COPD

Question 1

COPD

Answer 1

non reversible, long tern deterioation in air flow cuased by damage to lung tissue. this causes obstruction- more difficult to ventilate. prone to infections.

not significantly reversible with bronchodilators.

susceptible to exacerbations (infective)

Question 2

presentation of COPD

Answer 2

long term smoking
chronic SOB
cough
sputum production
wheeze
recurrent respiratory infection

Question 3

MRC dyspnoea scale

Answer 3

This is a 5 point scale that NICE recommend for assessing the impact of their breathlessness:

Grades:

Grade 1 – Breathless on strenuous exercise
Grade 2 – Breathless on walking up hill
Grade 3 – Breathless that slows walking on the flat
Grade 4 – Stop to catch their breath after walking 100 meters on the flat
Grade 5 – Unable to leave the house due to breathlessness

Question 4

COPD diagnosis

Answer 4

spirometry: obstructive picture
overall lung capacity
FEV1/FVC <0.7

Reversibility test
Beta 2 agonist (salbutamol)

The severity of the airflow obstruction can be graded using the FEV1:

Stage 1: FEV1 >80% of predicted
Stage 2: FEV1 50-79% of predicted
Stage 3: FEV1 30-49% of predicted
Stage 4: FEV1 <30% of predicted

Question 5

other investigations f COPD

Answer 5

spirometry post-BD
CXR
BMI
FBC
mMRC?
CAT
sputum
spO2
SPEF
CT chest
ECG +/- echo
TLco
Alpha-1 antitrypsin

CXR (rule out lung cancer)
FBC (polycythemia in response to chronic hypoxia)
BMI 
sputum culture
ECG (heart function)
CT thorax (fibrosis)
serum alpha-1-antitrypsin
TLCO

Question 6

COPD long term management

Answer 6

• pneumococcal
• annual flu vaccine

1. beta-2-agonist (salbutamol) or short acting antimuscarining (ipatropium bromide)
2. if they do not have asthmatic or steroid responsive fetures= LABA and LAMA

if asthmatic/steroid LABA plus ICS (fostair, symbicort)

more severe:
Nebulisers (salbutamol and/or ipratropium)
Oral theophylline
Oral mucolytic therapy to break down sputum (e.g. carbocisteine)
Long term prophylactic antibiotics (e.g. azithromycin)
Long term oxygen therapy at home

Question 7

exacerbation of COPD

Answer 7

ABG: co2 = carbonic acid = acidic. low PH, raised O2= retaining co2

raised bicarbonate indicates chronically retaining co2

Question 8

respiratory failures

Answer 8

Low pO2 indicates hypoxia and respiratory failure
Normal pCO2 with low pO2 indicates type 1 respiratory failure (only one is affected)
Raised pCO2 with low pO2 indicates type 2 respiratory failure (two are affected)

Question 9

oxygen therapy in COPD

Answer 9

too much o2 in someone who is prone to reatining co2 can depress their respiraotry drive.

venturi mask (allows some oxygen to leak out of the side so that normal air can be inhaled too)

Venturi masks deliver 24% (blue), 28% (white), 31% (orange), 35% (yellow), 40% (red) and 60% (green) oxygen.

Question 10

oxygen saturation

Answer 10

If retaining CO2 aim for oxygen saturations of 88-92% titrated by venturi mask
If not retaining CO2 and their bicarbonate is normal (meaning they do not normally retain CO2) then give oxygen to aim for oxygen saturations > 94%

Question 11

treatment of COPD exacerbation

Answer 11

at home:
Prednisolone 30mg once daily for 7-14 days
Regular inhalers or home nebulisers
Antibiotics if there is evidence of infection

in hospital:
Nebulised bronchodilators (e.g. salbutamol 5mg/4h and ipratropium 500mcg/6h)
Steroids (e.g. 200mg hydrocortisone or 30-40mg oral prednisolone)
Antibiotics if evidence of infection
Physiotherapy can help clear sputum

severe cases not responding to tx:
IV aminophylline
Non-invasive ventilation (NIV)
Intubation and ventilation with admission to intensive care
Doxapram can be used as a respiratory stimulant where NIV or intubation is not appropriate

Question 12

obstructive respiratory disease

Answer 12

FEV1/FVC <0.7
COPD
- emphysema
- bronchitis

Bronchiectasis

• classically CF
• recurrent infections
• dilation
• destruction of the muscles and elastin in bronchus
• inflammation of ulceration

Question 13

type I resp failure

Answer 13

hypoxaemia
low o2
normal co2
hyperaemia is resistant to o2 therapy

O2 failure
resp insufficiency

V/Q mismatch (PE)
do not fix with oxygen

Question 14

type II resp faliure

Answer 14

hypercapnia
low o2
high co2
failure to exchange or remove co2
will correct with oxygen therapy

pump failure (HF)
fix with oxygen

COPD in type II respiratory failure: 28% venturi masks, aim for sats of 88-92%

Question 15

key words

1. barrel chested
2. green/rusty sputum
3. strawberry tongue
4. whooping cough

Answer 15

Barrel-Chested = COPD
Greenish/Rusty Sputum= Pneumonia
Strawberry Tongue = Kawasaki Disease
Whooping cough= Pertussis

Question 16

NIv indication

Answer 16

PaCO2 >6.5

pH <7.35

Question 17

infective exacerbation of COPD

Answer 17

SOB, worsening cough, sputum production, widespread wheeze and elevated inflammatory markers on bloods.

imaging: CXR
mx: oxygen therapy (sats 88-92%), salbutamol and ipratropium nebulisers, oral prednisone, oral antibiotics (doxycycline)

if CAP (consolidation everywhere) then escalate to CURB-65

if refractory causes- NIV