Obstructive Diseases

Question 1

Definition of COPD

Answer 1

Chronic Obstructive Progressive Disease (COPD) is characterised by airflow obstruction that is progressive in severity, not fully reversible and does not change markedly over several months
COPD is the umbrella term for:
•	Chronic bronchitis
•	Emphysema
•	Chronic Asthma

Question 2

Causes of COPD

Answer 2

COPD is caused by:
•Cigarette smoking (90%) – those with significant smoking history (20 pack years +); Pack years = no of packs smoked per day x years of smoking
•Occupational exposure – Coal miners, lead painting, car mechanics
•Alpha-1 Antitrypsin deficiency - strong genetic link
•Social deprivation

Question 3

Pathology of COPD

Answer 3

1. Airways become irritable and inflamed
2. Inflamed and irritated airways lead to narrowing of airways
3. Narrowing of airways leads to difficulty moving air in and out of lungs
4. Difficulty of moving air leads to trapping of air in airways
5. Trapping of air in airways leads to SOB plus an increase in sputum contributes to SOB and risk of infection

Increase in sputum is caused by:

1. Excess mucus is produced
2. Mucus is thicker and stickier
3. The cilia are trapped by mucus and unable to beat
4. Smoking paralyses the cilia
5. Therefore:
   a. Dust and bacteria stay trapped in the airways
   b. Mucus build-up and provides warm moist environment for bacteria to grow
   c. Recurrent infections can develop

Question 4

Medical Diagnosis of COPD

Answer 4

If COPD is suspected it will be diagnosed using the following:

1. Detailed patient History – from MDTs = practice nurses, GPs, Physios, consultants all to ensure correct diagnosis
2. Clinical signs:
   a. Breathlessness on exertion
   b. Cough
   c. Increased sputum
   d. Risk factors – smoking, occupation, family history
   e. Rule out other causes
3. Spirometry
   a. Diagnosis – gold standard for obstructive diseases
   b. Categorise severity
   c. Monitor progression
4. CXR - looking for clear clinical signs; may be done yearly to see changes

Question 5

Classification of COPD

Answer 5

Once diagnosed COPD will be classified according to severity:
Early disease = often few symptoms. Morning cough (smokers cough), chest infections in the winter, breathlessness when exercising vigorously (not at rest). Clinical examination may be normal although spirometry may be reduced

Moderate disease = a range of respiratory symptoms. Cough, wheeze, SOB with moderate exertion. Clinical examination may reveal wheeze, barrel chest, flattened diaphragm on CXR

Severe Disease = severe symptoms, cyanosis. Weight loss, raised JVP, peripheral oedema, overuse of accessory muscles

Question 6

Types of COPD

Answer 6

Chronic bronchitis, emphysema and chronic asthma

Question 7

Define Bronchitis

Answer 7

• A chronic disease of the lungs where the bronchi become inflamed.

Question 8

What are the 3 main clinical S&S of bronchitis

Answer 8

• Inflammation causes more mucus to be produced, which narrows the airway and makes breathing more difficult.
• Increased sputum production – over production of mucus in the airways which becomes difficult to clear
• Wheezing is very common especially after coughing. This is because the inflamed airways may narrow for short periods of time. This also reduces the amount of air that enters the lungs.

Question 9

Define Emphysema

Answer 9

A condition where the alveoli of the lungs become inflamed and lose their natural elasticity

Question 10

Pathology of Emphysema

Answer 10

• Alveoli over expand and lose their ability to fill up and contract properly
• As air fills up in these sacs, some rupture and become one sac (bullae) reducing the surface area for the exchange of oxygen and carbon dioxide
• When you breathe out, the trapped air cannot be released and breathing becomes more and more difficult

Question 11

Define Asthma

Answer 11

•Asthma is an episodic increase in airway obstruction caused by various stimuli (allergies, dust, pollen) resulting in increased airway resistance (seen in PFTs)
•Inflammation + Bronchoconstriction
•Reversible
Hypertrophy of mucous glands may lead to mucous plugging, airway obstruction, which may become chronic & severe

Question 12

Define chronic asthma

Answer 12

Asthma is often a reversible airway disease, but it can become chronic with some fixed airway damage and therefore comes under COPD umbrella.
This occurs when patients have recurrent asthma exacerbations that are not treated quickly leading to scarring and chronic inflammation so in turn leads to permanent narrowing

Question 13

Symptoms of asthma

Answer 13

Breathlessness, Wheeze, Tightness in the chest

Question 14

Medical treatment of COPD

Answer 14

1. Inhalers
2. Rescue Steroids and Antibiotics - for exacerbation (infective or non-infective)
3. Other medication
4. Flu and Pneumonia vaccines - prevent life-threatening complications

