Management of COPD

Question 1

Who should you consider a diagnosis of COPD in?

Answer 1

Patients over 35 years of age who are smokers/ex-smokers and have symptoms like exertional SoB, chronic cough or regular sputum production

Question 2

What investigations are recommended in patients with suspected COPD?

Answer 2

Post-bronchodilator spirometry to demonstrate AFO (FEV1/FVC ratio <70%)
CXR
FBC
BMI

Question 3

What might you see on CXR in COPD patients?

Answer 3

Hyperinflation, bullae, flat hemidiaphragm

Essential to rule out lung cancer

Question 4

Why should an FBC be done in all COPD patients?

Answer 4

Exclude secondary polycythaemia

Question 5

How is the severity of COPD categorised?

Answer 5

Based on FEV1

Question 6

What is considered mild COPD (stage 1)?

Answer 6

FEV1 >80%

Question 7

What is considered moderate COPD (stage 2)?

Answer 7

FEV 50-79%

Question 8

What is considered severe COPD (stage 3)?

Answer 8

FEV1 30-49%

Question 9

What is considered very severe COPD (stage 4)?

Answer 9

<30%

Question 10

What are features of COPD?

Answer 10

Cough (often productive)
SoB
Wheeze
In severe cases R sided heart failure may develop –> peripheral oedema

Question 11

What are signs of COPD?

Answer 11

Reduced chest expansion
Prolonged expiration/wheeze
Hyperinflated (barrel) chest
Respiratory failure - tachypnoea, cyanosis, use of accessory muscles, pursed up breathing, peripheral oedema

Question 12

What is involved in the general management of COPD?

Answer 12

Smoking cessation advice
Annual flu jab
One off pneumococcal vaccination
Pulmonary rehab to those who are functionally disabled by COPD

Question 13

What is the first line treatment for COPD?

Answer 13

SABA or SAMA first line

Question 14

For those with COPD who still have breathlessness/exacerbations despite short acting bronchodilators, what is the next step determined by?

Answer 14

Asthmatic features/features suggestive steroid responsiveness

Question 15

What criteria may be used to help determine if a patient has asthmatic/steroid responsive features?

Answer 15

Any prev diagnosis of asthma/atopy
Higher blood eosinophil count
Substantial variation in FEV1 over time (at least 400ml)
Substantial diurnal variation in peak expiratory flow (at least 20%)

Question 16

How should those with no asthmatic features be managed if short acting bronchodilators do not control their symptoms?

Answer 16

Add LABA or LAMA

If already taking SAMA, discontinue and switch to SABA

Question 17

How should those with asthmatic features be managed if short acting bronchodilators do not control their symptoms?

Answer 17

LABA + ICS
If patients remain breathless or have exacerbations, triple therapy (LAMA, LABA and ICS) may be used
Use combined inhalers where possible

Question 18

Who might be offered oral theophylline for their COPD?

Answer 18

After trials of short and long acting bronchodilators or to those cannot use inhaled therapy

Question 19

The dose of theophylline must be reduced if what two drugs are being co-prescribed?

Answer 19

Macrolides/fluoroquinolone

Question 20

What antibiotic is recommended for oral prophylactic antibiotic therapy in COPD?

Answer 20

Azithromycin

Question 21

What are prerequisites to having prophylactic antibiotic therapy in COPD?

Answer 21

Not smoking
Optimised medical treatments
Continuing to have exacerbations
CT thorax to rule out bronchiectasis
Sputum culture to rule out atypical infections and TB
LFTs and ECG to rule out QT prolongation (as azithromycin can prolong the QT interval)

Question 22

For what COPD patients should mucolytics be considered?

Answer 22

Those with a chronic productive cough and continued if symptoms improve

Question 23

What are features of cor pulmonale?

Answer 23

Peripheral oedema, raised JVP, systolic parasternal heave, loud P2

Question 24

How is cor pulmonale managed?

Answer 24

Loop diuretic for oedema

Consider long term oxygen therapy

Question 25

Which factors may improve survival in patients with stable COPD?

Answer 25

``` Smoking cessation (most important intervention!!) Long term oxygen therapy Lung volume reduction surgery in selected patients ```

Question 26

Patients who receive LTOT should breathe supplementary oxygen for how many hours a day?

Answer 26

At least 15

Question 27

What patients should be assessed to see if they are eligible for LTOT?

Answer 27

``` Very severe airflow (FEV1 <30%), consider for severe airflow (FEV1 30-49%) Cyanosis Polycythaemia Peripheral oedema Raised JVP O2 sats <=92% on air ```

Question 28

How is eligibility for LTOT assessed?

Answer 28

ABG on 2 occasions at least 3 weeks apart in those with stable COPD on optimal management

Question 29

Who should be offered LTOT?

Answer 29

Patients with a pO2 <7.3kPa or those with a pO2 of 7.3-8kPa with one of the following: - Secondary polycythaemia - Peripheral oedema - Pulmonary HTN

Question 30

Can LTOT be offered to those who continue to smoke?

Answer 30

No

Question 31

NICE suggest a structured risk assessment involving what is carried out before prescribing LTOT?

Answer 31

Risk of falls from tripping over equipment | Risk of burns and fires and increased risk for those who live in homes where someone smokes

Question 32

What are features of AECOPD?

Answer 32

Increase in SoB, cough, wheeze Increase in sputum suggests an infective cause May be hypoxic and confused

Question 33

What are the most common causes of infective exacerbations of COPD?

Answer 33

H. influenzae (most common) Strep pneumoniae Moraxella catarrhalis Human rhinovirus most common viral cause

Question 34

What is the management of AECOPD?

Answer 34

Increase bronchilator use, consider nebulising Prednisolone 30mg for 7-14 ddays Oral antibiotics if sputum is purulent/signs of pneumonia

Question 35

When antibiotic is given (when appropriate) in AECOPD?

Answer 35

Amoxicillin or clarithromycin/doxycycline