COPD

Question 1

Define COPD

Answer 1

Common progressive disorder characterized by airway obstruction (FEV1

Question 2

What two diseases is COPD made up of?

Answer 2

Chronic Bronchitis

Emphysema

Question 3

What is chronic bronchitis defined as?

Answer 3

It is defined clinically as the presence of cough and excessive mucus production on most
days for at least 3 consecutive months for 2 successive years.

Question 4

What is emphysema defined as?

Answer 4

It is defined histologically as permanent destructive enlargement of the airspaces distal to the terminal bronchiole.

Question 5

What are the two types of COPD patients

Answer 5

Pink puffers

Blue bloaters

Question 6

What is a pink puffer?

Answer 6

Pink puffers have increased alveolar ventilation, a near normal paO2 and a normal or low PaCO2. Breathless but no cyanosed, and may progress to type 1 respiratory failure.

Question 7

What is a blue bloater?

Answer 7

Blue bloaters have decreased alveolar ventilation with a low paO2 and high paCO2. They are cyanosed but not breathless and may go on to develop cor pulmonale. Rely on hypoxic drive to maintain respiratory effort.

Question 8

What are the key presenting sy,ptms of COPD (5)

Answer 8

• Exertional dyspnoea
• Chronic cough
• Regular sputum production
• Frequent winter “bronchitis”
• Wheeze

Question 9

How do you assess COPD severity?

Answer 9

FEV1

Question 10

Give the number categories for COPD severity

Answer 10

> 80% - Mild
50-79% - Moderate
30-49% - Severe

Question 11

What is the MRC breathlessness scale?

Answer 11

Quantifies the disability associated with breathlessness

Question 12

Do MRC flashcards

Answer 12

Do MRC flashcards

Question 13

What is the risk of in-hospital death with MRC 5?

Answer 13

22.8%

Question 14

What is cor pulmonale?

Answer 14

Right ventricular enlargement as a result of pulmonary hypertension, which in COPD comes about as a result of a ventilation-perfusion mismatch causing vasoconstriction, or loss of capillary beds due to bullous formation.

Question 15

Give four signs of cor pulmonale

Answer 15

• Peripheral oedema
• Raised JVP
• Hepatomegaly
• RV gallop rhythm

Question 16

Give 5 clinical signs of COPD in the lungs

Answer 16

• Decreased expansion
• Resonant or hyper-resonant percussion note
• Quiet breath sounds
• Hyperinflation
• Use of accessory musles of inspiration

Question 17

Give three systemic signs of COPD

Answer 17

Wheeze
Cyanosis
Cor pulmonale

Question 18

Give 6 investigations for COPD

Answer 18

FBC
CXR
ECG
ABG
LF Test
Alpha-1 antitrypsin

Question 19

What is an FBC for

Answer 19

Detecting increased PCV (anoxia stimulates RBC production)

Question 20

What four features can be seen on COPD CXR?

Answer 20

• Hyperinflation (>6 ribs seen above diaphragm in mid-clavicular line
• Flat hemidiaphragms
• Large central pulmonary arteries
• Descreased peripheral vascular markings

Question 21

What can be seen on ECG?

Answer 21

• Right atrial and ventricular hypertrophy

Question 22

What are you looking for on ABG

Answer 22

Decreased PaO2 and potentially increased PCO2

Question 23

What will the lung function test show in COPD

Answer 23

• Obstructive + air trapping (FEV1

Question 24

What is a COPD exacerbation?

Answer 24

An exacerbation is a sustained worsening of the patient’s symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset.

Question 25

What is the usual presentation of COPD exacerbation/

Answer 25

Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour.

Question 26

What three things must be explored in history of someone with COPD exacerbation?

Answer 26

Ask about usual/recent treatments, smoking status and MRC dyspnoea scale

Question 27

Give five differentials for COPD exacerbation

Answer 27

``` Asthma Pulmonary oedema URT obstruction PE Anaphylaxis ```

Question 28

What is initial management of COPD exacerbation?

Answer 28

ABCDE

Question 29

What is first step after ABCDEs? (include drugs and dosages)

Answer 29

Nebulized bronchodilators | Salbultamol 5mg/4h and ipratropium bromide 500micrograms/6h

Question 30

What is after nebulized salbutamol?

Answer 30

Controlled O2 therapy if SaO2

Question 31

What are you aiming for in COPD oxygen therapy?

Answer 31

Sats of 88-92% (94-98 if no hypercapnia on ABG) | PaO2 >8kPa and a rise in PaCO2

Question 32

What is next after salbutamol and O2 therapy?

Answer 32

Steroids

Question 33

What steroid drugs are given and in what dosasge?

Answer 33

IV hydrocortisone 200mg and oral prednisolone 30mg OD (continue for 7-14 days)

Question 34

What antibiotics must be given and in what dosages?

Answer 34

If evidence of infection amoxicillin 800mg/TDS or clarithromycin

Question 35

If salbutamol, steroids and O2 fail to work, what is last ditch medication?

Answer 35

IV aminophylline

Question 36

What happens if no response to Salbutamol, steroids, O2 and IV aminophylline

Answer 36

1) Consider non-invasive positive pressure ventilation if RR >30 or pH

Question 37

If no NIV available what must be done?

Answer 37

3) Consider a respiratory stimulant drug (doxapram 1.5-4mg IV). Used only if NIV not available.

Question 38

What must be done before discharge? (4)

Answer 38

Discuss - Steroid reduction - Home O2 - Smoking cessation - Pneumococcal and flue vaccination

Question 39

What are the two general treatments for COPD

Answer 39

Lifestyle (stop smoking, encourage exercise, decrease obesity, pneumococcal and influenza vaccination, pulmonary rehap/palliative care) PRN short-acting anti-muscarinic (ipratropium) or B2 agonist

Question 40

What do you give on top of general management in COPD?

Answer 40

- Combination of long acting B2 agonist _corticosteroids such as symbicort

Question 41

What do you give in very severe COPD on top of severe treatment and general management?

Answer 41

Tiotropium + inhaled steroid + long acting B2 agonist | - Consider steroid trial, home nebulizers, theophylline

Question 42

Give three ways to treat pulmonary hypertension

Answer 42

- Assess the need for long term oxygen therapy - Treat oedema with diuretics - Pulmonary rehabilitation greatly valued by patients

Question 43

What does the cochrane meta-analyses say in terms of steroids and Long-acting broncho agonists

Answer 43

Cochrane meta-analyses 2007 favour steroids + LABA vs either alone. Steroids on own increase risk of pneumonia, LABA increase risk of exacerbations.