Name 4 pulmonary features of COPD
- Pulmonary vascular remodelling + impaired cardiac performance
- chronic bronchitis (mucus secreting glands enlarge + increase number goblet cells + inflammatory cell infiltrate → increased sputum production
- changes in pulmonary + chest wall compliance (loss elastic tissue, inflammation, fibrosis in airway wall → premature airway closure, gas trapping, dynamic hyperinflation
- emphysema (unopposed proteases + antioxidants → destroy alveoli)
Name 5 systemic features of COPD
- muscular weakness
- increased circulating inflammatory markers
- peripheral oedema (impaired salt + water excretion)
- weight loss (altered fat metabolism)
- increase prevalence osteoporosis
Name 10 risk factors COPD
Non-modifiable
- genetic: alpha 1 antitrypsin deficiency
- airway hyper-reactivity
Modifiable
- tobacco smoke! 95% of cases
- indoor air pollution
- occupational: coal dust, silica, cadmium
- low birth weight (reduce lung function potential)
- lung growth: childhood infections, maternal smoking
- infections (faster decline in FEV1, lung damage)
- low socioeconomic status
- cannabis smoking
Differential diagnoses to COPD (4)
- Chronic asthma
- Tb
- bronchiectasis
- congestive cardiac failure
Name 2 classical phenotypes in COPD
- pink puffers (emphysema): thin, breathless, maintain normal paco2 until late stage disease
- blue bloaters (chronic bronchitis): oedema, develop hypercapnia earlier, secondary polycythaemia
In practice they overlap.
Investigations for COPD (3)
Radiography
- CXR: rule out other causes (heart failure), complications of smoking eg cancer and presence bullae
Bloods
- FBC: document polycythemiA (increased hct and/or hb= thick blood )
Spirometry: post-bronchodilator FEV1 / FvC < 70 %
GOLD Spirometric classification of COPD severity? (4)
All need to have post dilator FEV1: FVC < 0,7
- Stage 1 /mild: FEV1 80% or more than predicted
- stage 2 / moderate: 50 - 79%
- stage 3/severe: 30 - 49%
- stage 4/very severe: < 30%
Name 4 complications COPD
- polycythaemia 2’ to hypoxaemia
- chronic hypoxaemia
- pulmonary HPT from vasoconstriction
- cor pulmonale
- pneumothorax due to rupture of emphysematous bullae
Treatment Acute exacerbation of COPD? (5)
- oxygen
- Reliever to improve lung function: salbutamol (SABA) 2 puffs per hour or ipratropium (anticholinergic) 2 puffs 4 hourly
- steroids
- antibiotics if suspect infection
- if treatment failed and still symptoms: intubate
Outpatient chronic treatment for mild COPD?
Salbutamol 2 puffs as needed
Outpatient chronic treatment for moderate COPD?
- salbutamol 2 puffs as needed and
- long acting bronchodilator: salmeterol (LABA)
Outpatient chronic treatment for severe COPD?
- salbutamol 2 puffs as needed
- LABA salmeterol
- inhaled glucocorticoid : beclate
Outpatient chronic treatment for very severe COPD? (6)
- salbutamol
- salmeterol
- inhaled glucocorticoid eg fluticasone, beclomethasone
- long term oxygen therapy
- add theophylline if frequent symptoms
- if still symptoms despite max therapy: add oral steroids
GOLD ABE assessment to tool for COPD?
ABE
A:
- exacerbation history per year 0-1 moderate exacerbations not leading to hospitalisation
- mMRC 0-1 (dyspnoea scale)
- cat assessment < 10 (questionnaire about symptoms)
B
- exacerbation history as for A
- mMRC 2 or more
- cat 10 or more
E
- in 1 year: 2 or more moderate exacerbations or 1 or more leading to hospitalisation
Signs copd (10)
- Vitals: tachypnoeA
- General : cachexia
- Head: pursed lip breathing
- neck: cricosternal distance < 3 cm, tracheal tug
- chest inspection: barrel chest, prolonged expiration, use accessory muscles of respiration, decreased expansion, Hoover sign
- chest palpation: hyperinflation
- percussion: resonant
- auscultation: quiet breath sounds over bullae, wheeze
Name 5 criteria for copd admission to ICU
- Severe dyspnoea that doesn’t respond to initial emergency therapy
- change in metal status
- persistent / worsening hypoxemia pa02 < 40 and/or respiratory acidosis ph < 7,25 andor hypercapnia > 60 despite supplemental oxygen therapy and noninvasive ventilation
- need for intubation and mechanical ventilation
- haemodynamic instability and need for vasopressors
Name 6 criteria for copd admission to hospital / high care
- Marked increase in symptoms
- severe underlying COPD
- failure initial management as outpatient/ed
- significant comorbidities
- old age
- Insufficient home support
COPD prognoses score?
BODE index for 4 year survival.
Uses fev1, 6 minute walk distance, dyspnoea, BMI
What is used for COPD prognosis
BODE index
- BMI
- obstruction: degree of airflow obstruction
- dyspnoea
- exercise capacity
