1
Q
What does COPD stand for?
A
Chronic obstructive pulmonary disease
2
Q
What is the number 1 cause of COPD?
A
Smoking
(Occupational exposure aswell)
3
Q
What type of disease is COPD?
A
Obstructive
4
Q
How is COPD characterised?
A
a lung disease characterised by persistent respiratory symptoms and airflow obstruction
5
Q
What 3 diseases is COPD a triad of?
A
- Emphysema
- Chronic bronchitis
- Small airway fibrosis
6
Q
What is the prevalence of COPD in the UK?
A
3 million
7
Q
What is the mortality rate of COPD in the UK?
A
30,000 per year
8
Q
What percent of COPD patients are associated with tobacco smoking?
A
80%
9
Q
What is a genetic cause of COPD?
A
Alpha-1 antitrypsin deficiency
10
Q
What is an Alpha-1 antitrypsin deficiency?
A
- an autosomal dominant condition which presents in younger patients (aged 20-40).
- Alpha-1 antitrypsin is a protease inhibitor with one of its actions being to prevent neutrophil elastase from breaking down alveolar structures.
- Therefore, a deficiency in alpha-1 antitrypsin leads to the increased destruction of alveolar structures, resulting in early-onset emphysema
- Some cases of alpha-1 antitrypsin deficiency involve impaired secretion of alpha-1 antitrypsin by the liver, resulting in accumulation of it in the liver, and therefore cirrhosis.
11
Q
How does a patient typically present with COPD?
A
COPD patients present with progressive dyspnoea and chronic productive cough.
12
Q
What is dyspnoea?
A
Shortness of breath
13
Q
How does dyspnoea typically present in COPD patients?
A
Initially exertional, but can progress to resting dyspnoea over the course of the condition.
14
Q
What does COPD patients’ sputum usually look like?
A
usually colourless sputum, which may become green during lower respiratory tract infections (LRTIs)
15
Q
What other symptoms do COPD patients usually present with?
A
- Recurrent LRTIs
- Fatigue
- Headaches (due to CO2 retention)
- Weight loss
- Oedema
16
Q
What scale is used to assess dyspnoea?
A
MRC Dyspnoea Scale
17
Q
How many grades are there on the dyspnoea scale?
A
5
18
Q
What are the 5 grades of dyspnoea characterised by?
A
Grade 1 - Breathless during strenuous exercise only
Grade 2 - Breathless when hurrying or walking up a slight incline
Grade 3 - Walks slower than people of the same age due to dyspnoea, or needs to pause for breath when walking at own pace
Grade 4 - Pauses for breath after walking 100m/a few minutes on the level
Grade 5 - Too breathless to leave the house, or breathless when dressing
19
Q
What are 4 common things seen on a patient with COPD’s past medical history?
A
- Previous exacerbations or hospitalisations
- Medical comorbidities, including lung disease (such as asthma)
- Psychiatric comorbidities, including depression and anxiety
- Previous operations
20
Q
What are most COPD exacerbation due to?
A
Infection (Chest infection/ pneumonia)
21
Q
What is the physiopathology of COPD?
A
The airways are lined by muscle and elastic tissue. In a healthy lung, the springy tissue between the
airways acts as packing and pulls on the airways to keep them open. With COPD, the airways are narrowed
because:
* the lung tissue is damaged so there is less pull on the airways
* mucus blocks part of the airway
* the airway lining becomes inflamed and swollen
22
Q
What is the difference between COPD and asthma?
A
With COPD, your airways have become narrowed permanently – inhaled medication can
help to open them up to some extent. With asthma, the narrowing of your airways comes
and goes, often when you’re exposed to a trigger – something that irritates your airways
– such as dust, pollen or tobacco smoke. Inhaled medication can open your airways fully,
prevent symptoms and relieve symptoms by relaxing your airways
23
Q
Upon physical examination, what are the 3 most common findings?
A
- Tachypnoea: due to an increased neural respiratory drive to breathe
- Wheeze on auscultation: due to inflammatory airway oedema and mucous obstructing the airway
- Pursed lips breathing: to increase airway resistance and therefore reduce expiratory flow limitation
24
Q
What are the less common findings of COPD on examinations?
