W2 - COPD Features and Management Flashcards by F D

Name the 6 symptoms of COPD

Weight loss
Wheeze
Chronic dyspnoea
Cough
Sputum
Chest tightness

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COPD is a combination of which 2 conditions, and what are they physiologically?

Chronic bronchitis - inflammation of bronchi

Emphysema - destruction of alveoli leading to loss of elasticity

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How many people in the UK have COPD? How many in the world?

1.2m in UK (more in Scotland than England)

80m worldwide have moderate to severe COPD

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Name 3 modifiable aetiological factors of COPD

Smoking

Lower income country (due to biomass fuel cooking and heating)

Air pollution

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Name 8 non- modifiable aetiological factors of COPD

Female
Increase in age
Lower socioeconomic status
Asthma/airway hyper-reactivity
Chronic bronchitis
Childhood infection
Smaller lungs
Alpha-1 antitrypsin deficiency

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What is AAT?

Alpha-1 antitrypsin is a protease inhibitor made in the liver

Toxins from inhaled cigarettes/infection are engulphed by neutrophils which release elastase. Normally, AAT mops up elastase

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What 3 signs may indicate alpha-1 antitrypsin deficiency?

Someone young with COPD features

Basal predominance to emphysema

Association with liver fibrosis or cirrhosis

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What % of smokers develop COPD? Which graph shows lung function vs age in smokers, stoppers and non-smokers?

Around 50% of smokers develop COPD

The Fletcher-Peto Curve

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Name 3 uncommon symptoms of COPD

Weight loss
Fatigue
Swollen ankles

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Name 9 signs of COPD

Cyanosis
Raised jugular venous pressure
Cachexia
Wheeze
Pursed lip breathing
Chest wall deformities
Hyperinflated chest
Use of accessory muscles
Peripheral oedema

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What’s the clinical diagnosis for chronic bronchitis, “stereotype” and 6 symptoms?

Chronic bronchitis - daily productive cough for 3+ months, in at least 2 consecutive years

“Blue bloater”

Overweight
Cyanotic
Elevated haemoglobin
Peripheral oedema
Rhonchi
Wheezing

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What’s the pathological diagnosis for emphysema, “stereotype” and 6 symptoms?

Permanent enlargement and destruction of airspaces distal to terminal bronchiole

“Pink puffer”

Older
Thin
Severe dyspnea
Quiet chest
Xray shows hyperinflation with flattened diaphragm

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What are the 5 clinical criteria to diagnose COPD

Typical symptoms
35+
Presence of risk factors
Absence of clinical features of asthma
Airflow obstruction confirmed by post-bronchodilator spirometry

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What are the 4 (and a bit!) stages of COPD, including FEV1 compared to predicted values?

Stage 1 - Mild - 80%
Stage 2 - Moderate - 50-79%
Stage 3 - Severe - 30-49%
Stage 4 - Very Severe - less than 30%

End stage COPD - not part of classification but often used in practice

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What score do we use to classify COPD?

GOLD score

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What 5 signs on a chest xray indicate COPD

Vascular hila
Hyperinflation
Bulla (reduced lung markings)
Small heart
Flattened diaphragm

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How many ribs can we count in an xray showing hyperinflation?

6+ anterior ribs
10+ posterior ribs

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What 6 things can we ask in a clinical history of COPD?

Tell me about your cough
What about breathlessness
Did you/anyone in your family have allergies, hay-fever or eczema
Did you have any childhood chest problems
Exposure history

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Name 6 pathophysiological causes of COPD

Thickening, irritation and inflammation of bronchi and bronchioles

Hypersecretion

Mucociliary dysfunction

Airflow obstruction caused by narrowing bronchi

Decrease in lung elastic recoil due to destruction of lung parenchyma causing loss of alveolar attachment

Increased physiological dead space

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Describe ventilation and perfusion in COPD and what causes it

Matched - mucus reduces ventilation, emphysema destroys alveoli, reducing perfusion

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Describe 7 severe COPD and complications

Hypercapnea can lead to drowsiness, flapping tremor and ventilatory failure (after becoming acidotic)

Hypoxic drive

Cor pulmonale

Secondary polycythaemia

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What is cor pulmonale?

Right sided heart failure due to lung disease

Alvolar hypoxia causes compensatory vasoconstriction to shunt blood to healthy alveoli. Over a long period pressure can build up in pulmonary arteries.

Smoking damages vasculature of heart. Heart muscle thickens, increasing pressure on left slide of heart, increasing jugular venous pressure and impairing left ventricle, reducing circulating blood volume.

Kidney compensation is activated (aldosterone and angiotensin system) leading to fluid retention

What is secondary polycythaemia

Response to chronic hypoxia. Body detects low O2 and produces more RBCs, increasing erythropoietin in kidneys causing increased blood viscosity, strokes, etc.

Name 6 UK anti-smoking legislation public health measures

Raising age at which tobacco can be purchased

Picture warnings on cigarette packets

Tobacco vending machines banned

Tobacco displays banned in large stores

Ban on smoking in cars carrying children

Standardised smoking packaging

If you're not sure if a patient has COPD, what 2 pulmonary function tests can you do, and what would the results be for COPD? What test can you do if still unsure?

Lung volume test - Increased residual volume - Increased total lung capacity - RV/TLC >30% Transfer factor - Reduced gas transfer - Reduced Dlco - Reduced Kco If still unsure, do HRCT of upper zone of lung

On HRCT, what 6 signs indicate COPD?

