COPD

Question 1

What is Chronic Obstructive Pulmonary Disease (COPD)?

Answer 1

A long term progressive condition consisting of airway obstruction, chronic bronchitis, and emphysema.

Question 2

What are the key features of COPD?

Answer 2

Irreversible airway obstruction, dyspnoea, productive cough.

Question 3

How does asthma differ from COPD?

Answer 3

Asthma is reversible and episodic; COPD is irreversible and progressive.

Question 4

What are the symptoms of COPD?

Answer 4

• Shortness of breath
• Chronic productive cough
• Wheeze
• Recurrent respiratory infections
• Weight loss
• Cor pulmonale

Question 5

What are the red flags to exclude in case of lung cancer or heart failure in COPD patients?

Answer 5

Haemoptysis, chest pain, clubbing.

Question 6

What is the MRC Dyspnoea Scale?

Answer 6

A 5-point scale for grading breathlessness.

Grade 1: Breathless only with strenuous exercise.
Grade 2: Short of breath when hurrying on the level or walking up a slight hill.
Grade 3: Walks slower than people of the same age on the level because of breathlessness, or has to stop for breath when walking at their own pace on the level.
Grade 4: Stops for breath after walking 100 yards (91 meters) or after a few minutes on the level.
Grade 5: Too breathless to leave the house or breathless when dressing.

Question 7

What does Grade 1 on the MRC Dyspnoea Scale indicate?

Answer 7

SOB on strenuous exercise.

Question 8

What is the diagnostic method for COPD?

Answer 8

Clinical diagnosis + spirometry with reversibility testing

Question 9

What spirometry result indicates COPD?

Answer 9

FEV1:FVC ratio less than 70% with no reversibility with salbutamol.

Question 10

How is severity of COPD classified?

Answer 10

GOLD criteria
* Stage 1: Mild - FEV1 > 80% of predicted
* Stage 2: Moderate - FEV1 50-79% of predicted
* Stage 3: Severe - FEV1 30-49% of predicted
* Stage 4: Very Severe - FEV1 < 30% of predicted.

Question 11

What are the first-line management options for COPD?

Answer 11

SABA or SAMA as relievers.

Question 12

What is the combination treatment if management with SABA/SAMA fails in COPD?

Answer 12

• LABA + ICS (if asthmatic features/steroid responsive)
• LABA + LAMA (if no asthmatic features/steroid features).

Question 13

What are the indications for long-term oxygen therapy (LTOT) in COPD?

Answer 13

• Oxygen saturations <92% in air/ cyanosis
• FEV1 <30% predicted (consider referring if <49%)
• Polycythaemia
• Peripheral oedema/raised JVP (suggesting cor pulmonale)

Question 14

What is the initial management for acute exacerbation of COPD?

Answer 14

• Oxygen therapy (88-92%)
• Nebulised SABA/SAMA
• Oral prednisolone 30mg OD for 5 days.
• Antibiotics (azithromycin) if infection

If severe:
IV aminophylline
NIV
Intubation and ventilation with ICU admission
Doxapram if NIV or intubation unsuccessful

Question 15

What investigations are performed during an acute exacerbation of COPD?

Answer 15

• ABG - Type 2 resp failure
• Chest X-ray: rule out lung cancer, bronchiectasis, look for hyperinflation, flattening of diaphragm and bullae
• ECG:
• FBC
• U&E
• Sputum culture: During exacerbations
• Blood cultures.

Question 16

What does a raised bicarbonate level in ABG indicate during an acute exacerbation of COPD?

Answer 16

Chronic CO2 retention.

Question 17

What are the indications for NIV in COPD exacerbation?

Answer 17

ABG shows acidosis + PaCO2 > 6, potential to recover, acceptable to patient.

Question 18

What are the contraindications for NIV?

Answer 18

• Untreated pneumothorax
• Confusion
• Structural abnormalities in face, airway, GI tract.

Question 19

What is a potential treatment if NIV or ventilation is unsuccessful in COPD patients?

Answer 19

Doxapram.

Question 20

What are some additional management options for COPD?

Answer 20

• Oral theophylline
• Oral mucolytics (e.g., carbocisteine)
• Prophylactic antibiotics (e.g., azithromycin)
• Oral corticosteroids (e.g., prednisolone)
• Oral phosphodiesterase 4 inhibitors (e.g., roflumilast)
• Lung volume reduction surgery.
• Palliative care.

Question 21

What should COPD patients be given when they go home after exacerbation?

Answer 21

Short course amoxicillin and prednisone

Question 22

What are the risk factors for COPD?

Answer 22

Smoking
Passive smoking
Marijuana smoking
Occupational exposure to dust and fumes
Wood/coal burning in household
Alpha 1 antitrypsin deficiency

Question 23

ECG changes in COPD?

Answer 23

Low voltage QRS complexes (heart gets squashed by hyperinflated lungs leading to more air space between heart and electrodes so smaller QRS complexes)

Right axis deviation
P pulmonale
RBBB
Multifocal atrial tachycardia (Associated with increased mortality)

Question 24

Conservative management of COPD?

Answer 24

Smoking cessation
One off flu and pneumococcal vaccine
Nutrition support and dietician care if weight loss
Pulmonary rehabilitation if < 3 on MRC scale or recent infective exacerbation admission
Respiratory physiotherapy to help with breathing and sputum clearance techniques

Question 25

Stepwise management of COPD?

Answer 25

1st line: SABA or SAMA as reliever therapy 2nd line: If asthmatic features: add LABA + ICS If no asthmatic features: take out SAMA and add SABA+LABA+ LAMA 3rd line: If doesn't respond then add either ICS/LAMA 4th line: If doesn't respond then refer to specialist for additional management

Question 26

What does secondary polycythaemia lead to?

Answer 26

Increased blood viscocity therefore increased risk of arterial or venous thrombosis

Question 27

Complications of COPD?

Answer 27

Polycythaemia Acute exacerbations Cor pulmonale Pneumothorax Depression and anxiety

Question 28

How does COPD cause pneumothorax?

Answer 28

Rupture of bullae → release of air into pleural space

Question 29

What are the target O2 sats in COPD if their CO2 is normal on an ABG?

Answer 29

94-98%