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Year 4 - GP > GP - COPD > Flashcards

GP - COPD Flashcards

1
Q

What is a Rescue Pack?

A

A rescue pack or ‘rescue medication’ is a supply of medication to be started at the onset of specific symptoms (subject to the pt’s condition)

  • e.g. steroids to be started in COPD at onset of SoB that affects their ADLs OR Abx if pt experiences abnormally coloured sputum
  • If pt starts rescue pack –> should seek medical attention (these instructions should be provided as written instructions)
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2
Q

What is COPD?

A

Progressive disease characterised by persistent respiratory symptoms and airflow limitation that is not fully reversible

  • COPD = picture of both emphysema + chronic bronchitis
  • In COPD air can get in but not out, due to airway obstruction (bronchitis) and reduced alveolar elascticity (emphysema)
  • This leads to hyperexpansion, and development of holes / bullae on CT
  • FEV1 < 80% of predicted (accounting for pts; age, sex and height)
  • FEV1/FVC (ratio) < 70%
  • Symptoms:
    • progressive shortness of breath,
    • wheeze,
    • cough,
    • sputum production (including haemoptysis)
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3
Q

Name 3 causes of airway obstruction.

A
  1. Asthma (reversible)
  2. COPD
  3. Bronciectasis
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4
Q

Name 4 causes of airway restriction.

A
  1. Interstitial lung disease (ILD) e.g. IPF
  2. Obesity
  3. Scoliosis
  4. Neuromuscular cause
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5
Q

What do pulmonary function tests show for

obstructive vs restrictive lung disease?

A

Obstructive:

  • Normal / ↓ FVC
  • ↓↓ FEV1 (% predicted)
  • Ratio FEV : FVC < 0.70

Restrictive:

  • ↓↓ FVC
  • ↓ FEV1 (% predicted)
  • Ratio stays the same
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6
Q

What is the GOLD classification of COPD?

A

The GOLD classification grades severity of airflow limitation in COPD (spirometric grade 1 to 4)

  1. Stage 1 - Mild (FEV1 > 80%)
  2. Stage 2 - Moderate (FEV1 50 - 79%)
  3. Stage 3 - Severe (FEV1 30 - 49%)
  4. Stage 4 - Very Severe (FEV1 < 30%)

Letters: (groups A to D) provides information regarding symptom burden and risk of exacerbation which can be used to guide therapy

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7
Q

How do the different GOLD ABCD classifications alter therapy?

A
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8
Q

What does CURB-65 stand for?

A
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9
Q

What are the genetic and environmental causes of COPD?

A

Genetic:

  • a1-antitrypsin deficiency

Environmental:

  • Smoking (including 2nd-hand)
  • Cannabis
  • Mineral dusts
    • coal
    • cadmium
    • grain and flour
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10
Q

What are the inhaled treatment options used in COPD?

A
  • SABA = short-acting beta2 agonist – this may be continued at all stages if required
  • SAMA = short-acting muscarinic antagonist
  • LABA = long-acting beta2 agonist
  • LAMA = long-acting muscarinic antagonist
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11
Q

What are some of the key differences between asthma and COPD?

A
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12
Q

When should Mucolytics be considered in COPD?

Give an example

A

Example: Carbocysteine

  • Chronic productive cough –> consider mucolytics (continue use if pts symptoms improve)
  • Do not use mucolytics to prevent exacerbations
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13
Q

What are the features of COPD?

A
  • FEV1 < 80% of predicted (accounting for pts; age, sex and height)
  • FEV1 / FVC (ratio) < 70% (post bronchodilator spirometry)
  • Progressive SoB (worse on exertion)
  • Tachypnoea
  • Wheeze
  • Chronic cough - with/without sputum production (including haemoptysis)
  • Frequent LRTI
  • Tar stained fingers (smoking)
  • Accessory respiratory muscle use:
    • sternocleidomastoid, scalenes, pec major + minor, serratus anterior, latissimus dorsi and abdominals
  • CXR features:
    • Hyperinflation ‘barrel-chest’
    • Bullae
    • Flattened diaphragm
  • ↓ chest expansion
  • ↓ breath sounds (e.g. over bullae)
  • Resonant or hyperresonant percussion note
  • ↓ cricosternal distance (<3cm)
  • Cor pulmonale (↑ JVP + oedema e.g. ankle)
  • Cyanosis
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14
Q

