Session 7

Question 1

What are the characteristics of COPD?

Answer 1

Airflow obstruction that is not fully reversible. It is progressive and predominantly caused by smoking. Chronic bronchitis and emphysema often coexist

Question 2

What are the causes of COPD?

Answer 2

Tobacco (90%), air pollution, occupational exposure and A1 antitrypsin deficiency (rare)

Question 3

What results from the chronic inflammatory response and oxidative injury in response to inhaled noxious substances?

Answer 3

Enlargement of mucus secreting glands of central airways (CB)
More goblet cells replacing ciliated epithelium (CB)
Ciliary dysfunction (CB)
Breakdown of elastin -> destruction of alveolar walls and loss of elastic recoil (E)
Formation of large air spaces with reduced SA called bullae (E)
Vascular bed changes -> pulmonary hypertension

Question 4

Why do the lungs expand in emphysema?

Answer 4

Due to loss of elastin - unable to resist natural tendency of chest wall to expand outwards

Question 5

How does chronic bronchitis present?

Answer 5

Chronic productive cough and frequent respiratory infections (excessive mucus that isn’t cleared)

Question 6

How does COPD lead to increased airway resistance?

Answer 6

Luminal obstruction by secretions
Narrowing of small bronchioles that are normally kept open by outward pull of alveoli
Decreased elastic recoil

Question 7

How does COPD lead to cor pulmonale

Answer 7

Progressive hypoxia -> pulmonary vasoconstriction -> pulmonary hypertension

Question 8

What are the signs of COPD?

Answer 8

Tachypnoea
Hyper resonance on percussion due to hyperinflation
Pursed lip breathing
Use of accessory muscles
Barrel chest (increased ap diameter)
Wheezing may be present

Question 9

What are the signs of late COPD?

Answer 9

Central cyanosis
Cor pulmonale
Flapping tremors due to hypercapnia

Question 10

What are the investigations and their findings for COPD?

Answer 10

Spirometry - FEV1:FVC less than 70%. This plus history = diagnosis
Decreased diffusion capacity for CO
CXR - flattened diaphragm, hyperlucent lungs, increased AP diameter, long heart shadow. Used to exclude cancer/fibrosis
Pulse oximetry and ABG analysis
A1 antitrypsin level

Question 11

What are the differences between asthma and COPD?

Answer 11

Asthma onset is early, a family history of allergy, rhinitis and eczema often present, symptoms may be episodic, obvious wheeze corrected by bronchodilators, common night time waking, and no decrease in diffusion capacity of CO

Question 12

What is the management for stable COPD?

Answer 12

Smoking cessation to prevent disease progression
Bronchodilators
Mucolytics to increase clearance
Inhaled corticosteroid
Pulmonary rehabilitation - MDT programme of exercise and nutrition to break cycle of breathlessness -> no exercise -> worse breathlessness
Long term O2 therapy, decreases pulmonary hypertension
Surgical - removal of bullae, lung volume reduction and transplant

Question 13

What is an acute exacerbation of COPD?

Answer 13

A change in the patients baseline level dyspnoea (difficulty breathing), cough and sputum beyond normal day to day variation and acute in onset.

Question 14

What is the management for an acute exacerbation of COPD?

Answer 14

Controlled O2 therapy to get 88-92% sats
Nebulised bronchodilators
Antibiotics for infectious features
Consider non invasive ventilation for those 2 reps failure

Question 15

What are the possible complications of COPD?

Answer 15

Recurrent pneumonia
Pneumothorax due to parenchymal damage
Respiratory failure
Cor pulmonale

Question 16

What are th risk factors for lung cancer?

Answer 16

Smoking (90%), asbestos, radon, genetic factors and other occupational carcinogens

Question 17

Why is the incidence of lung cancer higher in lower socio economic groups?

Answer 17

Increased smoking and decreased access to healthcare

Question 18

Where does lung cancer tend to metastasise to?

Answer 18

Brain, bone, liver, adrenals, pericardium or draining lymph nodes

Question 19

What are the symptoms of lung cancer?

Answer 19

Primary - Asymptomatic, Cough, dyspnoea, wheezing, haemoptysis, chest pain, weight loss, malaise, breathlessness
Regional metastasis - dysphagia, SVC obstruction
Distant metastasis - bone pain, headache/double vision/confusion

Question 20

What is paraneoplastic syndrome?

Answer 20

The presence of a symptom/disease due to the presence of cancer in the body, but not due to presence of cancer cells. They are mediated by humoral factors secreted by the tumour or immune response

Question 21

What paraneoplastic diseases can result from lung cancer?

Answer 21

Endocrine - hypercalcaemia, cushings
Haematological - anaemia
Other - nephrotic syndrome, anorexia

Question 22

What are the techniques for diagnosis and staging of lung cancer?

Answer 22

First suspicion - CXR, bronchioscopy, biopsy (histological diagnosis)
Diagnosis and staging - CT, PET, isotope bone scans

Question 23

What are the two main types of lung cancer?

Answer 23

Non small cell carcinoma (80%) - squamous, adenocarcinoma or large cell. 2/3 inoperable at presentation
Small cell carcinoma (12%) - 3/4 have metastasis at presentation

Question 24

What does the prognosis of lung cancer depend on?

Answer 24

Cell type (small cell worse)
Stage of disease
Biochemical markers
Co morbidities

Question 25

What are the treatments for lung cancer?

Answer 25

Surgery - mostly for non small cell
Radiotherapy - either radical with curative intent for palliative for symptom control
Chemotherapy - potentially curative for small cell. Symptom control for no small cell. Combination therapy =chemo+radio
Palliative care