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Flashcards in COPD Deck (32)
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1

What spirometry result is diagnostic of COPD

A) Pre-bronchodilator FEV1/FVC ratio <0.7

B) Post-bronchodilator FEV1/FVC ratio <0.7

C) Pre-bronchodilator FEV1/FVC ratio <0.8

D) Post-bronchodilator FEV1/FVC ratio <0.8

B) Post-bronchodilator FEV1/FVC ratio <0.7

How is COPD confirmed?
• The diagnosis of COPD requires spirometry to confirm the presence of persistent airflow limitation (post-bronchodilator FEV1 / FVC < 0.7) since spirometry is the most reproducible and objective measurement of airflow limitation available.
• COPD cannot be diagnosed on clinical features and / or chest x-ray findings alone.
• Emphysema may be present in the absence of airflow limitation. Complex lung function tests will aid this diagnosis.
• Many patients with COPD have some reversibility of airflow limitation (mainly FEV1) with bronchodilators.

However, reversibility alone does not equate to a
clinical diagnosis of asthma because the clinical features and pathophysiology of COPD and asthma overlap and both conditions can coexist in some patients

2

A 39 year old female smoker (20 pack year) has an ongoing cough the past few months. She is otherwise well with normal vitals and examination findings and no fevers, chest pain, haemoptysis or weight loss. You decide to perform a pre and post spirometry which she struggled with and her results show airflow limitation that's not fully reversible - FEV1/FEV ratio <0.74 and FEV1 <82% predicted. What would be your next step in management

A) Advise her she likely has a post viral cough which should clear within the next few weeks

B) Request a CT chest and routine bloods

C) Consider referral for lung function testing

D) Prescribe amoxicillin as a trial and review her in a week

C) Consider referral for lung function testing

There is some risk with spirometry of over diagnosis in older people or under diagnosis in younger people,
especially when the FEV1 / FVC is close to 0.7. Consider referral for lung function testing at an accredited lung function testing laboratory if there is uncertainty, or the patient has difficulty performing the test.

Spirometry should be performed using standardised techniques

Perform pre- and post-bronchodilator spirometry to confirm COPD, which is characterised by airflow limitation that is not fully reversible (postbronchodilator FEV1 / FVC ratio < 0.7 and FEV1< 80% predicted).

Interpret borderline spirometry results with caution, particularly in older (> 65 years of age) and younger patients (< 45 years of age), or those without a history of smoking or exposure to occupational / environmental pollutants or dust

In patients with borderline spirometry, consider alternative diagnoses and investigate appropriately. Follow-up spirometry is also recommended

3

Which spirometry result would be most suggestive of asthma or co-existent asthma and COPD

A) FEV1 increase 12% and >160ml

B) FEV1 increase 10% and >200ml

C) FEV1 increase 10% and >300ml

D) FEV1 increase 12% and >400ml

D) FEV1 increase >12% and >400ml

Is it COPD or asthma?

• An FEV1 increase ≥ 12% and ≥ 200 mL constitutes a positive bronchodilator response. An FEV1 increase ≥400ml may suggest underlying asthma or coexistent asthma and COPD

• Asthma and COPD may co-exist. While a larger bronchodilator response may point to concurrent asthma or asthma-COPD overlap, a thorough history and further investigations may be needed to confirm this.

If the FEV1 response to bronchodilator is:

- ≥ 400 mL, consider asthma or asthma-COPD overlap

- < 400 mL (but ≥ 200 mL and ≥ 12%), consider asthma-COPD overlap or an asthma component depending on history and pattern of symptoms

4

What FEV1 would you expect in a COPD patient who becomes breathless walking on level ground, recurrent chest infections requiring PO corticosteroids and/or antibiotics and increased limitation of daily activities

A) 80% predicted

B) 64% predicted

C) 54% predicted

D) 38% predicted

C) 54% predicted

Guide to the severity of COPD:

Mild ≈ 60 - 80% predicted
• few symptoms
• breathless on moderate exertion
• little or no effect on daily activities
• cough and sputum production

Moderate ≈ 40 - 59% predicted
• breathless walking on level ground
• increasing limitation of daily activities
• recurrent chest infections
• exacerbations requiring oral corticosteroids +/or ABx

Severe < 40% predicted
• breathless on minimal exertion
• daily activities severely curtailed
• exacerbations of increasing frequency and severity

