COPD

Question 1

what is COPD

Answer 1

COPD is a preventable and treatable (but not curable) respiratory condition that is characterised by persistent respiratory symptoms and airflow obstruction.

Question 2

What conditions does COPD encompass? (these are the old terms used to describe COPD)

Answer 2

emphysema and chronic bronchitis

Question 3

what is emphysema

Answer 3

its a pathological term referring to loss of parenchymal (functional aka helping gas exchange aka alvioli) lung texture

Question 4

what is chronic bronchiolitis

Answer 4

clinical term referring to cough and sputum production for at least 3 months in each of 2 consecutive yrs

Question 5

modifiable risk factors of COPD

Answer 5

Smoking - accounts for 90% of COPD cases. cigs but also water pipe, marijuana, and other types

Occupational exposure - coal or silica dust, welding fumes, industrial chemicals etc.

Air pollution

Childhood or in-utero lung damage - maternal or passive smoking, preterm birth, severe respiratory infections.

Question 6

non modiafiable COPD risk factors

Answer 6

Alpha-1-antitrypsin deficiency - a rare, congenital cause of COPD, present in 2% of COPD cases. It should be considered in those diagnosed under 45 years.

Asthma

Question 7

what are the key COPD symptoms

Answer 7

cough: often productive
dyspnoea (SOB)
wheeze
a history of recurrent lower resp tract infections

Question 8

nature and progression of SOB

Answer 8

progresses over time and worse on exertion

Question 9

other symptoms of COPD

Answer 9

weight loss

fatigue

reduced exercise tolerance

waking at night with dyspnoea

barrel chest (hyperinflation

pursed lip breathing

in severe cases, right-sided heart failure may develop resulting in peripheral oedema

Question 10

signs on physical examination

Answer 10

• Hyper-resonance on percussion
• End-expiratory wheeze on auscultation
• Coarse crackles
• Reduced breath sounds

Question 11

What are the key investigations?

Answer 11

spirometry

standardised symptoms score (mMRC/ CAT: latter more detailed but less widely used)

Pulse oximetry

ABG

CXR

FBC

BMI calculation

Question 12

how to use spirometry data for COPD diagnsosis

Answer 12

1) -post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70%

2) after obstruction is demonstrated:

-The severity of COPD is categorised using the FEV1*:
FEV1%= observed/ predicted value-
>80% stage 1 mild
50-79= stage 2 moderate, 30-49% stage 3 severe
<30% stage 4 very severe

3) Measuring peak expiratory flow is of limited value in COPD, as it may underestimate the degree of airflow obstruction.

4) symptoms SHOULD be present to diagnose COPD in these patients

Question 13

what does CXR show

Answer 13

• Hyperinflation (>6 anterior ribs seen above diaphragm)
• Bullae- If large may mimic a pneumothorax
• Hyperlucent lung fields
• Flat hemidiaphragm
• can exclude lung cancer

Question 14

Alpha-1-antitrypsin levels- when do we do this?

Answer 14

If young patient, who has never smoked

Question 15

What would we see on CT for A1AT deficiency and how does this differ to COPD?

Answer 15

would see Emphysema in lower lobes while COPD has upper lobe emphysema

Question 16

why do we do an FBC as an investigation for COPD?

Answer 16

Exclude secondary polycythaemia

Question 17

when do we do an ABG and why

Answer 17

If acute exacerbation to check O2 and CO2 levels because COPD causes CO2 retention and type 2 respiratory failure

Question 18

What’s the first step of MANAGEMENT and why?

Answer 18

Smoking cessation because its the most effective COPD management

Question 19

what are the options of smoking cessation therapy

Answer 19

Nicotine replacement therapy -patches or as shorter acting oral forms (lozenges, chewing gum) or nasal sprays; reduces urges and withdrawal symptoms by substituting for nicotine inhaled via tobacco smoke1

oral varenicline- a nicotinic receptor partial agonist that binds less effectively than nicotine

oral buproprion (seems to be a nicotinic receptor antagonist with dopaminergic and adrenergic actions; it may work by blocking effects of nicotine, relieving withdrawal, or reducing depressed mood)

Question 20

what is the most appropriate smoking cessation drug for pregnant women

Answer 20

NRT since varenicline and bupropion are contraindicated

Question 21

Bupropion- who is this contraindicated in?

