COPD

Question 1

investigations for COPD

Answer 1

post-bronchodlator spirometry to demonstrate airflow obstruction - FEV1/FVC ratio <70%

chest x-ray
- hyperinflation
- bullae -> if large, may mimic pneumothorax

FBC - exclude secondary polycythaemia

Question 2

different severities of COPD based on FEV1

Answer 2

all have post-bronchodilator FEV1/FVC <0.7

FEV1 of predicted
- mild = >80%
- mod = 50-79%
- severe = 30-49%
- v severe = <30%

Question 3

what cardiac problem can develop in severe COPD

Answer 3

right sided heart failure -> resulting in peripheral oedema

Question 4

non-smoking cause of COPD

Answer 4

alpha-1 antitrypsin deficiency!

Question 5

alpha-1 antitrypsin deficiency

Answer 5

common inherited condition caused by a lack of protease inhibitor (Pi) normally produced by the liver

• causes emphysema
• in young, non-smokers

Question 6

alpha-1 antitrypsin deficiency inheritance

Answer 6

autosomal recessive

(on chromosome 14)

Question 7

alpha-1 antitrypsin deficiency presentation

Answer 7

panacinar emphysema - most marked in lower lobes

adults = cirrhosis + hepatocellular carcinoma
kids = cholestasis

Question 8

alpha-1 antitrypsin deficiency investigations

Answer 8

A1AT concentrations
derrange LFTs

spirometry = obstructive pattern

Question 9

alpha-1 antitrypsin deficiency management

Answer 9

no smoking
bronchodilators, physio

IV alpha1-antitrypsin protein concentrates

surgery - lung volume reductionsurgery, lung transplantation

Question 10

most common infective causes of COPD exacerbations

Answer 10

haemophilus influenzae = commonest

strep pneumoniae
moraxella catarrhalis

viruses (30% of exacerbations) - human rhinovirus

Question 11

outpatient management of COPD exacerbation

Answer 11

• increase frequency of bronchodilator use
• give prednisolone 30mg for 5days

only give Abx if purulent sputum or clinical signs of pneumonia

Abx = amoxicillin or clarithromycin or doxycycline

Question 12

admission criteria for COPD exacerbation

Answer 12

severe breathlessness
acute confusion or impaired consciousness
cyanosis
oxygen sats <90%
social reasons - inability to cope at home
significant comorbidity - cardiac, diabetes

Question 13

oxygen therapy given in severe exacerbation of COPD

Answer 13

28% Venturi mask at 4L/min + aim for oxygen sats of 88-92%

if pCO2 is normal - adjust target range to 94-98%

Question 14

secondary care management of COPD exacerbation

Answer 14

oxygen therapy
nebulised bronchodilator
- salbutamol
- ipratropium (muscarinic antagonist)

steroid therapy
IV theophylline - if not responding to bronchodilator

Question 15

management of COPD patient who develop type 2 respiratory failure

Answer 15

non-invasive ventilation
- used for COPD with resp acidosis

bilevel positive airway pressure (BiPaP) is typically used

Question 16

general/supportive management of COPD

Answer 16

smoking cessation
annual influenza vaccination
one-off pneumococcal vaccination

pulmonary rehab - if functionally disable by COPD

Question 17

medical management of COPD

Answer 17

1st = SABA or SAMA

if asthmatic features -
- LABA + ICS
- then LAMA + LABA + ICS (switch from SAMA to SABA)

no asthmatic features -
- LABA + LAMA (switch from SAMA to SABA)

Question 18

features which suggest whether a COPD patient has asthmatic/steroid responsive features

Answer 18

• any previous diagnosis of asthma or atopy
• higher blood eosinophil count
• substantial variation in FEV1 over time (at least 400ml)
• substantial diurnal variation in PEF

Question 19

when is oral theophylline used in COPD mx

Answer 19

after trial of short + long acting bronchodilators or to people who cannot use inhaled therapies

• the dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribes

Question 20

prophylactic antibiotic therapy in COPD

Answer 20

azithromycin !
- do LFTs + ECG to exclude QT prolongation (azithro can do this)

only if
- dont smoke, optimised tx + continue to have exacerbations
- have had a CT thorax (to exclude bronchiectasis) + a sputum culture (to exclude atypical infections/ tuberculosis)

Question 21

standby medication COPD

Answer 21

offer short course of oral corticosteroid + antibiotics if;
- exacerbation within last year
- understand how to take, aware of assoc risks + benefits
- know when to seek help + replace

Question 22

phosphodiesterase-4 (PDE-4) inhibitors

Answer 22

reduce risk of COPD exacerbation in patients with severe COPD + hx of severe exacerbations

example = roflumilast

Question 23

cor pulmonale features

Answer 23

peripheral oedema
raised JVP
systolic parasternal heave
loud P2

Question 24

cor pulmonale management

Answer 24

loop diuretic for oedema
consider long term oxygen therapy

NOT recommend - ACEi, CCB

Question 25

factors which may improve survival in patients with stable COPD

Answer 25

smoking cessation long term oxygen therapy (for those who fit criteria) lung volume reduction surgery in select patients

Question 26

smoking cessation medical options

Answer 26

nicotine replacement therapy vareniciline bupropion -> bottom 2 contraindicatied in prenancy

Question 27

bupropion

Answer 27

a norepinephrine-dopamine reuptake inhibitor + nicotinic antagonist start 1-2weeks before target stop date - small risk of seizures - 1 in 1000 - contraindicated in epilepsy, preg, breast feed, eating disorders

Question 28

criteria for long term oxygen therapy (LTOT)

Answer 28

pO2 <7.3 or pO2 7.3-8 + one of; - secondary polycythaemia - peripheral oedema - pulmonary hypertension blood gases measured twice at least 3wks apart DO NOT give to current smokers

Question 29

varenicline

Answer 29

nicotinic receptor partial agonist - start 1 week before target stop date - caution in hx of depression or self harm