5

Which of these treatments may increase risk of pneumonia

A) Inhaled Terbutaline

B) Inhaled Corticosteroids

C) Inhaled LAMA/LABA dual therapy

D) Oral Montelukast

B) Inhaled Corticosteroids

There is evidence for an increased risk of pneumonia for patients treated with inhaled corticosteroids, however safety concerns should be balanced against the benefits of reduced exacerbations and reduced decline in quality of life

Avoid long-term (> 2 weeks) use of systemic corticosteroids

6

A COPD patient currently taking Atrovent when required presents for their GPMP and repeat spirometry shows a drop from 74% to 66% this past year. He's noticed some more mucus being brought up each morning but no decline in SOB or daily activities.
What would be the best management option

A) Increase atrovent use to BD rather than PRN

B) Add salbutamol for PRN use and review in 4 weeks

c) Give short course of prednisolone and review in 4 weeks

C) Add regular formetorol to regime and review in 4 weeks

C) Add regular formetorol to regime and review in 4 weeks

Follow the stepwise management in COPD

Still mild symptoms

- START with short-acting relievers: (used as needed):
SABA (short-acting beta2agonist) OR SAMA (short-acting muscarinic antagonist)

ADD long-acting bronchodilators:
LAMA (long-acting muscarinic antagonist) OR LABA (long-acting beta2-agonist)
Consider need for combination LAMA/LABA depending on symptomatic response

7

Which one of these statements is incorrect:

A) Vaccination reduces the risks associated with influenza and pneumococcal infection

B) Influenza vaccination reduces the risk of exacerbations but not hospitalisation for COPD

C) Pneumococcal vaccination reduces the risk of exacerbations and hospitalisation, with no difference between vaccine types

D) Pneumococcal vaccination reduces the risk of exacerbations but not hospitalisation, with no difference between vaccine types

C) Pneumococcal vaccination reduces the risk of exacerbations and hospitalisation, with no difference between vaccine types

Vaccination reduces the risks associated with influenza and pneumococcal infection

Influenza vaccination reduces the risk of exacerbations but not hospitalisation for COPD

Pneumococcal vaccination reduces the risk of exacerbations but not hospitalisation, with no difference between vaccine types

8

Which statement is correct:

A) There is some risk with spirometry of over diagnosis in older people or under diagnosis in younger people

B) There is some risk with spirometry of over diagnosis in older and younger people

C) There is some risk with spirometry of under diagnosis in older people or over diagnosis in younger people

D) There is some risk with spirometry of under diagnosis in older and younger people

A) There is some risk with spirometry of over diagnosis in older people or under diagnosis in younger people

All patients with a diagnosis of COPD should have a post-bronchodilator spirometry test documented in their clinical record.

There is some risk with spirometry of over diagnosis in older people or under diagnosis in younger people, especially when the FEV1 / FVC is close to 0.7.

Consider referral for lung function testing at an accredited lung function testing laboratory if there is uncertainty, or the patient has difficulty performing the test.

9

Most patients with COPD have co-morbidities. Name the five most prevalent

A) Hyperglycaemia, atherosclerosis, hyperthyroidism, dyslipidaemia and osteoporosis

B) Hyperglycaemia, atherosclerosis, hypertension, dyslipidaemia and osteoporosis

C) Hyperthyroidism, osteoarthritis, hypertension, dyslipidaemia and osteoporosis

D) Hypothyroidism, atherosclerosis, hypertension, dyslipidaemia and rheumatoid arthritis

B) Hyperglycaemia, atherosclerosis, hypertension, dyslipidaemia and osteoporosis

Most patients with COPD have comorbidities. The five most prevalent comorbidities are hyperglycaemia, atherosclerosis, hypertension, dyslipidaemia and osteoporosis

Some of these comorbid conditions may also influence the outcome of COPD

COPD may increase the overall morbidity and mortality in excess of that related to the primary diagnosis

10

Reasons to refer to specialist respiratory services

Diagnostic uncertainty and exclusion of asthma.

Unusual symptoms such as haemoptysis.

Rapid decline in functional performance.

Persistent symptoms.

Frequent chest infections (i.e. more than annually).


Onset of ankle oedema.

Oxygen saturation, SpO2 < 92% when stable
(refer for assessment for long-term oxygen therapy)

Assessing suitability for pulmonary rehabilitation, if uncertain.

Bullous lung disease on CXR or CT.

