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COPD (Primary Survey (Breathing (Venturi mask (start at 24-28%) and…
COPD
Primary Survey
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Circulation: HR, BP, cap refill, IV access, bloods (ABG/VBG, FBC, UEC)
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Clinical Features:
Risk factors: smoking, dust and chemical exposure, age, alpha-1 antitrypsin deficiency, recurrent infections
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Other: reduced exercise tolerance, SOB
O/E:
Blue bloaters (chronic bronchitis): increased body habitus, cyanosis, peripheral oedema, CO2 retainers
Pink puffers (emphysema): barrel chest, thin body habitus, pursed lips, pink skin, accessory muscle use, tachypnoea
Signs of cor pulmonale: increased JVP, right ventricular heave, peripheral oedema, loud P2, clubbing
Other: end expiratory wheeze, distant breath sounds, hyper-resonance, coarse crackles, decreased chest expansion
Exacerbation sx: 2 of: increased sputum production, change in sputum colour or increased dyspnoea
Acute Management
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Ventilation: If deteriorating, consider ICU admission for non-invasive ventilatory support w/ BiPAP; If needed intubate
Pathophysiology:
Emphysema:
Protease > antiprotease --> chronic inflammation and destruction of alveolar wall --> loss of surface area for gas exchange and irreversible small airway obstruction --> enlarged air space distal to terminal bronchiole and air trapping e.g alpha-1 antitrypsin (antiprotease) deficiency or smoking (increases proteases)
Chronic bronchitis:
Oxidative stress and inflammation (e.g. from smoking) --> large airways infiltrated by inflammatory cells --> airway narrowing, fibrosis and mucociliary dysfunction
Goblet cell proliferation and hypertrophy of bronchial mucinous glands --> increase mucous production
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Infective Exacerbation:
Associated organisms: haemophilus, strep pneumoniae, moraxcella
Investigations
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Diagnosis:
Spirometry:
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Increased TLC, RV, FRC (signs of air trapping)
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CXR: signs of hyperinflation (>6 anterior ribs, flattened hemi-diaphragms, clear/black lung fields), decreased peripheral lung markings, bullae, large central pulmonary arteries
Other: FBC (raised Hct), ECG, CT, ABG, ECHO (pulmonary HTN)
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Long term management
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Further management
- Coriticosteroids: give short course oral and if improved, place on long term inhaled corticosteroid e.g. fluticosone
- Other: pulmonary rehab, chest physio, nutrition, MDT involvement
- Long acting bronchodilators (salmeteral and/or tiotropium bromide)
- Long term oxygen (effective if being used for 18 hours/day): O2 <55mmHg OR < 60mmHg with cor pulmonale, RSHF, polycythemia
- Short acting bronchodilator (salbutamol and/or ipratropium bromide) PRN
Definition:
Chronic, obstructive irreversible respiratory condition characterised by airway disease and parenchymal destruction
SE of beta agonists: tremor, tachycardia and arrythmias (K+ decreased)
SE of corticosteroids: immune suppression (pneumonia,, oral thrush), increased glucose, adrenal suppression