Diagnosis and Management of COPD

Question 1

COPD description

Answer 1

a broad, non specific term that describe a group of
pulmonary disorder with symptoms of chronic cough and expectoration, dyspnea, and impaired expiratory air flow.

COPD is brought about by a mixture of obstructive diseases of the airways (e.g. bronchitis or bronchiolitis) and destruction of the lung tissue parenchyma (emphysema).

Question 2

airflow obstruction in COPD is usually reversible, true or false

Answer 2

false
The airflow obstruction is usually progressive and irreversible, and it may be associated with airway hyperactivity

Question 3

main cause for COPD

Answer 3

smoking and exposure to
environmental tobacco smoke

Question 4

risk factors of COPD

Answer 4

smoking
genetics
history of tuberculosis
dusty work environment
pollution and biomass combustion
asthma
ageing and comorbidities
premature birth

Question 5

pathogenesis of COPD

Pathogenesis refers to the process by which a disease or disorder develops, including the mechanisms that contribute to its onset, progression, and maintenance.

Answer 5

Bronchioles are normally held open by elastin fibres that are attached to the alveolar walls. In COPD the small airways are narrowed by inflammation
and fibrosis of alveolar wall, destruction of elastin attachments and occlusion of lumen by mucus and
inflammatory exudate

Question 6

how do we diagnose COPD

Answer 6

can be diagnosed with the symptoms that the patient presents with

history of exposure to COPD risk factors..etc

Lung function tests (spirometry)

Question 7

symptoms of COPD

Answer 7

exertional breathlessness
chronic cough
regular sputum production
frequent winter ‘bronchitis’
Wheeze

Question 8

according to the guidelines, when are HCPs to suspect a diagnosis of COPD in a patient

Answer 8

when the patient presents with any of the main risk factors or COPD, plus any of these symptoms;

** exertional breathlessness
* chronic cough
* regular sputum production
* frequent winter ‘bronchitis’
* Wheeze

Question 9

list any additional questions to ask someone that presents with symptoms indicative of COPD with regards to other symptoms they might be experiencing

Answer 9

ask if there is any;

• wieght loss
• ankle swelling
• reduced exercise and tolerance
• fatigue
• waking up a night with breathlessness
• occupational hazard

Question 10

chest pains and coughing up blood are major symptoms in COPD, true or false

Answer 10

false, as they are uncommon in COPD and could be a different diagnosis

Question 11

how do we assess someone with suspected COPD

Answer 11

Take history about;
The onset of the disease
Any known exposures to the disease
Impact of symptoms on daily life and occupation:
Previous exacerbations or hospitalization.
Past medical history and comorbidities
Family history

Question 12

which test is used as a confirmatory test in COPD

Answer 12

Spirometry

Question 13

name some other tests used to investigate suspected COPD in patients

Answer 13

Chest X-rays to exclude other causes
Full blood count (to identy anaemia or polycythaemia)

Question 14

FEV1description

Answer 14

forced expiratory volume in one second

FVC = forced vital capacity

Question 15

a post bronchodilator FEV1/FVC of less than 0.7 confirms what?

Answer 15

persistent airflow obstruction

Question 16

airway obstruction is irreversible in asthma, true or false

Answer 16

false, it is largely reversible in asthma

Question 17

what does a FEV1 less than 0.7 indicate

note that the FEV1 number allows the degree of airflow limitation to be quantified

Answer 17

a limitation in airflow

less than 0.5 indicates severe airway obstruction

Question 18

what does the MRC( Medical Research
Council) dyspnoea scale do?

Answer 18

it grades the effects of breathlessness on daily activity. grades are from 1-5, with 1 being when they are the least affected by breathlessness, and 5 being when they are the most affected(severely) by breathlessness

it is used alongside spirometry values to assess the severity of COPD

Question 19

the aim of the COPD assessment test (CAT)

Answer 19

to check the impact of COPD on wellbeing and daily life

has a scoring range of 0-40, and consists of 8 questions

note that is is** not a diagnostic tool**

Question 20

when to refer someone with COPD to a respiratory specialist

Answer 20

when;
Lung cancer is suspected (for example they have haemoptysis or suspicious features on chest X-ray).

• There is diagnostic uncertainty
• COPD is very severe or rapidly worsening.
• Cor pulmonale is suspected.
• The person is less than 40 years of age and/or there is a family history of alpha-1-antitrypsin deficiency. If alpha-1-antitrypsin deficiency is confirmed, screening is indicated for the person’s family.

