COPD

Question 1

define chronic bronchitis

Answer 1

productive cough for at least 3 months per year for 2 consecutive years that cannot be explained by an alternative diagnosis

Question 2

define emphysema

Answer 2

permanent dilatation of pulmonary air spaces distal to the terminal bronchioles that is cuased by the destruction of the alveolar walls and pulmonary capillaries required for gas exchange

Question 3

endogneous risk factors

Answer 3

lung growth and development abnormalities - recurrent pulmonary infections, premature birth
a1-antitrypsin deficiency
airway hyperresponsiveness
antibody deficiency syndrome eg. IgA deficiency
primary ciliary dyskinesia

Question 4

presenting findings of COPD

Answer 4

chronic cough with expectoration especially in the morning
dyspnea and tachypnoea
pursed lip breathing
prolonged expiratory phase
end expiratory wheezing
crackles
muffled breath sounds
cyanosis
tachycardia

Question 5

features of advanced COPD

Answer 5

congested neck veins
baarrel chest
use of accessory respiratory muscles due to diaphraagmatic dysfunction
hyperresonant lungs
decreased breath sounds
right heart failure and cor pulmonale
weight loss and cachexia

Question 6

cor pulmonale

Answer 6

pulmonary heart disease
altered structure or impaired functioning of the right ventricle caused by a primary disorder of the respiratory system

Question 7

pink puffers

Answer 7

emphysema predominating
noncyanotic
cachectic
pursed lip breathing
mild cough

Question 8

blue bloater

Answer 8

chronic bronchitis predominating
productive cough
overweight
peripheral oedema

Question 9

a1-antitrypsin deficiency

Answer 9

deficiency of a protease inhibitor
presents with panacinar emphysema and cirrhosis
age of onset usually younger
often also have hepatic signs and symptoms related to hepatitis or cirrhosis

Question 10

centrilobular/centriacinar emphysema

Answer 10

most common type
seen in smokers
destruction of respiratory bronchiole (central portion of acinus) sparing distal alveoli
usually affects upper lobes

Question 11

panlobular/panacinar emphysema

Answer 11

rarer type
associated with a1-antitrypsin deficiency
characterised by destruction of entire acinus (respiratory bronchiole and alveoli)
usually affects the lower lobes

Question 12

initial tests for COPD

Answer 12

spirometry - FEV1/FVC < 70% after bronchodilator inhalation confirms the diagnosis
serum AAT level

Question 13

restrictive lung disease

Answer 13

eg. pulmonary fibrosis
inability to inflate fully

Question 14

obstructive lung disease

Answer 14

eg. bronchial asthma, COPD
difficulty exhaling air

Question 15

assessment for respiratory failure

Answer 15

pulse oximetry: obtain in patients with signs of respiratory distress or signs of right heart failure
measure aat rest and on ambient air or usually oxygen prescription
ABG: obtain in patients with SO2 < 92% and/or acute illness

Question 16

ABG findings of COPD

Answer 16

may show hypoxemic resp failure (low PO2) with or without hypercapnic respiratory failure
(high PCO2)
chronic hypercapnia due to CO2 trpping is common in patients with severe COPD

Question 17

imaging

Answer 17

not required for diagnosis
signs of pulmonary hyperinlfation
- increased anteroposterior diameter (barrel chest)
- pushed down and flattened diaphragm
- horizontal ribs and widened intercostal spaces
- lyperlucency of lung tissue
- long and narrow heart shadow
signs of bullous emphysema: parenchymal bullae or pulmonary blebs

Question 18

lifestyle modifications for COPD

Answer 18

counsel on smoking cessation eg. varenicline, buproprion, nicotine replacement therapy, lozenges, transdermal patch, gum
encourage physcal activity to recduce the risk of acute exacerbations
educate on indoor air pollution, work related pollution
recommend vaccinations
pulmonary rehabilitation

Question 19

mild COPD

Answer 19

60-80% predicted FEV1 post bronchodilator
breathless on moderate exertion, few symptoms or effects on ADLs

Question 20

moderate COPD

Answer 20

40-59% predicted FEV1 increasing dyspneoa, breathless on the flat, increasing limitation of ADLs

Question 21

severe COPD

Answer 21

<40% predicted FEV1
dyspnoea on minimal exertion, ADLs severely curtailed

Question 22

pharmacotherapy for COPD

Answer 22

symptomatic bronchodilator: short acting bronchodilator SABA salbutamol and/or ipratropium used when needed
regular bronchodilator: long acting beta-2 agonist LABA added when frequent deterioration in symptoms prompts additional medication use

Question 23

regular bronchodilators that can be added in more severe disease

Answer 23

long acting anticholinergic tiotropium once daily
and then
fluticason propionate with salmeterol xinafoate

Question 24

oral medications for COPD

Answer 24

oral slow release theophylline
may be useful after trial of short and long acting bronchodilator or where no inhlater use is possible

Question 25

SABA

Answer 25

A class of bronchodilating medications with a short duration of action (< 6 hours). These medications also have a quick onset of action (1-5 minutes). Used to treat acute exacerbations of asthma and COPD. Usually administered via a nebulizer or metered-dose inhaler.

Question 26

LABA

Answer 26

A class of bronchodilating medications with a long duration of action (≥ 12 hours). Onset of action is variable (quick for formoterol, longer for salmeterol). Used for long-term control of symptoms of asthma and COPD. Usually administered via a nebulizer or metered-dosed inhaler.

Question 27

LAMA

Answer 27

A class of muscarinic antagonists that have a long duration of action (typically ≥ 12 hours). Used for maintenance therapy for asthma and chronic obstructive pulmonary disease. Examples include tiotropium, aclidinium, umeclidinium, and glycopyrrolate.

Question 28

SAMA

Answer 28

A class of muscarinic antagonists with an onset of action of 10-15 minutes and a short duration of action (4-6 hours). Used to treat acute exacerbations of asthma and COPD. Examples include ipratropium and aclidinium.

Question 29

ICS

Answer 29

inhaled corticosteroid eg. fluticasone

Question 30

other drugs for COPD

Answer 30

palliative pharmacotherapy for dyspnoea eg. opiates
mathyxanthines eg. theophylline

Question 31

LTOT

Answer 31

long term oxygen therapy
PaO2 < 55 mmHg or SaO2 < 88% at rest despite optimal medication
or pulmonary hypertension, CHF, polycythaemia
target O2 saturation >90%
continous oxygen therapy for > 15 hours/day
reevaluate after 60-90 days with ABG or pulse oximetry

Question 32

ventilatory support

Answer 32

continuous positive airway pressure is useful in patients with COPD and pbstructive sleep apnoea
long term noninvasive positive pressure ventilation may be considered in select patients with severe chronic hypercapnia

Question 33

surgical management

Answer 33

surgical bullectomy - in severe emphysema with hyperinflation and large bullae
lung volume reduction - for severe emphysema and hyperinflation without large bullae
lung transplantation

Question 34

complications of COPD

Answer 34

chronic respiratory failure
acute exaacerbation of COPD
cor pulmonale
secondary spontaneous pneumothorax due to rupture of bullae (especially in bullous emphysema)