Give some examples of the following sympathomimetric drugs:

  1. B2 adrenergic agonists
  2. Muscarinic antagonists (anti-muscarinics)
A

ß2 agonists:

  • Short acting (SABA)
    • e.g. salbutamol, terbutaline
  • Long acting (LABA)
    • e.g. salmeterol, formoterol

Muscarinic antagonists:

  • ipratropium (SAMA)
  • tiotropium (LAMA)
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15
Q

SABA:

  1. Give 3 examples.
  2. MoA?
  3. Common side effects / counselling points?
A
  1. Salbutamol, Terbutaline, albuterol
  2. B2 adrenergic receptors in smooth muscle cells –> induce bronchodilation
  3. Action of SABAs on B2 adrenergic receptors in other parts of the body cause side-effects:
    • tachycardia
    • palpatations
    • anxiety
    • tremor
    • increase blood glucose
    • Drives K+ into cells –> hypokalaemia (thus SABAs e.g. salbutamol can be used to manage hyperkalaemia)
    • !! take care if patient has cardiovascular disease !!
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16
Q

SAMA:

  1. Give an example
  2. When are they used in COPD?
  3. MoA?
  4. Common side effects / counselling points?
A

SAMA:

  1. Ipratropium, brand name “Atrovent”
  2. Used to relieve breathlessness in COPD e.g. brought on by exercise/ exacerbations. 1st line (or SABA)
  3. SAMAs are muscarinic ACh receptor antagonists –> pushes autonomic NS towards sympathetic activity by blocking parasympathetic:
    • increase HR
    • relax smooth muscle (bronchodilation)
    • reduce GI secretions
    • pupil dilation
  4. When inhaled there are fewer systemic effects
    • but dry mouth is common (patient can use water/ sugar-free gum)
    • caution patients at risk of angle-closure glaucoma (SAMAs can cause pupil dilation which can precipitate this)
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17
Q

LABA:

  1. Give some examples.
  2. When are they used in COPD?
  3. MoA?
  4. Common side effects / counselling points?
A

LABA:

  1. Salmeterol, formeterol
  2. 2nd-line in management of COPD with or without asthmatic features
  3. B2 adrenergic receptor agonists –> smooth muscle relaxation (bronchodilation)
  4. Common side-effects:
    • tachycardia
    • palpatations
    • anxiety
    • tremor
    • hyperglycaemia
    • Drives K+ into cells –> hypokalaemia
    • !! take care if patient has cardiovascular disease!!
18
Q

LAMAs:

  1. Give 2 examples.
  2. When are they used in COPD?
  3. MoA?
  4. Common side effects / counselling points
A

LAMAs:

  1. Tiotropium (Spireva), glycopyrronium (Seebri Neohaler)
    • Tiotropium bromide is more effective than salmeterol (LABA) in preventing exacerbations for pts with moderate-to-very severe COPD
  2. 2nd-line in COPD with no asthmatic features (in conjunction with a LABA)
  3. SAMAs are muscarinic ACh receptor antagonists –> pushes autonomic NS towards sympathetic activity by blocking parasympathetic:
    • increase HR
    • relax smooth muscle
    • reduce GI secretions
    • pupil dilation in eye
  4. When inhaled there are fewer systemic effects:
    • but dry mouth is common (patient can use water/ sugar-free gum)
    • caution patients at risk of angle-closure glaucoma (SAMAs can cause pupil dilation which can precipitate this)
19
Q

Inhaled Corticosteroids (ICS):

  1. Give 3 examples.
  2. When are ICS used in COPD?
  3. How are they prescribed?
  4. Common side effects / counselling points
  5. How is use of ICS in COPD different to asthma?
A
  1. Beclomethasone, fluticasone, budesonide
  2. 2rd-line - only in pts with asthma-like symptoms or features suggesting steroid responsiveness (alongside a LABA)
  3. Can be prescribed seperately or as part of a combination inhaler with a LABA e.g. Symbicort (salmeterol + fluticasone)
  4. Fewer systemic effects of corticosteroid when inhaled - but some SEs include:
    • oral thrush
    • headache
    • cough
    • sore throat or mouth
    • hoarse voice
    • pneumonia (in pts with COPD)
    • Rare: adrenal suppression, sleep disorder
    • Advise: rinse mouth / gargle to reduce risk of thrush
  5. Unlike in asthma:
    • ICS do not prevent disease progression in COPD
    • Airway inflammation in COPD is often poorly responsive to steroids
20
Q

How do xanthines work?