Cor pulmonale, also known as pulmonary heart disease, is a condition where the right side of the heart fails due to increased blood pressure in the lungs, often caused by lung diseases

note that Referral to a respiratory specialist may also be required to assess the need for:
* Oxygen therapy.
* Long-term non-invasive ventilation.
* Nebulizer therapy or long-term oral corticosteroids.
* Lung surgery

Question 21

aims of COPD treatment

Answer 21

to reduce symptoms

improve exercise tolerance

improve quality of life

prevent/ reduce exacerbations

individualise care

reduce mortality

prevent disease progression

Question 22

name some pharamcological treatments used in treating COPD

Answer 22

Short-Acting Muscarinic Antagonists
(Anticholinergics) - SAMAs

Short Acting Beta-2 Agonist (SABA) like salbutamol and terbutaline

Long-Acting Beta2 Agonists (LABAs) like salmeterol(serevent), formoterol, indacaterol and olodaterol

Long Acting Muscarinic Antagonist / Anticholinergics (LAMAs) like tiotropium

Question 23

describe SAMA’s, their MoA and anything important to know about them

Answer 23

they work by relaxing the bronchial smooth muscles(bronchodilation)

they last up to 6 hours

they are more effective when used with SABAs

they improve the quality of life, breathlessness and mucous secretion

some common side effects are dry mouth, Arrhythmias; constipation; cough; dizziness; dry mouth; headache; nausea

usual dose for SAMAs are 1-2 puffs 3-4 times daily

an example is Ipratropium(atrovent)

Question 24

should SAMAs be used in pregnancy

Answer 24

yes they can be used in pregnancy as long as benefits outweigh the risks

Question 25

how do SABAs work

Answer 25

These are selective beta2 agonists which cause bronchodilation. Used for immediate relief rather than prophylactic use ## Footnote examples are salbutamol and terbutaline

Question 26

some side effects of SABAs

Answer 26

arrhythmias, dizziness, headache, hypokalaemia, palpitations, tremor

Question 27

LABAs have a similar mode of action to SABAs, true or false

Answer 27

true

Question 28

how long do LABAs last for

Answer 28

12 hours

Question 29

LABAs are used in patients using SABAs regularly, true or false

Answer 29

true

Question 30

exanples of LABAs

Answer 30

salmeterol(serevent), formeterol, indacterol and olodaterol

Question 31

MoA of LAMAs

Answer 31

similar to that of SAMAs, i.e, LAMAs (e.g., tiotropium, aclidinium, glycopyrronium, umeclidinium) work by blocking muscarinic (M₃) receptors in the airways, leading to bronchodilation. they are used to replace SAMA therapy ## Footnote they last 12 hours

Question 32

some effects of LAMAs

Answer 32

Improves FEV1, quality of life, reduce exacerbation and dyspnoea

Question 33

what therapy is used for a person with stable COPD who develops a chronic producutive cough(produces sputum)

Answer 33

Oral mucolytic therapy, with Carbocisteine

Question 34

list the fundamental (non inhaled therapies) treatments for confirmed COPD according to the guidelines

Answer 34

Offer treatment and support to stop smoking * Offer pneumococcal and influenza vaccinations * Offer pulmonary rehabilitation if indicated * Co-develop a personalised self-management plan * Optimise treatment for comorbidities ## Footnote these treatment plans should be revisted in every review

Question 35

when do we start inhaled therapies in COPD

Answer 35

only if; first line non-inhaled interventions have been offered **and** inhaled therapies are needed to relieve breathlessness **and** exercise limitation, and people have been trained to use inhalers and can demonstrate satisfactory technique ## Footnote Review medication and assess inhaler technique and adherence regularly for all inhaled therapies

Question 36

first line inhaled therapy for COPD

Answer 36

Offer SABA or SAMA to use as needed

Question 37

if first line inhaled therapies do not work, and person has exacerbations, what do we do

Answer 37

if the person shows no asthmatic features or features suggesting steroid responsiveness, then offer **LABA+LAMA** however if the person has asthmatic features or features suggesting steroid responsiveness, then consider, **LABA + ICS** ## Footnote i.e we opt for long term treatments "Steroid responsiveness" in a medical context means a condition or disease that shows a positive response to treatment with corticosteroids, or "steroids," characterized by improvements in symptoms, lung function, or other relevant measures

Question 38

what do we offer the patient if their day-day symptoms adversely affect their quality of life what do we do if what we offer them does not work still

Answer 38

Consider 3-month trial of LABA + LAMA + ICS if no improvement, then revert back to LABA + LAMA

Question 39

if the person has 1 severe or 2 moderate exacerbations of their COPD within a year, what do we do

Answer 39

**Consider LABA + LAMA + ICS**

Question 40

if a patient with asthmatic features or features suggesting steroid responsiveness has day-day symptoms that adversely impact their quality of life, or has 1 severe or 2 moderate exacerbations within a year, then what do we do

