Definition of COPD
Irreversible obstruction of the airways
Name the 2 types of COPD
Chronic Bronchitis – bronchi walls become inflamed and fibrosed, which can lead to luminal plugs (complete occlusion of airways). This increased airway resistance and limits airflow. Also causes mucus hypersecretion
Emphysema – loss of alveolar attachments, so their surface area and elastic recoil is decreased which limits airflow.
Risk Factors of COPD - 4
- tobacco smoking
- occupational dust exposure
- Alpha-1 antitrypsin deficiency (bcos it normalled inhibits excessive acitivity of neutrophil elastase)
- Advancing age makes prognosis worse
Symptoms of COPD - 3
3 characteristic symptoms are:
1. chronic cough
2. dyspnoea
3. sputum production with cough
Signs of COPD - 7
- Accessory muscle use
- purse lip breathing
- barrel chest
- prolonged expiration
- wheeze
- hyper-resonant percussion
- reduced chest expansion
- Cyanosis
Investigations of COPD and give positive results - 7
- FBC - will have polycythaemia due to chronic hypoxia
- ABG - reduced paO2 and raised paCO2
- ECG - may show RV hypertrophy
- CXR - shows hyperinflated chest (can see more than 6 ribs), bullae, decreased lung markings
- Spirometry - obstructive lung disease signs (FEV1:FVC less than 0.7)
- Sputum culture - identifys exacerbating organisms
- BNP - to asses HF
What are main complications of COPD - 5
- reduced quality of life - leads to depression and anxiety
- Cor pulmonale - right sided HF as a consequence of chronic hypoxia
- chest infections
- Pneumothorax
- resp failure
Differentials of COPD - 4
Asthma
Bronchiectasis
Heart Failure
Pulmonary Fibrosis
Non pharmacological management of COPD - 3
- smoking cessation
- flu and pneumococcal vaccinations
- pulmonary rehabilition
Pharmacological Management of COPD - 4 step programme
1) SABA or SAMA (these are always continued as pt goes up steps
2) LABA and LAMA if persistent exacerbations but no asthmatic features. LABA and ICS if persistent exacerbations and asthmatic features
3) LABA, LAMA and ICS (3 month trial) if pt is still getting symptoms that affect daily life, or having 1 or 2 severe exacerbations in a year
4) If still symptomatic, consider specialist referral
Other adjuncts used may be oral theophylline, mucolytic agents and antidepressants
Name examples of SABA, SAMA, LABA, LAMA and ICS
SABA - salbutamol
SAMA - Ipratropium
LABA - salmeterol and formoterol
LAMA - titotropium
ICS - beclometasone
What advice should be given about inhaled corticosteroids?
Should only be used in acute exacerbations, not for maintenance
Indications for COPD surgery - 4
Pts who remain breathless despite maximal medical therapy should be considered if they have:
- upper lobe emphysema
- FEV1 is over 20% predicted
- paCO2 less than 7.3
- TLCO (carbon monoxide test) over 20% predicted
Management of an acute COPD exacerbation
- Ensure patent airway and sats of over 88%
- Nebulisers - salbutamol and ipratropium
- Steroids - oral predisolone or IV hydrocortisone
- Antibiotics if signs of infection
features of a COPD exacerbation - 3
severe cough for more than 2 days
discoloured and purulent sputum
systemic features - fever, sob
Explain what pulmonary rehabilitation is
programme of care including moderate supervised exercise and eduction
What is asthma-COPD overlap syndrome
When pts with COPD also have some reversible airway features or steroid responsiveness.
Causes of asthma-COPD Overlap syndrome - 3
- A person has ‘confirmed’ asthma (i.e. has been investigated as recommended in topic 3) but
continues to smoke (or is exposed to occupational risk factors) - A person has other atopic conditions and develops COPD
- A person with COPD is noted to have a raised eosinophil count.
When should pts be referred for Long Term Oxygen Therapy - 6
Oxygen saturations of 92% or less breathing air
Very severe (forced expiratory volume in 1 second [FEV1] less than 30% predicted) or severe (FEV1 30–49% predicted) airflow obstruction.
Cyanosis.
Polycythaemia.
Peripheral oedema.
Raised jugular venous pressure.
