COPD

Question 1

What is the definition of COPD

Answer 1

Preventable + treatable disease - characterised by PERSISTENT airflow limitation that is usually progressive + associated with an increased chronic inflammatory response in the airways and the lungs due to noxious particles and gases

Irreversible due to structural changes in the lungs

Question 2

What is COPD

Answer 2

• Airflow limitation: progressive + abnormal response of lungs to noxious particles or gases
• Blockage: from bronchi to respiratory bronchioles - due to plug in lumen
• Chronic inflammation —> irreparable tissue damage
• Triggered by cigarette smoke + environmental factors over many years and leads to Oxidative stress leading to lung issues + inflammation

Question 3

The 2 types of COPD

Answer 3

Chronic Obstructive Bronchiolitis - fibrosis of small airways
Emphysema - enlargement of alveoli + alveolar wall destruction

Question 4

What is Type A COPD and its characteristics

Answer 4

Emphysema
- SOB for few years
- Absence or non-productive cough
- Recent weight loss
- Barrel chest with flat diaphragm + over-inflation of lungs
- Narrowed pulmonary vessels
- Moderate hypoxaemia (low O2 levels)
No mucus associated
Lungs loses its elasticity due alveolar wall destruction

Question 5

What is Type B and its characteristics

Answer 5

Chronic obstructive bronchitis (COB)
- Progressive increase in SOB + activity
- Chronic production cough for many years
- Gradually increase in severity + duration / limitation
Mucus associated
Mucus hypersecretion occurs

Question 6

Acute Bronchitis

Answer 6

Inflammation of large bronchi in lungs that is usually caused by viruses or bacteria and may last several days or weeks

Symptoms:
- cough
- sputum (phlegm) production
- SOB
- wheezing related to obstruction of the inflamed airways

Question 7

Chronic Bronchitis

Answer 7

increased secretion of mucus due to inflammation —> airway obstruction + increased chance of bacterial infection

Increased mucus production:
- enlargement of mucus secreting glands
- increased goblet cell number
- inflammatory cell proliferation
Coughing, mucus hyper-secretion, wheezing, breathlessness

Question 8

Emphysema

Answer 8

Characteristics: - associated with breathlessness

Loss of elasticity in alveoli walls
- Reduced A1- anti - trypsin (an anti protease resulting in destruction of elastic fibres)
Acquired - tobacco smoking
Intrinsic - A1 anti trypsin deficiency (liver dysfunction)

Collapse of alveoli
- Loss of reticular structure
- Loss of associated vasculature
Alveoli can become distended and form large air filled spaces
Reduced O2 saturations and Increased CO2 concs

Question 9

Exacerbations of COPD

Answer 9

Most COPD exacerbations are triggered by respiratory viral infections e.g. rhinovirus

Question 10

Treatments

Answer 10

Symptom reduction
- pulmonary rehab + exercise
- SABA - relief of symptoms ‘
- One long acting inhaled bronchodilator (LABA/LAMA)
- LABA-LAMA combo - when single long acting bronchodilator not enough
Risk reduction
- One long acting inhaled bronchodilator (LAMA preferred over LABA)
- ICS-LABA combo - no bacterial colonisation + eosinophil count > 32%
- LABA-LAMA combo - bacterial colonisation + eosinophil count < 2%
- Roflumilast - only in patients with concomitant CB
Oral mucolytics (carbocisteine)

Question 11

PDE4 Inhibtors - Rofumilast

Answer 11

• cAMP = trigger for cell signalling pathway
• PDE4 = enzyme that metabolises cAMP
• inhibition of PDE4 —> increased cAMP levels in cells + reactivation of signalling pathways for reducing inflammation
• cAMP —> decreased immune response (less inflammation), reduced bronchodilation (less fibrosis)

Question 12

Oral mucolytics

Answer 12

Carbocisteine and N-acteylcysteine (NAC)
- Excessive mucus production impairing airways
- NAC hydrolyses disulfide bonds of mucus proteins
- decreases mucus viscosity
- allows for mucus clearance
- decreased sputum hyper-secretion
Improves FEV1, less SOB, lower exacerbation rate, lower adhesion

