metabolic acidosis is caused by?
Either increase in H+ or decrease in HCO3- (bicarb)
59
How can you differentiate between high H+ or low HCO3- causing the metabolic acidosis?
Calculate anion gap
60
How do you calculate the anion gap?
1. Either Na+ - HCO3- - Cl- = anion gap (8-16 mmol/L) | 2. Or Na+ + K+ - HCO3- - Cl- = anion gap (12-20 mmol/L)
61
What causes a high anion gap?
Increase in unmeasured anions Hydrogen ions reacting with the bicarbonate ions Causes commonly by metabolic acidosis
62
What are common causes of high anion gap imetabolic acidosis?
Lactic acidosis Ketoacidosis Toxins Renal failure
63
What happens in a normal anion gap metabolic acidosis? What causes this?
Lost bicarbonate ions are replaced with chloride ions Commonly due to: Diarrhoea Renal tubular acidosis
64
What are the two methods of compensation?
Adjustments to ventilation | Adjustments to kidney absorption and excretion
65
What happens in metabolic acidosis to compensate?
Respiratory compensation usually begins within the first hour: Ventilation increases driving off CO2 Reduces carbonic acid in blood Increase pH
66
What are the compensatory mechanisms in metabolic alkalosis?
Hypoventilation This is less pronounced Rarely retains CO2 beyond 7.5 kPa
67
What is the compensatory mechanism for respiratory acidosis?
Kidneys attempt to retain more bicarb and excrete more H+ - to raise pH Takes place over several days Therefore more commonly seen in chronic respiratory diseases
68
What is ARDS?
Acute respiratory distress syndrome
69
What is the criteria for awake prone positioning?
In patients requiring and FiO2 > 28%
70
What does prone positioning do? So why is it used in ARDS?
Decreases the pleural pressure gradients between dependent and non-dependent lung regions Therefore used in ARDS to reduce: Ventilation/perfusion mismatching Hypoxaemia Shunting (pulmonary shunt = passage of deoxygenated blood from the right side of the heart to the left without participation in gas exchange in the pulmonary capillaries
71
How does prone positioning help?
Gravitational effects Conformational shape matching of the lung to chest cavity Generates more homogenous lung aeration and strain distribution Enhances recruitments of dorsal lung units
72
What is further contributing to incidence of COPD?
Environmental pollutants
73
What increases environmental pollutants in developing countries?
Use of biomass fuel for domestic energy | e.g. dung cakes, residues from crop, firewood
74
What leads to inefficient gas exchange in COPD?
Alveolar dead space
75
What does inefficient gas exchange lead to?
Ventilation perfusion mismatch
76
What does the body do to retain the V/Q ratio?
V/Q ratio is the amount of air that reaches your alveoli divided by the amount of blood flow in the capillaries in your lungs Localised vasoconstriction in the affected lung areas that are not oxygenated well
77
What causes hypercapnia in COPD patients?
Patients have a reduced ability to exhale the carbon dioxide adequately
78
What does chronic CO2 elevation lead to?
Acid-base disorders and a shift of normal respiratory drive to hypoxic drive Chemoreceptors develop tolerance to chronically elevated arterial carbon dioxide level Shifts the normal acid-base balance toward acidic
79
What is the target O2 sats for COPD patients?
88% to 92%
80
What is the hasselbach equation?
pH = 6.1 + log − HCO3/0.03pCO2
81
What is the significance of COPD patients with renal failure and COPD exacerbation?
Kidneys are unable to reabsorb bicarbonate to compensate for chronic respiratory acidosis Over time, mixed respiratory and metabolic acidosis sets in causing dangerously low levels of pH The mortality rate is much higher
82
Why do you not want sats above 92% in COPD?
The failure of the hypoxic drive Haldane effect: The increased partial pressure of oxygen in the blood displaces the carbon dioxide from hemoglobin and thereby increasing the CO2 level The increased partial pressure of oxygen reverses the hypoxic vasoconstriction at the pulmonary artery level which leads to the blood going to areas of lungs with no ventilation. Increasing dead space and thus increasing acidosis The increased amount of oxygen displaces nitrogen, which leads to atelectasis
83
How can hypercarpnia related complications be prevented?
Careful monitoring and proper management of COPD Smoking cessation Healthy lifestyle and regular exercise help prevent diseases that can worsen respiration
84
Side note:
Hypercapnia = hypercarbia = CO2 retention | they all mean the same thing

Y2 - CSI (8 decks)

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