A
- Barrel Chest
- Peripheral Cyanosis
- Cor Pulmonale, due to pulmonary hypertension, which results from chronic hypoxic pulmonary vasoconstriction
- Co2 retention flap
25
What features of asthma differentiate from COPD?
1. Diurnal variation in symptoms and peak flow
2. History of atopy
3. Eosinophilia (blood and sputum)
4. Lung function tests: bronchodilator reversibility
26
What features of bronchiectasis differentiate from COPD?
1. Expectorate larger volumes of sputum
2. More frequent lower respiratory tract infections, often starting in childhood
3. High-resolution chest CT: bronchial dilation
27
What features of congestive cardiac failure differentiate from COPD?
Orthopnoea
Paroxysmal nocturnal dyspnoea
History of cardiovascular disease
Fine basal inspiratory crepitations
Bloods: elevated BNP
Echocardiogram: reduced ejection fraction
28
What features of lung cancer differentiate from COPD?
Weight loss
Haemoptysis
Chest X-ray and bronchoscopy: the presence of tumour
29
What features of tuberculosis differentiate from COPD?
Drenching night sweats
Weight loss
Positive sputum culture and microscopy
30
What bedside investigations are used to diagnose COPD?
1. Spirometry
2. Pulse oximetry
3. Sputum sample
4. ECG
31
What is typical finding of a COPD patient's spirometry?
Typical finding in COPD: FEV1/FVC < 70%
FEV1 is also used to classify the severity of COPD
32
What would an oxygen saturation of a COPD patient look like?
Aim for SpO2 of 88-92%
33
Why should you avoid administering O2 to COPD patients?
O2 displaces CO2 in haemoglobin, which increases CO2 in the blood
Increased CO2 in the blood cannot be removed due to failure of alveolar ventilation in emphysema, leading to hypercapnic respiratory failure
34
What may be found in a ECG of a patient with COPD?
cor pulmonale (peaked p waves and right axis deviation)
35
Why is a sputum sample of a COPD patient so beneficial?
enables targeted antibiotic therapy during exacerbations of COPD
36
During stable COPD what is usually found on an ABG?
PaCO2 >6.0 and bicarbonate >30 indicates that the patient is a “CO2-retainer”
37
During exacerbations of COPD what is usually found on an ABG?
check for respiratory acidosis (PaCO2 >6.0 and pH <7.35)
38
What would typically found on a chest X-ray of a patient with COPD?
1. hyperinflation
2. >6 anterior ribs or >10 posterior ribs visible in the mid-clavicular line
3. Flattened diaphragm
4. Hyperlucent lungs
39
What is involved in conservative management of stable COPD?
Smoking cessation
Pulmonary rehabilitation
Annual influenza vaccine and one-off pneumococcal vaccine
Personalised self-management plan
40
What is first line medical treatment of COPD?
the first-line
therapy is a long-acting beta-2 agonist and long-acting muscarinic antagonist (LABA/LAMA) combination
Note that if a LAMA is introduced, a short-acting muscarinic antagonist (SAMA) should be discontinued,
whereas a short-acting beta-2 agonist (SABA) may be continued with all other combinations of inhalers.
41
What can be offered to patients with COPD if they have asthmatic features or evidence of steroid responsiveness?
they should be offered an
ICS/LABA combination inhaler
42
When should patients be offered triple therapy (ICA/LABA/LAMA)?
Triple therapy (ICS/LABA/LAMA) should be considered for any patient that continues to experience day-today symptoms or if they have one severe (hospitalisation) or two moderate exacerbations in the space of
12 months. Before escalating to triple therapy, a clinical review should be conducted
43
When can long term oxygen therapy be introduced?
Indications (one of the following):
SpO2 <88%
PaO2 <7.3kPa
44
Why will long-term oxygen therapy not be offered to current smokers?
Contraindicated in current smokers due to the risk of explosion and/or burn
45
What surgical management can be offered to COPD patients?