COPD < 40 years of age.

Persistent dyspnoea, marked hyperinflation, severe airflow limitation or emphysema

Dyspnoea associated with chest tightness, anxiety or dizziness (refer for consideration of dysfunctional breathing*)

Daytime sleepiness, complaints by partner of
heavy snoring

11

What is the most important intervention to prevent worsening of COPD

Smoking cessation is the most important intervention to prevent worsening of COPD

12

Benefits of varenicline is smoking cessation

Based on a small number of trials, varenicline is more effective than nicotine replacement monotherapy but equally effective as a nicotine replacement combination therapy

13

What is the greatest risk factor for a further COPD exacerbation

A) An injury that now further limits mobility

B) A urinary tract infection

C) Increased daily smoking amount

D) A recent history of an exacerbation (within the last 12 months)

D) A recent history of an exacerbation (within the last 12 months)

A recent history of an exacerbation (within the last 12 months) is the greatest risk factor for a further exacerbation

Frequent exacerbations lead to faster decline in FEV1, impaired health status, and increased mortality

Prompt intervention for exacerbations improves recovery/quality of life and reduces hospitalisation

14

When should second dose pneumococcal vaccine (23vPPV) be given in a 66 year old with newly diagnosed COPD who received their first 23vPPV at 65 years old

A) At diagnosis

B) 68 year old

C) 70 years old

D) No need for a second dose

C) At 70 years old

For older adults who have already received an age-based first dose of 23vPPV at age 65 years (non Indigenous) or 50 years (Indigenous), a single revaccination dose of 23vPPV is recommended a minimum of 5 years after the previous dose

15

When should a newly diagnosed 42 year old indigenous receive their 23vPPV dose

A) At diagnosis

B) 45 years old

C) 50 years old

D) 65 years old

A) At diagnosis

For those with newly diagnosed COPD who have never received pneumococcal immunisation: a first dose of 23vPPV is recommended at diagnosis followed by up to two additional doses

16

Pneumococcal vaccinations recommendations

Not at increased risk of Invasive Pneumococcal Disease or non-smoker:

Non-indigenous - At 65 yrs (no second dose)
Indigenous - At 50 yrs, second dose 5 years after first

Smokers, newly diagnosed COPD, existing COPD, who have never received age-based dose:

Non-indigenous <65 yrs
- At diagnosis
- second dose 5 years after first
- third dose at 65yrs or 5 years after second dose (whichever is later)

Indigenous <50 yrs
- At diagnosis
- second dose 5 years after first
- third dose at 50yrs or 5 years after second dose (whichever is later)

Smokers, newly diagnosed COPD, existing COPD, who have already received age based dose:

Non-Indigenous ≥ 65yrs
- Second dose given 5 years after first
- No third dose necessary

Indigenous ≥ 50yrs
- Second dose given 5 years after first
- No third dose necessary

17

Benefits of mucolytics in COPD

Mucolytics including N-acetylcysteine, erdosteine, carbocysteine or ambroxol have been shown to reduce exacerbations in moderate to severe COPD

18

At what stage should specialist referral be made for consideration of supplemental O2 therapy

A) SpO2 <94%

B) SpO2 <92%

C) SpO2 <90%

D) SpO2 <88%

B) SpO2 <92%

For stable patients with possible persisting hypoxaemia (suggested by SpO2 < 92% measured using a pulse oximeter), refer to specialist respiratory services to assess the need for oxygen therapy

Long-term oxygen therapy has survival benefits for COPD patients with hypoxaemia.

Hypoxaemia is defined by PaO2 ≤ 55 mmHg or by PaO2 ≤ 59 mmHg plus evidence of polycythaemia, pulmonary hypertension or right heart failure

19

What are the main triggers for a COPD exacerbation

Triggers for exacerbations include viral or bacterial respiratory infection, left ventricular failure, psychosocial stressors and air pollution

20

How do you define a COPD exacerbation

A COPD exacerbation is characterised by a change in the patient’s baseline dyspnoea, cough and / or sputum that is beyond normal day-to-day variations, is acute in onset and may warrant a change in regular medicine or hospital admission

21

What is the greatest predictor of a COPD exacerbation

The greatest predictor of an exacerbation is a history of exacerbations as these events cluster in time and become more frequent as the severity of COPD worsens

Exacerbations become more frequent in those with a history of prior exacerbations, more severe disease (based on FEV1) and other predictors (including history of heartburn, poorer quality of life and elevated white cell count)

