Causes of COPD
Chronic exposure to pollutants
Types of COPD
Chronic bronchitis and Emphysema
How do you define chronic bronchitis?
Cough with sputum for 3 or more months for 2 or more years
State a characteristic of parapneumonic effusion
Exudative (> 35 g/L protein)
Recurrent lung infections
Environmental tobacco smoke
Occupational dust and chemical inhalation
Describe the MRC Dyspnoea Scale
1 - Not troubled by dyspnoea unless vigorous exertion
2 - Dyspnoea when walking up incline
3 - Walks slower than other people bc of dyspnoea or stops for breath at own pace
4 - Stops for breath after 100m after few mins
5 - Too breathless to leave the house, or on dressing
Pink puffer signs/symptoms
Thin (low BMI)
Blue bloater sign/symptoms
Cough w/ phlegm
- FeNO (Fraction expired nitrous oxide)
is raised non-specific in lung damage
FEV1:FVC < 0.7 = obstruction
- Bronchodilator reversibility test
LESS than 12% increase in FEV1 = irreversible ∴ COPD, not asthma
Key presentation of COPD
Productive cough with white or clear sputum, wheeze and breathlessness
Following years of smoker’s cough!!
SABA - short-acting beta-2-agonist e.g. salbutamol, terbutaline
LABA - long-acting beta-2-agonist e.g. salmeterol, formoterol
SAMA - short-acting musarinic-antagonist e.g. ipratropium
LAMA - long-acting muscarinic-antagonist e.g. tiotropium bromide
ICS e.g. beclomethasone
- SABA + LABA + LAMA
- SABA + LABA + LAMA + ICS
When should LTOT be given?
Chronic readings of < 88% O2 sats
PaO2 < 7.3 kPa
OR PaO2 between 7.3 - 8kPA AND have at least one of following:
- 2° polycythaemia
- Peripheral oedema
- Pulmonary oedema
Describe how LTOT should be given
> 15 hrs/day
What surgery can be done for Px with COPD?
When is this most effective?
Lung volume reduction surgery
In Px with upper lobe emphysema and low exercise capacity
What treatment should you avoid in COPD Px?
Chronic treatment with systemic corticosteroids
bc the benefit to risk ratio is too low
What prophylaxis treatments are offered for COPD Px? Why?
Influenza and pneumococcal vaccines
Bc exacerbations caused by recurrent resp diseases
Stages of COPD
FEV1 % - compared to predicted value
STAGE 1 - ≥ 80% (mild)
STAGE 2 - 50 - 79% (moderate)
STAGE 3 - 30 - 49% (severe)
STAGE 4 - < 30% (v severe)
What might an XR show for a COPD patient?
*Low, flattened diaphragm
Long narrow heart shadow
↓ Peripheral lung markings
Congestive heart failure
What are the most common causes of COPD exacerbations?
Viral upper respiratory tract infections
Infections of tracheobronchial tree
Ix COPD exacerbations
Bloods - WBC count
Tx COPD exacerbations
O2 - target = 88 - 92% !!
Bronchodilators - SABA and/or SAMA
potentially Non-Invasive ventilation
When should antibiotics be given for COPD exacerbations?
3 cardinal signs :
1. ↑ Dyspnoea
2. ↑ Sputum vol
3. ↑ Sputum purulence
Why is the O2 target sat lower for COPD patients?
Bc of low respiratory drive
∴ can cause hypercapnia is O2 target sat is normal (94-98%)
What are some indication for hospital admissions in COPD patients?
Significant increase in symptom intensity
Onset of new physical signs
No response to treatment
Not sufficient home support
COPD is characterised by ?
Asthma is characterised by?
State some microscopic and macroscopic differences between asthma and COPD
Smooth muscle hypertrophy
Basement membrane thickening
Little fibrosis and alveolar disruption
Little smooth muscle hypertrophy and basement membrane thickening
Lots of fibrosis and alveolar disruption
Types of asthma
Allergic / Eosinophilic (70%)
Allergens & atophy
Non-allergic / Non-Eosinophilic (30%)
Exercise, cold air, stress, obesity
What age does asthma usually present itself?
Starts in childhood, 3-5 years
Peak prevalence is 5-15 years
Which countries have a higher prevalence of Asthma?
New Zealand, UK, Australia
Name some precipitating factors of Asthma
Drugs - NSAIDs, aspirin
Which hypersensitivity reaction is Asthma?
Pathophysiology of Asthma
Overexpression of TH2 cells in airway stimulates ↑ IgE production (∴ T1 hypersensitivity)
AND eosinophilia (∴ release of toxic proteins e.g. maltose binding protein)
∴ Leads to chronic remodelling and mucus hypersecretion
Key presentation of Asthma
Cough, Dyspnoea, tight chest
Bilateral wheeze on auscultation
Describe the differences between brittle disease type 1 and 2
TYPE 1 : severe, bad all the time
TYPE 2 : sudden dips - sometimes ok, sometimes not
Associated symptoms of Asthma!