Question 15

Physiotherapy treatment of COPD

Answer 15

Smoking Cessation:
•Educate effects of smoking - by using Fletcher-Peto Diagram
•4x more likely to quit with help, advice and nicotine replacement
•Stop smoking services (every contact counts) are widely available in the community
•Stopping smoking will help to slow the progression of the disease
•We can refer as physios at any time

Pulmonary Rehabilitation
As important as medication - Will help to reduce admissions and aid recovery time post exacerbation
1.Exercise
2.Education
3.Self-management
4.Diet
5.Lifestyle modifications

Question 16

How do bronchodilators work

Answer 16

Decrease spasm by relaxing the smooth muscle and empty the lungs of trapped air

Question 17

How do anti-inflammatory drugs work

Answer 17

In asthma they reduce inflammation

In COPD they reduce ‘flare ups’ or exacerbations

Question 18

What is correct inhaler technique

Answer 18

• Aerosol inhaler or canisters, should be a ‘slow and steady’ internal sigh
• Dry powder inhalers should be taken ‘Quick and deep’
• Inhalers should be prescribed only after patients have received training and the final decision is based on patient preference and assessment of correct use

Question 19

Importance of correct inhaler technique

Answer 19

One of the biggest causes in increase in exacerbation rate is poor technique hence Inhaler technique must be checked regularly by a trained person (nurse, doctor, physio, pharmacist)

Question 20

Benefits of using spacers

Answer 20

• Easy to use, no coordination needed, allow time for medication to be inhaled
• Single or multiple breath techniques
• Improves lung deposition
• Reduces side effects

Question 21

Considerations when using spacers

Answer 21

• Important to teach care and cleaning of device to patient

- should be replaced yearly

Question 22

Common short-acting bronchodilators

Answer 22

Salbutamol – Ventolin,Airmir, Salamol
Terbutaline (Bricanyl)
Salmeterol (serevent)/ Formoterol (oxis)

Question 23

Common side effects of short-acting bronchodilators

Answer 23

Shaky hands
Cramp in hands and feet
Racing heart or palpitations
Flushing
Headache

Question 24

Common examples of long-acting bronchodilators

Answer 24

Tiotropium (Spiriva)
Aclidinum Bromide (Eklira Genuair)

Question 25

Common side effects of long-acting bronchodilators

Answer 25

``` Dry mouth Blurred vision Racing heart or palpitations Constipation Difficulty urinating ```

Question 26

Common combination inhalers

Answer 26

Duaklir – contains both aclidinum (long acting) and formoterol (short acting) to take one puff twice a day Stiolto – contains both tiotropium (long acting) and olodaterol (Short acting) to take two puffs once a day Bronchodilator + anti-inflammatory (steroid): Symbicort, Seretide, Fostair

Question 27

How are corticosteroids delivered

Answer 27

inhalers, nebules, tablets, and injection. The inhaled route is preferred

Question 28

Common types of corticosteroids

Answer 28

beclomethasone budesonide fluticasone prednisolone

Question 29

Side effects of corticosteroids

Answer 29

osteoporosis, hypertension, dermal thinning, and reduced growth rate in children Inhaled: mouth infection (thrush) and hoarseness (husky voice)

Question 30

How to reduce inhaled corticosteroid side effects

Answer 30

Using a spacer Rinsing mouth after taking it Using correct inhaler technique

Question 31

Effects of corticosteroids in asthma

Answer 31

Reduce the number and activity of mucosal mast cells and eosinophils Reduce inflammatory reactions such as oedema and mucus secretion Suppress late phase inflammatory reactions

Question 32

Effects of corticosteroids in COPD

Answer 32

Do not affect the rate of decline in FEV1 Have a beneficial effect on exacerbation rate in severe disease Reduce the rate of decline in health status Improve long term survival

Question 33

How to improve compliance with medication

Answer 33

- Improve patient understanding - Tailor treatment to suit the patient - Use treatments where patients rapidly perceive the effect of medication - Reduce the complexity of treatments - Reduce the cost to the patient

Question 34

Other medication available in COPD

Answer 34

Theophyllines possess both bronchodilator and anti-inflammatory properties. They can be taken in tablet form but require blood test monitoring to make sure they are in the body in the appropriate level as they can be dangerous in very high levels. Mucolytics: carbocisteine can be used to reduce the thickness of sputum and therefore aid sputum clearance. Patients are given a loading dose when they first start it and it is gradually reduced to the maintenance dose.- Normally a maintenance dose is 2 x 375mg tablets morning and evening after food. Nebulisers: Bronchodilators, steroids and antibiotic treatments can all be nebulised. However, large does carry greater side effects with them and this is not routinely recommended. They also carry potential infection control risks.