Answer 40

Offer LABA + LAMA + ICS

Question 41

describe acute exacerbation of COPD

Answer 41

s a sustained worsening of the person's symptoms from their usual stable state, which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour

Question 42

in severe COPD exacerbations, what is recommended

Answer 42

hospitalisation of the patient

Question 43

if patient has moderate exacerbations, where there is a sustained worsening of respiratory symptoms in COPD, what is recommended ## Footnote note that at this stage most/all inhaled therapies would have been exhausted

Answer 43

treatment with systemic corticosteroids and/or antibiotics

Question 44

Many exacerbations in COPD (including some severe exacerbations) are caused by bacterial infections so will respond to antibiotics, true or false

Answer 44

false Many exacerbations (including some severe exacerbations) are not caused by bacterial infections so will not respond to antibiotics

Question 45

first choice oral antibiotic treatments for COPD

Answer 45

Amoxicillin 500 mg three times a day for 5 days or Doxycycline 200 mg on first day, then 100 mg once a day for 5-day course in total or Clarithromycin 500 mg twice a day for 5 days ## Footnote this is guided by the most recent sputum cultures. review antibiotic choice after every sputum sample test

Question 46

second choice oral antibiotics if first choice has shown no improvement in symptoms after 2-3 days

Answer 46

can offer an alternate first choice antibiotic that has not been previously used, or Co-amoxiclav 500/125mg 3 times a day for 5 days or Co-trimoxazole 960mg twice a day for 5 days or Levofloxacin 500mg once a day for 5 days (only if other alternative choice antibiotics are unsuitable; with specialist advice)

Question 47

which systemic corticosteroid is offered for COPD patients in exacerbation managements, and what counselling points are offered

Answer 47

Offer 30 mg oral prednisolone daily for 5 days counsel on; common side effects like osteoporosis, menstrual irregularities, Cushing's syndrome, electrolyte imbalance, GI discomfort...etc(refer to BNF for more ) not stopping corticosteroids abruptly interactions if taking any other meds why, when and how to stop corticosteroid treatment etc ## Footnote Revise counselling points on corticosteroids

Question 48

what is a nebuliser

Answer 48

a medical device that transforms liquid medication into a fine mist or aerosol, allowing it to be inhaled directly into the lungs for faster and more effective absorption, particularly for respiratory conditions

Question 49

apart from systemic corticosteroids and antibiotics, what other alternative is offered for exacerbation management in COPD

Answer 49

Nebulised bronchodilators driven by air; * Ipratropium 250-500mcg QDS or * Salbutamol 2.5-5mg QDS/PRN

Question 50

how to follow up a person who has had an exacerbation of COPD

Answer 50

Consider: Other possible diagnoses, such as pneumonia. Symptoms or signs suggestive of a more serious illness or condition, such as cardiorespiratory failure or sepsis. Previous antibiotic use which may have led to resistant bacteria. The need for admission.

Question 51

describe expectoration

Answer 51

refers to the act of coughing up and spitting out material produced in the respiratory tract, such as mucus or phlegm.

Question 52

difference in the ways carbocisteine and erdosteine behave as antimucolytics

Answer 52

carbocisteine works on muco-secreting cells, modulating their activity, by making the mucus less thick essentially. it also improves mucocilliary clearance while erdosteine is a PRO-DRUG that breaks mucus bonds(SH). **it also possesses anti-adhesive(reduces bacterial sticking to the mucus) and antioxidadnt properties ** ## Footnote max amount of days that one can take erdosteine is 10days

Question 53

usual dose of carbocisteine

Answer 53

Carbocisteine - initially 2.25g daily in divided doses then reduced to 1.5g daily in divided doses, as condition improves.

Question 54

how many aerochamber colours are there and what are the age groups indicated for each colour

Answer 54

orange is for infants , under 1 yrs yellow is for children of 10yrs or under blue is for adults and those over 10yrs

Question 55

prednisolone tablets are best taken as a single dose, true or false

Answer 55

true. so we take them all at once.

Question 56

is it best to take prednisolone in the morning or at night

Answer 56

in the morning so as to reflect the natural diurnal release of cortisol in the body. Taking at nighttime could cause sleep disturbances

Question 57

what medications does the rescue pack for COPD usually contain and at what doses

Answer 57

prednisolone 5mg , 6 times a day(30mg) for 5/7days AND Amoxicillin 500mg, 1 TDS if not penicillin allergic

Question 58

when should a patient start their rescue pack for COPD

Answer 58

if experiencing 2 of the following symptoms for more than 24 hours following increased reliever usage; Increased breathlessness which interferes with daily activities Change in sputum (phlegm) quantity· Change in sputum (phlegm) colour