Name some examples of Xanthines.

A

Xanthines inhibit phosphodiesterase (PDE) –> which increases intracellular cAMP levels, causing bronchodilation

  • Theophylline
  • Aminophylline

NICE only recommends theophylline in COPD after trials of short & long-acting bronchodilators or to people who cannot used inhaled therapy

Oral theophylline dose should be reduced if pt is co-prescribed macrolide or fluoroquinolone Abx

21
Q

What are the potential side effects of long term ICS use?

A
  1. Oral thrush (candidiasis)
  2. Headache
  3. Cough
  4. Sore throat or mouth
  5. Hoarse voice
  6. Pneumonia (in pts with COPD)
  7. Rare: adrenal suppression, sleep disorder
22
Q

What should you keep a COPD patient’s O2 sats between and why?

A

SpO2 88-92%

  • COPD patients retain lots of CO2
  • Thus they rely on their hypoxic drive to maintain their respiratory effort –> Don’t take that away!
23
Q

Outline the steps of drug management of COPD.

24
Q

In patients with COPD or suspected COPD what condition is important to exclude?

A

Secondary polycythaemia

  • Polycythaemia = increased haematocrit (volume percentage of RBCs in blood)
  • Normal haematocrit ranges:
    • Adult male = 0.40 - 0.52
    • Adult female = 0.37 - 0.45
  • Hypoxia associated disease e.g. COPD, can stimulate increase in erythropoietin –> stims erythropoiesis –> increased no. of RBCs
25
What 'general' management can be offered for COPD (besides pharmacological interventions) ?
1. **Smoking cessation** - refer to cessation clinic * nicotine replacement therapy (NRT) * varenicline or bupropion (offer only in combination with commitement to stop before specific date i.e. target stop date) 2. **Annual influenza** vaccination 3. **One-off pneumococcal** vaccination 4. **Pulmonary rehabilitation** - refer if pt views themselves as functionally disabled by COPD or have had recent hospitalization for acute exacerbation 5. **Consider LTO2** (long term oxygen therapy)
26
**Varenicline** * MoA? * What is it's prescription schedule? * Side effects?
Varenicline = **nicotinic ACh receptor partial agonist** * **Schedule**: * Start 1-week before pts target stop date * Prescribe for 12-weeks (monitor pt regularly + only continue if not smoking) * **Side-effects:** * **nausea** (common) * headache * insomnia * abnormal dreams * DON'T use in pregnancy OR breastfeeding
27
**Bupropion** * MoA? * What is it's prescription schedule? * Side effects?
**Bupropion** = noradrenaline & dopamine reuptake inhibitor and nicotinic antagonist * **Schedule**: * Start 1-2 weeks before pts target stop date * **Side-effects:** * **small risk of seizures** (1 in 1000) * DO NOT use in: epilepsy, pregnancy or breastfeeding
28
Presence of what features in COPD might suggest has asthmatic / steroid responsive features?
1. Previous, secure **diagnosis** of **asthma** or **atopy** 2. **Raised blood eosinophil count** - FBC is recommend for all COPD pts 3. Significant **variation in FEV1** **over time** (at least 400 ml) 4. Significant **diurnal variation** in **peak expiratory flow** (PEFR variation at least **20%**)
29
What medication is recommended for management of peripheral oedema caused by Cor Pulmonale?
**Loop Diuretic** e. g. **Bumetanide** or **Furosemide** * Do not use ACE-inhibitors, Ca2+ channel blockers or alpha blockers
30
What bacteria most commonly cause exacerbation of COPD?
1. **Haemophilus influenzae** (most common cause) 2. Streptococcus pneumoniae 3. Moraxella catarrhalis
31
What % of COPD exacerbations are caused by viruses? What is the most common virus causing COPD exacerbations?
**~ 30%** **Rhinovirus** = most common
32
How are acute exacerbations of COPD managed?
1. **Increase frequency of bronchodilator** therapy (short-acting) or consider **nebulised** bronchodilators e.g. salbutamol 2. **Prednisolone 30mg daily for 7-14 days** 3. **Oxygen** - check ABGs for CO2 retention 4. **Antibiotics** (common practice but not NICE recommended) * Oral **amoxicillin**, **clarithromycin** or **doxycycline**