Lung volume-reduction surgery: for very severe COPD, which does not respond to optimal medical management
Lung transplantation: if not suitable for other surgical options
46
What are some complications of COPD?
1. Hypercapnic respiratory failure (PaO2 < 8.0 and PaCO2 > 6.0)
2.Secondary polycythaemia (raised haemoglobin): due to chronic hypoxaemia
3. Cor pulmonale: right heart failure, caused by pulmonary hypertension as a result of chronic hypoxic pulmonary vasoconstriction
4. Bronchiectasis: due to chronic and repeated infections
5. Anxiety and depression
6. Osteoporosis: due to chronic steroid use, smoking, lack of bone-strength exercise and vitamin D deficiency
7. Sleep disturbance
47
What is an Exacerbation of COPD?
An exacerbation of COPD is defined as a sustained deterioration in a patient’s respiratory symptoms beyond their normal day-to-day variability. This worsening of respiratory symptoms occurs acutely and normally requires additional medical therapy.
48
What can trigger an exacerbation of COPD?
1. Respiratory Tract infection
- Streptococcus pneumoniae and Haemophilus influenzae are the most common bacterial culprits. Viral causes include rhinoviruses, influenza and respiratory syncytial virus (RSV)
2. Pollutants can also trigger an exacerbation.
49
What symptoms could indicate acute exacerbation of COPD?
Worsening breathlessness
Productive cough: the patient may have noticed a change in the volume, consistency or colour of their sputum.
Malaise
Fatigue/lethargy
Increased wheeze: due to obstruction of alveoli and bronchi.
Coryzal symptoms
Haemoptysis
Chest tightness or pain
Peripheral oedema
50
What clinical signs may be seen in acute exacerbation of COPD?
Tachycardia
Tachypnoea
Hypoxia
Cyanosis
Reduced level of consciousness
51
ABCDE Approach : A
Can the patient talk?
Yes: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.
No:
Look for signs of airway compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
Open the mouth and inspect: look for anything obstructing the airway such as secretions or a foreign object.
52
What may compromise the airway in a patient with acute COPD?
Inhaled foreign body: symptoms may include sudden onset shortness of breath and stridor.
Blood in the airway: causes include epistaxis, haematemesis and trauma.
Vomit/secretions in the airway: causes include alcohol intoxication, head trauma and dysphagia.
Soft tissue swelling: causes include anaphylaxis and infection (e.g. quinsy, necrotising fasciitis).
Local mass effect: causes include tumours and lymphadenopathy (e.g. lymphoma).
Laryngospasm: causes include asthma, gastro-oesophageal reflux disease (GORD) and intubation.
Depressed level of consciousness: causes include opioid overdose, head injury and stroke.
53
What interventions can be used for a compromised airway?
1. Head-tilt chin-lift manoeuvre
2. Jaw thrust
3.Oropharyngeal airway
4. Nasopharyngeal airway
5. CPR
54
ABCDE approach: Breathing - What observations should be made?
Review the patient’s respiratory rate:
A normal respiratory rate is between 12-20 breaths per minute.
Tachypnoea is a common feature of COPD exacerbations and indicates significant respiratory compromise.
Bradypnoea in the context of hypoxia is a sign of impending respiratory failure and the need for urgent critical care review
Review the patient’s oxygen saturation (SpO2):
A normal SpO2 range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk of CO2 retention.
Hypoxaemia is a typical clinical feature of COPD.
55
ABCDE approach: Breathing - What inspections should be made?
1. Cyanosis
2. Shortness of breath: signs may include nasal flaring, pursed lips, use of accessory muscles, intercostal muscle recession and the tripod position.
3. Cough
4. Wheeze
56
ABCDE approach: Breathing - What should be checked during palpation?
Assess the position of the patient’s trachea to identify deviation which may indicate underlying tension pneumothorax.
Locate the apex beat, which is typically located in the 5th intercostal space in the midclavicular line. A large pleural effusion, tension pneumothorax or right ventricular hypertrophy can cause a displaced apex beat.