Signet ring sign Honeycombing Traction bronchiectasis Lung cysts Centrilobular emphysema Paraseptal emphysema

In primary care when managing acute COPD, what 9 symptoms can worsen?

* SOB * Wheeze * Chest tightness * Cough * Sputum * Unable to smoke * Systemic upset - eating, drinking, ADLs * Temperature (if infective) Fatigue

In primary care when managing acute COPD, what 8 signs and symptoms indicate a severe exacerbation?

* Breathless (RR>22/min) * Accessory muscle use * Purse lip breathing * Cyanosis (Sats <92% o/a) * Significant decrease in exercise tolerance * Signs of sepsis (if infective) * Fluid retention * Confusion

When managing acute COPD in secondary care, what 4 triggers should we look out for?

Bacterial/viral infection Sedative drugs Pneumothorax Trauma

When managing acute COPD in secondary care, what 8 signs and symptoms should we look out for?

Confusion Cyanosis Severe breathlessness Flapping tremor Drowsy Pyrexial Wheeze Tripod position

When managing acute COPD in secondary care, what 6 investigations can we do?

CXR Blood gases FBC U&E Sputum culture VTS

When managing acute COPD in secondary care, what 4 treatments could we consider? What 1 other thing can we do?

O2 Nebulised bronchodilator (B2 and anti-muscarinic) Oral/IV corticosteroid +/- antibiotic (IV aminophylline, respiratory stimulant, NIV) Treat any co-existing conditions

What 2 tools can we use to assess severity of COPD?

COPD Assessment Tool (CAT) mMRC Breathlessness Scale

When assessing severity of COPD, what 2 things can we look out for?

History of moderate and severe exacerbations and future risk (number per year, hospitalisation) Presence of co-morbidities (heart disease, atrial fibrillation, obesity)

The COPD Assessment Test asks about what 8 things?

Cough Mucus Chest tightness Breathless upon exertion Limitation of activity Confidence leaving home Sleep interruption Energy level

COPD Assessment Test scores indicate what?

0-9 Low 10-20 Medium 21-30 High 31-40 Very high

What are the grades for the mMRC breathlessness scale?

0 - breathless on exertion 1 - SOB when hurrying 2 - stop for breath 3 - stop for breath after every few mins 4 - too breathless to leave house

What can we treat for COPD?

Improve exercise tolerance Prevent exacerbations Nutrition/weight loss Complications Anxiety/depression Co-morbidities Dysfunctional breathing Palliative care

What 5 non-pharmacological aspects can we manage in COPD?

Pulmonary rehabilitation Smoking cessation Vaccination Nutritional assessment Psychological support

Name 4 types of classes of drugs for managing COPD

Short-acting bronchodilators Long-acting bronchodilators High dose inhaled corticosteroids (ICS) Long Term Oxygen (LTOT)

Name 2 types of short acting bronchodilators and give an example of each

SABA, e.g. salbutamol SAMA, e.g. ipratropium

Name 2 types of long acting bronchodilators and give 2 examples of each

LAMA (long-acting anti-muscarinic agent), e.g. umeclidinium, tioptropium LABA (long-acting anti-muscarinic agent), e.g. salmeterol, formoterol, olodaterol

Name 2 types of high dose inhaled corticosteroids give an example of each

Relvar, i.e. fluticasone, vlianterol Fostair MDI

Which 3 methods are the cheapest ways to treat COPD?

Flu vaccination (£1000) Stop smoking support with pharma (£2000) Pulmonary rehabilitation (£2000-£8000)

Which 3 methods are the most expensive ways to treat COPD?

Telehealth (£32,000) Triple therapy (£7000-£187,000) LABA (£8000)

What 3 categories of medicines can we give to manage COPD exacerbation?

Short acting bronchodilators Steroids Antibiotics (if evidence of infection)

In COPD exacerbation management, consider hospital admission if any of what 5 criteria are present?

Tachypnoea Low oxygen sats (<90-92) Hypotension Cyanosis Acute confusion

In ward-based management of COPD exacerbation, what 4 treatments can we offer? What complication should we look for and how can we look for it?

O2 (only if sats are 88-92% as lower suggests hypoxic drive) Nebulised bronchodilators Corticosteroids Antibiotics Look for resp failure - clinical or arterial blood gas

What 2 complications of COPD should we look for in hospital admission and what's the treatment?

Acute respiratory failure Hypoxia and CO2 retension Treat with non-invasive ventilation (NIV)

What 8 methods can we use to investigate COPD exacerbation?

* FBC * Biochem and glucose * Theophylline concentration (in patients using theophylline preparation) * Arterial blood gas (documenting amount of O2 delivered and by what delivery device) * Electrocardiograph * Chest X-ray * Blood cultures in febrile patients Sputum microscopy, culture and sensitivity

Name 4 platforms of patient education in the management of COPD

My COPD My Lungs My Life Don't Waste a Breath No Delays

In what 4 ways can patients self-manage COPD on the My COPD app?

Info regarding condition Managing symptoms Inhaler techniques When to seek medical advice

In what ways can we manage breathlessness and dysfunctional breathing in the palliation of COPD?

Pharmacological, e.g. morphile, lorazepam (anxiety) Psychological support Palliative care referral

In what 3 ways can we create an anticipatory care plan in the palliation of COPD?

Hospital admission Ceiling of treatment DNACPR