Atopic triad : Asthma, Hayfever, Eczema
Samter’s tried : Asthma, Aspirin allergy, Nasal Polyps
Same as COPD
Multiple peak flow measurement required!!
How are mast cells involved in asthma?
When IgE binds to mast cell receptor, mast cell responds to allergen binding to IgE
∴ releases chemicals
What chemicals do mast cells release when allergens bind to IgE (which in turn is bound to mast cells?)
Cytokines - TNF-a, IL3, IL4, IL5
Describe the microscopy of the mucus of an Asthma patient
Describe the stages of an Asthma attack
Mild / moderate -
*PEFR > 50%
RR < 25
Pulse < 110
RR >/= 25
Pulse >/= 110
Inability to complete sentences
*PEFR < 33%
SaO2 < 92% or PaO2 < 8kPa
Normal PaCO2 (4.6-6 kPa)
Altered conscious levels, exhaustion, arrhythmias, hypotension, silent chest!!, cyanosis, poor effort
↑ PaCO2 and/or req ventilation with raised airway pressures
- SABA + ICS
————————— check their technique!!
- SABA + ICS + LTRA
- SABA + ICS + LABA +/- LTRA
- ↑ ICS dose
- Maybe another drug e.g. omalizumab anti-IgE antibody
Tx for acute asthma attack
O SHIT ME
Draw the graph of different types of lung cancer
What questions do you ask to take the history of a Px you suspect has asthma?
*RCP 3 Qs -
1. Recent nocturnal waking?
2. Asthma symptoms in day?
3. Interference w/ day to day activities?
Where are the majority of TB cases?
Africa and Asia (India, China)
What’s the cause of death for most people with HIV?
Name the 4 main causes of TB
Describe the mycobacteral species that cause TB
Aerobic, non-motile, non-sporing slightly curved rods/bacilli
Thick waxy capsule
Acid fast bacilli go red/pink with Ziehl-Neelsen
How is cystic fibrosis inherited?
Cause of Cystic fibrosis
Mutation of chromosome 7 - codes for CFTR protein
RF Cystic fibrosis
Presentation of Cystic fibrosis
Resp - recurrent infections, bronchiectasis
Neonates - jaundice, failure to thrive, meconium ileus
GI - Bowel obstruction, steatorrhoea
Other - male infertility, DM
Other than respiratory problems, what other systemic problem do Px with cystic fibrosis have?
What is a common ECG finding for pulmonary embolism?
Why does PE cause tachycardia?
Body attempts to increase cardiac output to compensate for hypoxia
Key presentation of cystic fibrosis
Thick mucus production
Pancreatic insufficiency - poor weight gain, steatorrhoea
Other signs/symptoms of cystic fibrosis
Neonates - meconium ileus
Male infertility - absent vas deferens and epidiymis
Increased freq of gallstones
Ix Cystic fibrosis
Lung function test
Faecal elastase test
GS : Sweat test - Na+ and Cl- > 60 mmol/L
Screening test of Cystic fibrosis
Genetic newborn screen - used in countries w ↑ prevalence or CF family history
Measures immunoreactive trypsinogen (IRT), neonatal heel prick
Why does pancreatic insufficiency cause steatorrhoea?
Enzymes are not released to digest fat
∴ Fatty stools
Tx Cystic fibrosis
*Nutrition & healthy weight gain (fat soluble vitamins - DAKE, diet = high calorie, high fat)
*Regular chest physio, postural drainage
Inhalers (ICS, SABA)
What Abx is commonly used against S. Aureus?
What Abx is commonly used against H. Influenzae?
What Abx is commonly used against Psuedomonas aeruginosa?
What are good prognostic markers for CF?
Lung function (FEV1) and BMI
What Abx is commonly used against MRSA?
Rifampicin and Fucidin
When would a lung transplant for CF be used?
Px sick but not too sick i.e. FEV1 close to 30%
Px on max therapy and compliant
Complications of CF
Brief pathophysiology of CF
Normally, CFTR protein allows Cl- to be transported across epithelial into secretions.
However, if damaged this doesn’t happen.
∴ water potential ↑
∴ water doesn’t move into secretions -> becomes thicker
∴ mucus isn’t wafted up ∴ bacteria colonises lungs
What is Sarcoidosis?
Interstitial lung disease, disease of alveolar/capillary interface
Immune response occurs repeatedly without a pathogen triggering it, cause not entirely known
Epidemiology of Sarcoidosis
20 - 40 years
F > M
African-Caribbeans more affected
Prior infection with M. tuberculosis
Key presentation of Sarcoidosis
Fever, weight loss, dry cough
Lupus pernio - purple rash on cheeks and shins, seen in chronic
Bilateral hilar lymphadenopathy
Can be asymptomatic & found incidentally on CXR