What is COPD?
A progressive and debilitating collection of diseases with airflow obstruction and abnormal ventilation with irreversible components e.g. emphysema and chronic bronchitis
What is an exacerbation of COPD?
Exacerbation of COPD is an increase in symptoms with worsening of the patient’s condition due to hypoxia that deprives tissue of oxygen and hypercapnia (retention of CO2) that causes an acid-base imbalance
Pathophysiology of Emphysema
- Emphysema is the result of an imbalance between Proteases and Anti-protease activity
- Inflammatory response from inhaled toxins, leads to elastin fibre breakdown and gradual destruction of the alveolar walls.
- Macrophages stored in the alveoli become stimulated
- Macrophages release proteases and cytokines
- Cytokines attract neutrophils from the blood into the alveoli
- Neutrophils release elastase (protease)
- Elastase targets elastic fibres resulting in the loss of elastic fibres and elastic recoil causing less surface area available for gas exchange
- Small bronchiole walls weaken, lungs cannot recoil as efficiently, air is trapped.
Pathophysiology of Chronic Bronchitis
- Increased mucus production for >3 months for at least 2 consecutive years
- An increase in the number of mucous-secreting cells in the respiratory tree
- Large production of sputum with productive cough
- Diffusion remains normal because alveoli not severely affected
- Gas exchange decreased due to lowered alveolar ventilation which creates hypoxia and hypercarbia
Signs and symptoms of COPD
- Tachypnoea
- Increased dyspnoea on exertion
- Progressive limitation of physical activity
- Prolonged expiratory phase (usually pursed lip breathing noted on exhalation)
- Barrel chest (increased chest diameter) (emphysema)
- Recent weight loss (emphysema)
- progressive dyspnoea
- frequent exacerbations
- poor exercise tolerance
- evidence of airways obstruction
- hyperinflation
- impaired gas exchange
- chronic respiratory failure
- “Pink puffer” – due to excess red blood cells (emphysema)
- Diminished breath sounds
- Use of accessory muscles
- Tachycardia
- Chronic cough (especially in the morning)
- Sputum production
- Unable to complete sentences
- Wheeze depending on amount of obstruction to air flow
- May have signs and symptoms of right heart failure – distended jugular vein – peripheral oedema – liver congestion
- “Blue bloater” – tends to be cyanotic (Chronic Bronchitis)
Risk Factors for COPD
- Smoking
- Air pollution
- Recurrent infections
- Alpha-1-antitrypsin deficiency
Differentials to consider for COPD?
- Asthma
- Pneumonia
- Pneumothorax
- Upper airway obstruction
Assessment of COPD
DRA(c)BCDE
DANGER assessment of COPD
- Assess for any potential dangers
* Manage any bleeds
RESPONSE assessment of COPD
AVPU - assess
AIRWAY assessment of COPD
- Clear?
* Correct if compromised
C-SPINE assessment of COPD
Is this a concern based on MOI?
BREATHING assessment of COPD
• Respiration rate?
• Wheeze?
• Increased/ decreased respiration
- PEFR
CIRCULATION assessment of COPD
- Heart rate?
- Palpable radial pulse?
- Oxygen saturations?
- Blood pressure?
- capillary refill?
- Skin tone- Cyanosed? Flushed?
- Correct if necessary
DISABILITY assessment of COPD
- Temperature
- Blood glucose
- PEARL
- Equal and bilateral air entry
- wheeze?
- 12 ECG
EXAMINATIONS assessment of COPD
- Signs of Oedema
- Signs of accessory muscle use
Past Medical History
- When did it start?
- What were they doing when it started?
- Has this happened before?
- Cough?
- Sputum?
Management of COPD
Treat as per JRCALC:
- Correct any ABC problems immediately.
- Sit patient forward in a comfortable position to ease respiration
- Follow the individualised treatment plan or alert card if available
- Administer nebulised salbutamol (5mg- no max) (limit oxygen driven nebulisation to 6 minutes)
- If severe, or Salbutamol unsuccessful, administer Ipratropium Bromide (500mcg – 500mcg max) in addition to Salbutamol.
- Titrate oxygen therapy to target saturations of 88-92%, or pre-specified range.
- 12 lead ECG
- Consider non-invasive ventilation if not responding to treatment
If time critical- rapid transfer and pre- alert to A&E, with ongoing management en-route.
Dosage of nebulised salbutamol for COPD
5mg- no max (limit oxygen driven nebulisation to 6 minutes)
Dosage of ipratropium bromide if severe COPD or if salbutamol unsuccessful
500mcg – 500mcg max (in addition to salbutamol)
