COPD

Question 1

Symptoms of COPD

Answer 1

Dyspnoea (exertional)
Chronic productive cough
Recurrent chest infections
Weight loss
Fatigue
Exercise intolerance

Question 2

Signs of COPD

Answer 2

Wheeze or quiet breath sounds
Peripheral oedema and raised JVP (right heart failure)
Cyanosis
Cachexia
Hyperinflated chest
Use of accessory muscles
Pursed lip breathing

Question 3

Pathophys of emphysema

Answer 3

Smoking inactivates alpha-1 antitrypsin (or hereditary deficiency) so that this can’t inhibit serum elastase
–> elastic tissues destroyed
–> Loss of elastic fibres of the alveoli and a decreased surface area –> can lead to collapsed alveoli
Can get air trapping as you exhale as the recoil mechanism isn’t working, causing bulla formation

Question 4

Pathophys of bronchitis

Answer 4

Problem in bronchioles

Smooth muscle hypertrophy and mucus hypersecretion

Question 5

Risk factors of COPD

Answer 5

Smoking
Genetic factors
Air pollution
Occupational exposure to dust, chemicals, noxious gases etc.

Question 6

CXR findings in COPD

Answer 6

Flattened diaphragm

Hyperinflation

Question 7

Describe the airflow obstruction in COPD

Answer 7

Progressive
Not fully reversible
Does not change markedly over several months

Question 8

How to calculate pack years?

Answer 8

Number of packs per day x number of years smoked

Question 9

Complications of COPD

Answer 9

Disability and impaired quality of life
Depression and anxiety
Cor pulmonale (right heart failure secondary to lung disease) — caused by pulmonary hypertension as a consequence of hypoxia
Frequent chest infections
Secondary polycythaemia due to hypoxia
Type 2 respiratory failure — caused by increased airway resistance
Lung cancer — COPD may increase the risk of lung cancer

Question 10

Investigations

Answer 10

Post-bronchodilator spirometry
CXR to exclude other pathology
FBC — to identify anaemia or secondary polycythaemia due to hypoxia
Pulse oximetry
ECG and echo if features of cor pulmonale
Sputum culture
ABG if acutely unwell, FEV1 <35% predicted, sats <92%, or signs of resp failure = shows decreased pa02 +/- hypercapnoea, may see resp acidosis
CT may be done if symptoms disproportionate to spirometry, if any abnormalities on CXR, before surgery etc.
Alpha-1 anti-trypsin if young, minimal smoking, family history

Question 11

Features of cor pulmonale

Answer 11

Peripheral oedema
Raised jugular venous pressure
Systolic parasternal heave
A loud pulmonary second heart sound (over the second left intercostal space)
Widening of the descending pulmonary artery on chest X-ray
Right ventricular hypertrophy on ECG

Question 12

Define airflow obstruction using FEV1/FVC

Answer 12

FEV1/FVC ratio of less than 0.7

Question 13

Grade severity of airflow obstruction using FEV1

Answer 13

Stage 1, mild — FEV1 80% of predicted value or higher
Stage 2, moderate — 50–79%
Stage 3, severe — 30–49%
Stage 4, very severe — <30%

Question 14

MRC dyspnoea scale

Answer 14

Grades 1-5
Prognostic
1 = not troubled by breathlessness except during strenuous exercise
2 = SOB when walking up slight hill or hurrying
3 = walks slower on the level or has to stop for breath when walking at own pace
4 = stops for breath after walking about 100m or after a few minutes on the level
5 = too breathless to leave house, breathless when dressing/undressing

Question 15

Differentials for COPD

Answer 15

Asthma
Bronchiectasis
Heart failure
Lung cancer
Interstitial lung disease
Anaemia
Tuberculosis

Question 16

What is an acute exacerbation of COPD?

Answer 16

Sustained worsening of person’s symptoms from their usual stable state, which is beyond normal day-to-day variations and is acute in onset

Question 17

Symptoms of acute exacerbation

Answer 17

Increased breathlessness, cough, sputum production, wheeze, chest tightness, fatigue
Change in sputum colour
Upper respiratory tract symptoms (e.g. cold or sore throat)
Reduced exercise tolerance
Ankle swelling
Acute confusion
Fever

Question 18

Differentials for acute exacerbation of COPD

Answer 18

Pneumonia
Recurrent aspiration
Pneumothorax
Acute heart failure
Pulmonary embolism 
Lung cancer
Pleural effusion
Upper airway obstruction

Question 19

When to refer for pulmonary rehabilitation?

Answer 19

If functionally disabled by COPD e.g. MRC dyspnoea scale grade 3 or above
OR have had a recent hospitalization for an acute exacerbation

Question 20

Benefits of pulmonary rehab

Answer 20

Improve QOL, increase exercise capacity, reduce breathlessness

Question 21

When to refer to physio

Answer 21

If excessive sputum, to learn the use of positive expiratory pressure masks and the ‘active cycle of breathing’ technique.