22

What are the benefits of early diagnosis and
treatment of exacerbations

Early diagnosis and treatment of exacerbations may prevent hospital admission and delay COPD progression

A delay (≥ 24 hours) in presentation for and initiation of treatment of an exacerbation doubles the chance of hospital admission

In contrast, early diagnosis and prompt management of exacerbations improve recovery / quality of life, reduce hospitalisation, and may prevent progressive functional deterioration

Preventing COPD exacerbations is important as mortality increases with the frequency of exacerbations, especially if these require hospitalisation

23

When should a patient with COPD be hospitalised

Marked increase in intensity of symptoms

Exacerbation characterised by increased dyspnoea, cough or sputum production, plus one or more of the following:
- inadequate response to appropriate community-based management
- inability to walk between rooms when previously mobile
- inability to eat or sleep because of dyspnoea
- cannot manage at home even with homecare resources
- high-risk comorbid condition (pulmonary or non pulmonary)
- altered mental status suggestive of hypercapnia
- worsening hypoxaemia or cor pulmonale
- newly occurring arrhythmia
- worsening or new hypoxaemia measured with pulse oximetry.

24

Which patients with a COPD exacerbation can be treated at home

When selecting patients for home management, look for the following:

- presence of ability to cope, good level of activity / general condition, social support, normal level of consciousness

- absence of cyanosis, rapid onset, worsening peripheral oedema, significant comorbidity, evidence of respiratory failure (e.g. pH ≤ 7.35, SpO2 < 90%)

25

Are inhaled bronchodilators effective for treatment of exacerbations

Inhaled bronchodilators are effective for initial treatment of acute exacerbations

Adequate doses of bronchodilator delivered by metered dose inhalers (MDI) with a spacer are as effective as nebulisers

In patients with exacerbations, prescribe increased doses of inhaled bronchodilator, such as:
- salbutamol (400 – 800 mcg), 4 - 8 puffs via MDI and spacer every 3 - 4 hours, titrated to response. SR ME

Check that the patient can use the delivery device properly considering factors such as cognition, manual dexterity, and press and breathe coordination between actuation and inhalation

26

Are oral corticosteroids effective for treating exacerbations

Oral corticosteroids reduce the severity of, and shorten recovery from exacerbations

Compared with intravenous corticosteroids, oral corticosteroids are more convenient, appear to be as rapid acting and are possibly more effective

In patients with exacerbations, prescribe oral corticosteroids (prednisolone 30 - 50 mg or equivalent, taken in the morning with or immediately after food) for 5 days and then stop
- tapering the dose after a short course is generally not required
- long-term oral corticosteroids should be avoided

27

When are antibiotics beneficial in treating a patient with an exacerbation

Exacerbations with clinical features of infection (increased volume and change in colour of sputum and/or fever) benefit from antibiotic therapy

A chest x-ray is not usually required in community-based management of exacerbations for most patients

Intravenous antibiotics are generally not required

Sputum culture is not recommended routinely unless there is lack of response or repeated bacterial infections within several months

28

What is the initial antibiotic course prescribed for an infective exacerbation of COPD

In patients with exacerbations and clinical features of infection, prescribe oral amoxicillin (500 mg every 8 hours or 1 g every 12 hours), or doxycycline (100 mg daily for 5 days). If the response to initial antibiotic therapy is inadequate, optimise bronchodilators and oral corticosteroid therapy and reassess the diagnosis

If the patient is not improving and the sputum culture grows a resistant organism, a change in antibiotics should be considered

In patients with pneumonia, manage according to pneumonia-specific guidelines in the Therapeutic Guidelines

29

Is oxygen beneficial in treating a patient with an exacerbation

Controlled oxygen delivery targeting the SpO2 goal 88 - 92% is indicated for hypoxaemia in patients with exacerbations

In patients with COPD and hypoxaemia, administer oxygen via nasal cannula aiming for a SpO2 of 88 - 92%

Avoid over-oxygenation / high concentrations of oxygen in patients with COPD as this may lead to acute respiratory failure and death

30

When is non-invasive ventilation (NIV) effective

Non-invasive ventilation (NIV) is effective for patients with acute respiratory acidosis indicated by elevated PaCO2 levels and pH < 7.35

NIV can reduce mortality, length of stay in hospital and the need for endotracheal intubation