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COPD (Examination (Chest (Auscultation (↓ breath sounds, Expiratory wheeze…

- - - - ↓ breath sounds
      - Expiratory wheeze
      - Prolonged expiratory phase
    - - ↓ cricosternal distance
      - Loss of cardiac dullness
      - Palpable liver edge
  - - - Inhalers
      - Peak flow meter
      - Nebuliser
    - - Airflow obstruction
        
        Pursed lip breathing
        
        Splinting diaphragm
      - Cushingoid
      - Cyanosed
      - Cachetic
    - - Hands
        
        Tar staining
        
        CO2 retention flap
        
        Bounding pulse
      - Face
        
        Central cyanosis
        
        Plethora: ↑Hb
  - - - ↑ JVP
        
        Left parasternal heave: RV hypertrophy
        
        Loud P2 ± S3
        
        MDM of tricuspid regurg
        
        Ascites and pulsatile hepatomegaly
        
        Peripheral oedema
    - - CO2 retention
      - Cor pulmonale
      - Clubbing: could indicate Ca
    - - Chronic asthma
      - Bronchiectasis
- - - - PEFR
      - BMI: independent mortality RF in COPD
      - Sputum: MC+S
    - - ↑ TLC and residual volume (RV)
      - FEV1 <80%
      - FEV1:FVC <0.7
      - ↓ transfer factor
    - - FBC: polycythaemia, ↑ WCC in exacerbations
      - ABG: Type 2 resp failure
      - CRP: if infective exacerbation
      - Albumin: malnutrition
      - α1-AT levels: if young and FHx
    - - CXR
        
        Acute
        
        Consolidation
        
        Pneumothorax
        
        Chronic
        
        Hyperinflation: >10 posterior ribs, flat diaphragm
        
        PHT: prominent pulmonary As, peripheral oligaemia
        
        Bullae
      - Echo
        
        Cor pulmonale
    - - 6 minute walk
      - ECG: RVH
  - - - Cough productive of sputum on most days for ≥3mo on ≥2 consecutive years
    - - Histological description of alveolar wall destruction w/ airway collapse and air trapping
- - - - Parameters
        
        mMRC Dyspnoea Score
        
        SOB only on vigorous exertion
        
        SOB on hurrying or walking up stairs
        
        Walks slowly or has to stop for breath
        
        Stops for breath after <100m / few min
        
        Too breathless to leave house or SOB on dressing
        
        Airflow Limitation
        
        Mild: FEV1 >80% (but FEV/FVC <0.7 and symptomatic)
        
        Mod: FEV1 50-79%
        
        Severe: FEV1 30-49%
        
        Very Severe: FEV1 <30%
        
        No. of exacerbations per year
    - - MDT
        GP, dietician, physio, resp physician, specialist nurses
        Regular review 1-2x / yr
      - Smoking Cessation: single most important intervention
        
        Specialist nurse and support programme
        
        Nicotine replacement therapy
        
        Varenicline: partial nicotinic agonist
      - Pulmonary Rehabilitation Therapy
        
        Tailored exercise programme
        
        Disease education
        
        Psychosocial support
      - Co-morbidities
        
        Nutritional assessment and dietary support
        
        CV risk Mx
        
        Vaccination: pneumococcal and seasonal influenza
    - - Principal Therapies
        
        Anti-muscarinics: short- or long-acting
        
        β-agonists: short- or long-acting
        
        Inhaled corticosteroids: in combination w/ β-B
      - Theophylline or Roflumilast: PDIs
      - Carbocisteine: mucolytic
      - Home emergency pack for acute exacerbations
      - LTOT
        
        Aim: PaO2 ≥8 for ≥15h / day (↑ survival by 50%)
        
        Indications
        
        Stable non-smokers w/ PaO2 <7.3
        
        PaO2 <8 + cor pulmonale or polycythaemia
    - - Recurrent pneumathoraces or large bullae
      - Bullectomy or lung reduction surgery
  - - - Discharge
        Spirometry
        Establish optimal maintenance therapy
        GP and specialist f/up
        Prevention using home oral steroids and Abx
        Pneumococcal and Flu vaccine
        Home assessment
        
        BODE Index
        Multidimensional tool to predict mortality in COPD
        Uses multiple independent risk factors
        BMI
        Obstruction: FEV1
        Dyspnoea: MRC score
        Exercise capacity: 6 min walk
        
        Mortality
        15% in-hospital mortality
    - - Nebulised Bronchodilators
        Air driven w/ nasal specs
        Salbutamol 5mg/4h
        Ipratropium 0.5mg/6h
        
        Steroids (IV and PO)
        Hydrocortisone 200mg IV
        Prednisolone 40mg PO for 7-14d
        
        Abx
        If evidence of infection
        Doxy 200mg PO STAT then 100mg OD PO for 5d
        
        NIV if no response
        Repeat nebs and consider aminophylline IV
        Consider NIV (BiPAP) if pH<7.35 and/or RR >30
        Consider invasive ventilation if pH<7.26
        Depends on pre-morbid state: exercise capacity,
        home O2, comorbidity