Question 22

Define chronic bronchitis

Answer 22

Presence of chronic productive cough and sputum for at least 3 months in each of two successive years.

Question 23

Pathophys of COPD

Answer 23

Chronic inflammation (i.e. due to the inhaled stimuli)

• -> narrowing and remodelling of airways, enlargement of mucus glands
• -> increased airway resistance due to decreased elastic recoil (smoke causes release of serine elastase which destroys elastic tissue), fibrosis, luminal obstruction of airways by secretions
• -> hyperinflation and destruction of lung parenchyma
• -> hypoxia
• -> vascular smooth muscle thickening
• -> pulmonary hypertension

Question 24

Causes of COPD

Answer 24

Smoking
Air pollution
Occupational dusts, chemicals, fumes
Alpha-1 anti-trypsin deficiency

Question 25

Fundamentals of COPD care

Answer 25

``` Smoking support/cessation Pneumococcal and flu vaccines Pulmonary rehab if indicated Personalised self-management plan Optimise treatment for comorbidities ```

Question 26

Inhaled therapies for COPD | - if asthmatic features or features suggesting steroid responsiveness

Answer 26

1) SABA or SAMA as needed 2) LABA + ICS 3) LABA + LAMA + ICS 4) Explore further treatment e.g. theophylline, oral mucolytic therapy, long term oxygen therapy

Question 27

Inhaled therapies for COPD | - if NO asthmatic features or features suggesting steroid responsiveness

Answer 27

1) SABA or SAMA as needed 2) LABA + LAMA 3) LABA + LAMA + ICS (3 month trial unless has 1 severe or 2 moderate exacerbations within a year) 4) Explore further treatment e.g. theophylline, oral mucolytic therapy, long term oxygen therapy

Question 28

Oral prophylactic antibiotic therapy - what is used?

Answer 28

Azithromycin (usually 250 mg 3 times a week)

Question 29

When might long term oxygen therapy be needed? | = 15 HOURS A DAY

Answer 29

``` FEV1 below 30% predicted Cyanosis Polycythaemia Peripheral oedema Raised JVP Saturations <92% ``` --> then do 2 ABGs 3 weeks apart If Pa02 <7.3kpa or <8kpa + polycythaemia, peripheral oedema, pulmonary hypertension --> risk assessment (CANNOT SMOKE)

Question 30

Varenicline mechanism + contraindications

Answer 30

Selective nicotine receptor partial agonist Avoid if Hx of mental illness as may cause suicidal thoughts. Contraindicated in pregnancy/breastfeeding, under 18 year olds, end-stage renal disease.

Question 31

Buproprion mechanism + contraindications

Answer 31

Antidepressant Increases risk of seizures, so contraindicated in epilepsy, alcohol withdrawal, eating disorders or CNS tumours. It is also contraindicated in bipolar disorder, pregnancy/breastfeeding, under 18 year olds, and severe cirrhosis.

Question 32

Features of a severe exacerbation

Answer 32

``` Acute confusion. Marked reduction in activities of daily living. Marked breathlessness and tachypnoea. Pursed-lip breathing. Use of accessory muscles at rest. New-onset cyanosis or peripheral oedema. ```

Question 33

What oxygen should be given (if no alert card)?

Answer 33

28% Venturi mask at a flow rate of 4 L/min, and aim for an oxygen saturation of 88–92%

Question 34

Organisms that may cause pulmonary infection in patients with COPD

Answer 34

- Often viral (30%) e.g human rhinovirus - Haemophilus influenzae (most common) - Moraxella catarrhalis - Streptococcus pneumoniae

Question 35

Investigations for acute COPD exacerbation

Answer 35

• Oxygen saturations • ABG • Sputum sample for microscopy and culture (if sputum is purulent) • Blood cultures (if pyrexial) Investigations to exclude other diagnoses: • CXR • ECG • Bloods – FBC, U&E, CRP, theophylline level, cardiac enzymes • CT/CTPA ?echo

Question 36

Treatment of COPD exacerbation

Answer 36

Increase frequency of bronchodilator use and consider giving via a nebuliser Give prednisolone 30 mg daily for 5 days Oral antibiotics 'if sputum is purulent or there are clinical signs of pneumonia'

Question 37

Treatment of COPD exacerbation

Answer 37

Oxygen Increase frequency of bronchodilator use and consider giving via a nebuliser Give prednisolone 30 mg daily for 5 days Oral antibiotics 'if sputum is purulent or there are clinical signs of pneumonia' May need non-invasive ventilation

Question 38

How to choose antibiotics for COPD exacerbation

Answer 38

First line = amoxicillin 500mg TDS for 5 days If amoxicillin allergy = doxycycline 200mg on first day then 100mg OD for a total of 5 days If contraindicated = clarithromycin 500mg BD for 5 days If increased risk of resistance = co-amoxiclav 500/125 mg TDS for 5 days.