33
Non-invasive ventilation (NIV): 1. What are the indications for NIV? 2. What are the contraindications? 3. Who should start NIV?
Non-invasive ventilation - key indications: * COPD with **respiratory acidosis** pH 7.25 - 7.35 * **Type II respiratory failure** - secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea * **Cardiogenic pulmonary oedema** unresponsive to CPAP * **Weaning** from **tracheal intubation** * RR \>25 Contraindications: * **Confusion** * **pH \< 7.25** * Agitation / lack of co-operation * **GCS \< 8** * risk of **gastric aspiration** * **facial trauma** * untreated **pneumothorax** ST2 + should commence a pt on NIV
34
What are the clinical features of **hypercapnia**?
* Dilated pupils * Bounding pulse * Hand flap (CO2 retention) * Myoclonus * Confusion * Drowsiness * Coma
35
When should you assess a pt for long term oxygen therapy? When should LTOT not be offered?
Assess patients for LTOT if any of the following: * **very severe airflow obstruction** (FEV1 \< 30% predicted) * assessment should be '**considered**' for patients with severe airflow obstruction (FEV1 30-49% predicted) * **cyanosis** * **polycythaemia** * **peripheral oedema** * **raised JVP** * SpO2 **≤ 92%** on room air Do not offer LTOT: * DON'T offer LTOT to pts continuing to smoke (despite smoking cessation advice & treatment & referral to smoking cessation clinic)
36
What are the **complications** of COPD?
**Complications of COPD:** * **Acute exacerbation** ± infection * **Secondary Polycythemia** (↑ hematocrit – % volume of RBCs in blood) * **Respiratory failure** (T1/T2) * **Cor pulmonale** (oedema + ↑ JVP) * **Pneumothorax** (rupture bullae) * **Lung carcinoma**
37
When should you give long term O2 therapy?
**Long-term Oxygen Therapy (LTOT) given IF:** * Pts SpO2 **\< 7.3 kPa** **OR** * SpO2 **7.3 - 8.0 kPa** and **1 of the following**: 1. secondary polycythaemia 2. peripheral oedema 3. pulmonary hypertension Assessment for LTOT = **ABG** on **2 occasions** at least **3-weeks apart** in pts with **stable COPD** on optimal management
38
What do the flow volume loops look like for: * normal * obstructive lung disease * restrictive lung disease
39
When should you consider a diagnosis of COPD?
Suspect COPD in: * Pts **\> 35-yrs** with a **risk factor** (smoking, occupational or environmental exposure e.g. coal dust, grains, silica) **AND 1 of the following**: * **SoB** - persistent, progressive, worse on exertion * **Chronic** / recurrent **cough** * Regular **sputum production** * **Frequent LRTIs** * **Wheeze**
40
Cor pulmonale is **right-sided HF** **secondary to lung disease** - caused by pulmonary HTN as a result of hypoxia What features might make you suspect Cor pulmonale?
1. Peripheral oedema 2. Raised JVP 3. Systolic parasternal heave 4. A loud pulmonary S2 (over the 2nd left intercostal space) 5. Hepatomegaly
41
What other differentials might you consider in a suspected COPD case?
* Asthma * Bronchiectasis * HF * Lung cancer * ILD e.g. asbestosis, pneumoconiosis, fibrosing alveolitis, or sarcoidosis * Anaemia * TB * Cystic Fibrosis * Upper airway obstruction
42
For an acute exacerbation of COPD, under what conditions should you consider hospital admission?
Consider hospital admission for acute exacerbation of COPD if pt has ANY of the following: * Severe breathlessness * Rapid onset of symptoms * Acute confusion or impaired conciousness * Cyanosis * Worsening peripheral oedema * New arrhythmia * Changes on CXR * Inability to cope at home or lives alone * Reduction in ADL or confined to bed * Is on LTOT * Significant comorbidity * SpO2 \< 90% on pulse oximetry Consider (where available) hospital-at-home schemes as alternative to admission

Year 4 - GP (18 decks)

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