Answer 21

Epilepsy patients

Question 22

what is the most effective smoking cessation therapy

Answer 22

Varenicline and combination NRT (a patch plus a short acting form)

Question 23

what should be monitored in patients taking varenicline and buproprion

Answer 23

adverse psychological reactions

Question 24

What other non-pharmacological management is there?

Answer 24

• Annual influenza vaccine
• One-off pneumococcal vaccine
• Pulmonary rehabilitation for people who view themselves as functionally disabled by COPD

Question 25

what is the first line TREATMENT (not management) of COPD

Answer 25

a short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is first-line treatment

Question 26

if breathlessness/ symptoms + exacerbations don't settle with first line what to do?

Answer 26

next step is determined by whether the patient has 'asthmatic features/features suggesting steroid responsiveness'

Question 27

what are the NICE criteria used to determine whether a patient has asthmatic/ steroid features?

Answer 27

NOT formal asthma reversibility testing JUST consider these: -any previous, secure diagnosis of asthma or of atopy -a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up -substantial variation in FEV1 over time (at least 400 ml) -substantial diurnal variation in peak expiratory flow (at least 20%)

Question 28

what is the action if there are no asthmatic features

Answer 28

add a long-acting beta2-agonist (LABA) ANDDD long-acting muscarinic antagonist (LAMA) if already taking a SAMA, discontinue and switch to a SABA

Question 29

what is the action if there are asthmatic features

Answer 29

LABA + inhaled corticosteroid (ICS)

Question 30

IN THOSE with asthmatic features that have taken the LABA+ ICS second line, what to do if they still have exacerbations?

Answer 30

-offer triple therapy i.e. LAMA + LABA + ICS -if already taking a SAMA, discontinue and switch to a SABA

Question 31

definition of COPD exacerbration

Answer 31

An exacerbation of COPD may be defined as an event characterised by increased dyspnoea and/or cough and sputum that worsens in <14 days and may be accompanied by tachypnoea and/or tachycardia.

Question 32

other relevant stable management treatments in COPD not used on everyone/ use dependent on each patient

Answer 32

-Oral theophylline only if failed inhaled therapies or cant use them (reduce those if antibiotics together) -Oral prophylactic antibiotic therapy: azythromycin prophylaxis only in people that have optimal management and still have exacerbrations + CT thorax + sputum uclutre + lFTs + ECG bc risk heart - standby medications (short course oral corticosteroids and AB) for people who have had an execerbration in last year and know how to handle this treatment -mucolytics - if chronic productive cough and continue if it works - phosphodiesterase-4 inhibitors (PDE-4) INHIBITORS they can reduce exacerbrations in people that have very severe copd and lots of exacerbrations despite optimal treatment - in people with cor pulmonale: use a loop diuretic for oedema, consider long-term oxygen therapy

Question 33

cor pulmonale what is it

Answer 33

(right sided heart failure) features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2

Question 34

Factors which may improve survival in patients with stable COPD

Answer 34

smoking cessation - the single most important intervention in patients who are still smoking long term oxygen therapy in patients who fit criteria lung volume reduction surgery in selected patients

Question 35

how is an acute exacerbation managed?

Answer 35

24% oxygen (blue venturi mask)- - Nebulised bronchodilators (Salbutamol & ipratropium bromide) - Corticosteroids (Oral prednisolone for 5 days or IV hydrocortisone if clinically unstable) - IV theophylline - Antibiotics- (with criteria) - NIV (BiPAP)- (with criteria)

Question 36

Antibiotics- when and which ones?

Answer 36

- Only if evidence of infection such as green sputum or signs of pneumonia - Amoxicillin, doxycycline or clarithromycin

Question 37

When do we not give clarithromycin?

Answer 37

In patients with congenital long QT syndrome

Question 38

NIV (BiPAP)- when?

Answer 38

if respiratory acidosis with high CO2 despite maximum medical treatment pH range 7.25-7.35

Question 39

most common cause of an acute exacerbation of COPD?

Answer 39

Haemophilus influenzae

Question 40

What do we give to critically ill (including CO2 retaining) patients?

Answer 40

High flow oxygen → reservoir mask at 15 l/min

Question 41

complications of COPD

Answer 41

- ACUTE EXACERbations - cor pulmonale - lung cancer - reccurent pneumonia - pheumothorax -resp. failure

Question 42

What is the reported prognosis of COPD based upon?

Answer 42

FEV1- significant correlation between increased FEV1 and lower risk of COPD exacerbation