COPD

Question 1

What is COPD?

Answer 1

COPD is a non-reversible, long-term deterioration in airflow through the lungs caused by damage to lung tissue.

Question 2

COPD patients are susceptible to exacerbations that worsen lung function. What triggers these exacerbations?

Answer 2

Infections (Infective Exacerbations)

Question 3

What kind of patient presentations suggest COPD?

Answer 3

Long-term smoker presenting with chronic shortness of breath, cough, sputum production, wheeze and recurrent respiratory infections, particularly in winter

Question 4

Differential diagnoses that can be considered while investigating COPD include

Answer 4

• lung cancer
• heart failure
• fibrosis

Question 5

Does COPD cause clubbing?

Answer 5

No

Question 6

Would you expect to see hemoptysis or chest pain among COPD patients?

Answer 6

It is unusual and should be further investigated

Question 7

List out the MRC Dyspnoea scale grades from NICE

Answer 7

1 - Breathless on strenuous exercise
2 - Breathless on walking up hill
3 - Breathlessness that slows walking on the flat
4 - Stop to catch their breath after walking 100 meters on the flat
5 - Unable to leave the house due to breathlessness

Question 8

How’d you diagnose COPD?

Answer 8

Clinical presentation and spirometry

Question 9

The severity of airflow obstruction can be graded using FEV1. List the stages.

Answer 9

1 - FEV1 > 80% of predicted
2 - FEV1 50-79% of predicted
3 - FEV1 30-49% of predicted
4 - < 30% of predicted

Question 10

Additional investigations that can be conducted to help with COPD diagnosis and management include:

Answer 10

• Chest X-Ray
• Full blood count
• Body Mass Index
• Sputum Culture
• ECG and echocardiogram
• CT Thorax
• Serum alpha-1-antitrypsin
• Transfer factor for carbon monoxide (TLCO)

Question 11

What is the purpose of chest X-Ray in COPD diagnosis?

Answer 11

To exclude other pathology (i.e. lung cancer)

Question 12

What is the purpose of full blood count in COPD diagnosis?

Answer 12

For polycythaemia or anaemia. Polycythaemia (raised haemoglobin) is a response to chronic hypoxia.

Question 13

What is the purpose of BMI in COPD diagnosis?

Answer 13

Baseline to later assess weight loss (e.g. cancer or severe COPD) or weight gain (e.g. steroids)

Question 14

What is the purpose of sputum culture in COPD diagnosis?

Answer 14

To assess for chronic infections such as pseudomonas

Question 15

What is the purpose of CT thorax in COPD diagnosis?

Answer 15

Alternative diagnoses such as fibrosis, cancer, or bronchiectasis

Question 16

What is the purpose of TLCO in COPD diagnosis?

Answer 16

Decreased in COPD. It can give an indication about the severity of the disease and may be increased in other conditions such as asthma

Question 17

Step 1 of Long-term COPD management

Answer 17

Short-acting bronchodilators such as::

• Beta-2 agonists (salbutamol or terbutaline)
• Short-acting muscarinic (ipratropium bromide)

Question 18

Step 2 of Long-term COPD management if the patient does not have asthmatic or steroid-responsive features

Answer 18

Combine LABA and LAMA (i.e. Anoro Ellipta, Ultibro Breezhaler, or DuaKlir Genuair)

Question 19

Step 2 of Long-term COPD management if the patient has asthmatic or steroid-responsive features

Answer 19

Combine LABA and ICS (i.e. Fostair, Symbicort, or Seretide)

Question 20

Step 2 of Long-term COPD management if the patient has asthmatic or steroid-responsive features and LABA + ICS does not work

Answer 20

Add LAMA to the LABA and ICS combination (i.e. Trimbo, or Trelegy Ellipta)

Question 21

Long-term Management options for severe cases include

Answer 21

• Nebulizers (Salbutamol and/or ipratropium)
• Oral theophylline
• Oral mucolytic therapy to break down sputum (e.g. carbocisteine)
• Long term prophylactic antibiotics (e.g. azithromycin)
• Long term oxygen therapy at home

Question 22

At which point of COPD is long-term oxygen therapy used?

Answer 22

During severe COPD that is causing problems such as chronic hypoxia, polycythaemia, cyanosis or heart failure secondary to pulmonary hypertension (cor pulmonale)

Question 23

Why can you not use oxygen therapy when the patient is smoking?

Answer 23

Oxygen plus cigarettes is a fire hazard

Question 24

An exacerbation of COPD presents as

Answer 24

acute worsening of symptoms such as cough, shortness of breath, sputum production and wheeze

Question 25

COPD exacerbation is triggered by

Answer 25

viral or bacterial infections

Question 26

CO2 makes blood acidotic by

Answer 26

breaking down into carbonic acid (H2CO3)

Question 27

Raised bicarbonate indicates

Answer 27

chronic retention of carbondioxide and the kidneys respond by producing more bicarbonate to balance the acidic CO2 and maintain a normal pH

Question 28

What happens to bicarbonate production by the kidneys during a COPD exacerbation?

Answer 28

The kidneys can’t keep up with the rising level of CO2 so they become acidotic despite having a higher bicarbonate

Question 29

List and explain the 3 types of respiratory failures

Answer 29

• Low pO2 indicates hypoxia and respiratory failure
• Normal pCO2 with low pO2 indicates type 1 respiratory failure
• Raised pCO2 with low pO2 indicates type 2 respiratory failure

Question 30

Other investigations that can be conducted to confirm a COPD exacerbation diagnosis

Answer 30

• Chest x-ray to look for pneumonia or other pathology
• ECG to look for arrhythmia or evidence of heart strain (heart failure)
• FBC to look for infection (raised white cells)
• U&E to check electrolytes which can be affected by infection and medications
• Sputum culture if significant infection is present
• Blood cultures if septic

Question 31

What would happen to the respiratory drive of someone who is prone to retaining carbondioxide and is given too much oxygen?

Answer 31

It can depress their respiratory drive slowing down their breathing rate and effort therefore leading to increased carbondioxide retention.

Question 32

How can oxygen be provided to someone who is prone to retaining carbondioxide?

Answer 32

Carefully balanced to optimise their pO2 whilst not increasing their pCO2. This is guided by oxygen saturations and repeat ABGs.

Question 33

General rule regarding target oxygen saturations in COPD is:

Answer 33

• If retaining CO2 aim for oxygen saturations of 88-92% titrated by venturi mask
• If not retaining CO2 and their bicarbonate is normal (meaning they do not normally retain CO2) then give oxygen to aim for oxygen saturations > 94%

Question 34

Typical treatment for a COPD exacerbation if patient is well enough to remain at home

Answer 34

• Prednisolone 30mg once daily for 7-14 days
• Regular inhalers or home nebulisers
• Antibiotics if there is evidence of infection

Question 35

Typical treatment for a COPD exacerbation if patient is in hospital

Answer 35

• Nebulised bronchodilators (e.g. salbutamol 5mg/4h and ipratropium 500mcg/6h)
• Steroids (e.g. 200mg hydrocortisone or 30-40mg oral prednisolone)
• Antibiotics if evidence of infection
• Physiotherapy can help clear sputum

Question 36

Treatment options in severe COPD exacerbation cases not responding to first line treatment

Answer 36

• IV aminophylline
• Non-invasive ventilation (NIV)
• Intubation and ventilation with admission to intensive care
• Doxapram can be used as a respiratory stimulant where NIV or intubation is not appropriate