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COPD (Signs & Symptoms (increased dyspnoea (:red_flag: Marked…
COPD
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Clinical Impression
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Assess the airway for patency, worse noting mallampati too just in case intubation is needed later on
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Carry out a 12-lead ECG
:check: Assess for signs of ventricular strain patterns
:check: Signs of Cor Pulmonale
RBBB is also common for people with COPD
:check: Rule out STEMI being the cause for SOB
Treatment
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Positioning
patient is most likely to be comfortable sitting up. Getting them to lean forward slightly might also allow for better auscultation of the heart. consider orthopnia is patient is laid down
Ventilation
Do you need to assist ventilation if <12 or >30. If high is it because they are compensating (increased ETCO2)
Bronchodilators
Salbutamol -Beta 2 agonist - Binds to the Beta 2 receptors and causes smooth muscle in the lungs to relax, thus reducing bronchospasm. Only give half doses to pt on Beta blockers (-lols). Overdose can cause beta 1 receptors to be agonised and induce tachycardia.
GTN
Organic Nitrates such as GTN work by releasing nitric oxide which causes smooth muscle to relax, especially in the venous return system. For patients that have bubbling/fluid at the bottom of the lungs GTN could be given to cause vasodilation, which in turn lowers pulmonary blood pressure and allows fluid back into the circulating system.
Corticosteroids
Prednisolone/Hydrocortisone - prednisolone is around 4x stronger that hydrocortisone.
They pass into the cytoplasm of cells and bind with glucocorticoid receptors (GCR). This then prevents transcription of inflammatory genes and promotes synthesis of anti-inflammatory proteins.
Anticholinergics
Ipatropium bromide - muscarinic cholinergic antagonist. Blocks the effects of ACH on the muscarinic receptors in the bronchial mucosa, resulting in reduced contraction of the smooth muscle in the airway and reduced mucus production
Common Pt Drugs
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Corticosteriods
Fluticasone (Flovent),
Budesonide (Pulmicort),
Prednisolone
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Antibiotics
Amoxicillin
Tetracycline
Clarithromycin
Flucloxacillin
Doxycycline
Vancomycin (if ? MRSA)
Co-amoxiclav (severe infection)
Benzylpenicillin (Severe infection)
Quinolone (if ? legionella)
Physiology
Bronchospasm
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Immune response
An allergen has attached to a mast cell triggering the release of Histamine. This binds to H1 receptors caused constriction of smooth muscle
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ECG Changes
Hypoxaemia due to poor perfusion in the lungs (V/Q mismatch) causes vaso constriction in the pulmonary vessels, this in turn increases atrial BP and over time causes damage to the muscle on the R side of the heart
Cor Pulmonale
Due to increased resistance in the pulmonary system the R ventricle enlarges (RVH)
Peaked P waves.
Low QRS voltages (most obvious in the limb leads).
Clockwise rotation (transitional lead = V6).
Virtually absent R waves in the right precordial leads (SV1-SV2-SV3 pattern)
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V/Q Mismatch
more commonly a V mismatch but due to symptoms that occur with COPD i.e coughing it is possible to cause trauma to the alveoli in addition a PE could be an alternative diagnosis for increased SOB
Mucus plugging
COPD pts are prone to getting infections due to the inability to shift mucus. Infected mucus is thicker in nature and can block the already narrow bronchus or prevent perfusion as it line the alveoli making it difficult for O2 & CO2 to perfuse across
Damaged Alveoli
Due to alveoli being more rounded due to damage, the surface area is reduced which reduces the amount of available surface for diffusion to take place
Pulmonary Pressure
The increase pressure of the blood leaving the heart due to the hypertrophy forces fluid out of the capillaries into the alveolar space. The fluid lowers ventilation due to the difficulty of the gases perfusing through the liquid
Damaged bronchioles
The elasticity of the lung tissue is reduced. This causes the fine bronchioles to collapse preventing airflow to the alveoli
Infection/Sepsis
Pneumonia/Bronchitis
The most common infections in COPD patients. due to thick mucus and ineffective coughing and ciliary action in the airways , bacteria and viruses held in the mucus remain in the lungs for longer periods of time giving them chance to reproduce and colonise
Antitrussive Drugs
One of side effects of COPD is increased coughing. Some patients may be on antitussive drugs to inhibit the cough reflex leading to increased levels of infective mucus in the airways