Question 13

Causes + RFs

Answer 13

Main cause = tobbaco smoke + toxic particles inhalation
Genetics - mutations in SERPINA1 gene (A1 antitrypsin deficiency —> protease expression —> Emphysema +/or CB

Question 14

Classification of COPD (GOLD)

Answer 14

COPD-A - ACOS (asthma, COPD overlap syndrome)
COPD-C - cigarette smoking
COPD-D - Abnormal lung development
COPD-G - genetically determined
COPD-I - infection associated
COPD-P - associated with biomass/pollution
COPD-U - unknown aetiology

Question 15

Signs + symptoms

Answer 15

Chronic SOB - persistent, progressive, worse with exercise
Cough with sputum - on and off
Wheezing
Chest tightness
History of RFs

Question 16

Diagnosis

Answer 16

RF = smoking usually
COPD diagnosis suspected in patients >/= 35 or over, who have a RF for COPD with one symptom of:
- breathlessness
- Chronic cough
- Sputum production
- Frequent bronchitis
- Wheeze

Question 17

Spirometry

Answer 17

Main lung function test - assesses obstructive vs restrictive causes of airway limitation
Obstructive: loss of flow > proportional loss of volume
Restrictive: loss of volume > proportional loss of flow

Question 18

Grading COPD

Answer 18

FEV1% predicted >/= 80% : stage 1 - mild

FEV1% predicted 50-79%: stage 2 - moderate

FEV1% predicted 30-49%: stage 3 - severe

FEV1% predicted < 30 %: stage 4 - very severe

Question 19

Non-pharmacological

Answer 19

Smoking cessation
Pack year history (number of cigs per day/20) x years smoked
Vaccines
- Pneumonococcal vaccines
- COVID vaccines
- Influenza vaccines
- Self-management plans
- Pulmonary rehabilitation

Question 20

Pulmonary Rehabilitation

Answer 20

Individually tailored + designed to optimise individual physical performance
All COPD patients offered referral if:
- mMRC of 3 or above
- all patients admitted to hospital because of COPD
Not suitable for UA or recent MI

Question 21

ICS in COPD

Answer 21

Regular ICS treatment —> increased pneumonia risk (low eosinophil blood count patients not indicated for ICS)
ICS never used as mono therapy
ICS reserved for patients with high blood eosinophil counts > 0.4 - ICS okay for moderately raised eosinophils

Question 22

What are the NICE guidelines for a patient with non asthmatic features or features suggesting steroid responsiveness

Answer 22

Offer a SABA or SAMA no matter what (prn)
Answer to question:
- offer LABA + LAMA
If person has day-day symptoms that affect quality of life then —> consider 3 month trail of LABA + LAMA + ICS, if NO improvement give LABA+LAMA
If person has 1 sever or 2 moderate exacerbations within a year —> consider LABA + LAMA + ICS

Question 23

What are the NICE guidelines for a patient with asthmatic features or features suggesting steroid responsiveness

Answer 23

Offer SABA / SAMA (prn)
Answer:
- Consider LABA + ICS
If person has day-day symptoms that adversely impact quality of life, or has 1 severe or 2 moderate exacerbations within a year LAMA + LABA + ICS

Question 24

GOLD

Answer 24

Group A and B -
0 or 1 moderate exacerbations (not leading to hospital admission)
Group E -
>/= 2 moderate exacerbations or >/= 1 leading to hospitalisation
Group A - bronchodilator mMRC 0-1, CAT < 10
Group B - LABA + LAMA mMRC >/= 2, CAT >/= 10
Group E - LABA + LAMA (consider LABA + LAMA + ICS)
Blood eos >/= 300

Question 25

Other treatments

Answer 25

Oral mucolytics drugs: carbocysteine 375mg TDS
- Used for patients with chronic sputum production despite maximal therapy
- only continue if symptomatic benefit observed
Prophylactic antibiotics:
- Before starting, need sputum culture + ECG + sensitivity
- COPD patients with high risk RTI. Frequent RTI may need preventative antibiotics. Initiated by specialist
- Azithromycin 250mg 3 x a week if: they’re a non-smoker, have optimised non-pharmacological + pharmacological therapies, have engaged in pulmonary rehab. + continue to have exacerbations