Assess chest expansion, which may be reduced in the context of consolidation and pleural effusion.
57
ABCDE approach: Breathing - What may be heard during auscultation?
Auscultate both lungs:
Bronchial breath sounds and/or coarse crackles are associated with consolidation.
Wheeze is a common finding in COPD patients and typically worsens during exacerbations.
58
ABCDE approach: Breathing - What may be found via percussion?
Percuss the patient’s chest to identify areas of dullness which may be associated with consolidation, lobar collapse or pleural effusion.
59
ABCDE approach: Breathing - What investigations should be used?
ABG ( PcO2, pH, PaCO2, HCO3, Lactate)
Chest X-ray - - useful in ruling out other diagnosis
Sputum culture
60
What should a patient's PaO2 be?
A normal PaO2 on room air should be greater than 10 kPa (75 – 100 mmHg).
If the patient is receiving supplemental oxygen then the PaO2 should be roughly 10 kPa less than the inspired oxygen concentration (FiO2).
61
What does pH and PaCO2 indicate?
CO2 binds with H2O in the blood and forms carbonic acid. As a result, if a patient is retaining CO2, pH decreases.
A low pH with a raised PaCO2 indicates the patient is failing to ventilate effectively and may require non-invasive ventilation.
62
What can HCO3 readings tell us?
Some patients with severe COPD will have chronically raised CO2 which can make ABG interpretation more complicated when they are acutely unwell, as it can be difficult to establish whether their raised CO2 is acute, chronic or acute on chronic in nature.
In the setting of chronic hypercapnia, the bicarbonate (HCO3-) rises to ‘mop up’ the acidic effect of carbonic acid and normalise the pH.
As metabolic compensation takes several days to occur (because it requires the kidneys to alter their production of HCO3-), a raised HCO3- in the acute context suggests that the patient has some degree of chronic hypercapnia with metabolic compensation.
63
What does lactate readings tell us?
A raised lactate indicates anaerobic metabolism secondary to reduced end-organ perfusion.
Sepsis is a common cause of a raised lactate.
64
ABCDE approach: Breathing - What interventions should be used?
1. Oxygen
2. Salbutamol
3. Ipratropium bromide
4. Steroids
65
Why/when should oxygen be used as an intervention?
Administer oxygen to all critically unwell patients during your initial assessment. If the patient has COPD and a history of CO2 retention you should use a venturi mask and titrate oxygen appropriately.
If the patient is conscious, sit them upright as this can also help with oxygenation.
66
Why/when should salbutamol be used as an intervention?
A high-dose inhaled beta-2 agonist (i.e. salbutamol) should be administered as a first-line treatment in the management of an acute exacerbation of COPD
If the patient is hypercapnic or acidotic, the nebuliser should be driven by compressed air rather than oxygen (to avoid worsening hypercapnia).
If the patient is also hypoxic, then oxygen therapy can be administered simultaneously via a nasal cannulae underneath the nebuliser.
Repeat doses of salbutamol at 15-30 minute intervals or give continuous nebulised salbutamol at 5-10 mg/hour if there is an inadequate response to initial treatment.
67
Why/when should ipratropium bromide be used as an intervention?
Ipratropium bromide 500 micrograms should be administered if the patient does not respond adequately to nebulised salbutamol.
Ipratropium bromide can be given with salbutamol in the same nebuliser.
68
Why/when should patients receive steroids as an intervention?
All patients with an acute exacerbation of COPD should receive oral corticosteroids to reduce airway inflammation.
NICE recommends oral prednisolone 30 mg once a day for 5 days.
69
What should be used if all the interventions fail to improve breathing of the patient?
Non-invasive ventilation (NIV) for persistent hypercapnic respiratory failure.
Respiratory stimulants and intravenous theophylline.
70
ABCDE approach: Circulation - what should be clinically assessed?
1. Pulse -Patients with an acute exacerbation of COPD may be tachycardic, particularly if beta-agonists have been administered.
A bounding pulse may be noted secondary to CO2 retention.
2. Blood pressure - Hypotension may be present in the context of sepsis
3. Capillary refill time - may be prolonged in the context of sepsis
4. Jugular Venous Pressure - raised JVP may indicate cor pulmonale
5. Palpation - Palpate the patient’s chest to feel for a ventricular heave or displaced cardiac apex both of which are associated with cor pulmonale.
71
ABCDE approach: Circulation - Auscultation
Auscultate the patient’s praecordium to assess heart sounds:
A gallop rhythm is a feature of congestive heart failure (e.g. secondary to cor pulmonale).
72
ABCDE approach: Circulation - Fluid balance
Calculate the patient’s fluid balance:
Calculate the patient’s current fluid balance using their fluid balance chart (e.g. oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts.
Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult.
73
ABCDE approach: Circulation - Investigations and procedures
1. Intravenous cannulation
Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests
2. Blood tests to rule out anaemia, infection, renal function, pyrexial
3. ECG to look for evidence of acute myocardial ischaemia
ventricular hypertrophy
arrhythmias
74
ABCDE approach: circulation - Interventions
1. Antibiotics- Antibiotics should only be used to treat exacerbations of COPD associated with a history of increased purulent sputum production or other features suggestive of pneumonia such as fever, raised inflammatory markers and signs of consolidation on chest X-ray.
2. Fluid resuscitation - ypovolaemic patients require fluid resuscitation:
Administer a 500ml bolus Hartmann’s solution or 0.9% sodium chloride (warmed if available) over less than 15 mins.
Administer 250ml boluses in patients at increased risk of fluid overload (e.g. heart failure).
After each fluid bolus, reassess for clinical evidence of fluid overload (e.g. auscultation of the lungs, assessment of JVP).
Repeat administration of fluid boluses up to four times (e.g. 2000ml or 1000ml in patients at increased risk of fluid overload), reassessing the patient each time.
75
ABCDE approach: Disability - Clinical assessment
1. Assess consciousness as patient may be hypoxic or hypercapnic using AVPU:
Alert: the patient is fully alert, although not necessarily orientated.
Verbal: the patient makes some kind of response when you talk to them (e.g. words, grunt).
Pain: the patient responds to a painful stimulus (e.g. supraorbital pressure).
Unresponsive: the patient does not show evidence of any eye, voice or motor responses to pain.
2. Pupils - Inspect the size and symmetry of the patient’s pupils. Asymmetrical pupillary size may indicate intracerebral pathology.
Assess direct and consensual pupillary responses which may reveal evidence of intracranial pathology.
3. Review drug chart
76
ABCDE approach: Disability - Investigations and procedures
1. Capillary blood glucose and ketones (Hypoglycaemia is defined as a plasma glucose of less than 3.0 mmol/l. In hospitalised patients, a blood glucose ≤4.0 mmol/L should be treated if the patient is symptomatic)
If the blood glucose is elevated, check ketone levels which if also elevated may suggest a diagnosis of diabetic ketoacidosis (DKA).
77
ABCDE approach: Disability - Imaging
CT head if intracranial pathology is suspected after discussion with senior.
78
ABCDE approach: Exposure - Clinical assessment
1. Inspection - Review the output of the patient’s catheter and any surgical drains.
Look for alternative sources of infection (e.g. wounds, abdomen, urine).
2. Calves - Assess the patient’s calves for erythema, swelling and tenderness which may suggest a deep vein thrombosis.
3. Temperature - Assess the patient’s temperature: fever may indicate an infective cause underlying the acute exacerbation of COPD.
79
ABCDE approach: Exposure - Investigations
1. Ultrasound or D- Dimer - If a DVT is suspected, calculate the patient’s DVT Wells score to determine if an ultrasound scan or D-dimer test should be performed to confirm or exclude the presence of a DVT.
2. Urinalysis - If the patient has symptoms of urinary tract infection perform urinalysis to screen for evidence of infection.
3. Blood cultures - if fever is identified perform blood cultures and consider starting antibiotics
4. Anticoagulation - If DVT is identified, consider anticoagulation
80
Yr 3 - Respiratory
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