Case 10 - COPD - Progress Test

Question 1

What conditions are encompassed in COPD?

Answer 1

Chronic bronchitis

Emphysema

Question 2

What are the features of COPD?

Answer 2

Cough (often productive)
Dyspnoea
Wheeze
Peripheral oedema in severe cases (from right sided heart failure)

Question 3

What investigations should be done to diagnose COPD?

Answer 3

Post-bronchodilator spirometry
- FEV1 / FVC < 70%

Chest XR

• hyperinflation
• Bullae
• Flat hemidiaphragm
• Exlude lung cancer

FBC
- exclude secondary polycytaemia

BMI

Question 4

How is severity of COPD classified?

Answer 4

Stage 1 - mild:
FEV1 > 80%

Stage 2 - moderate:
FEV1 50-79%

Stage 3 - severe:
FEV1 30-49%

Stage 4 - very severe:
FEV1 < 30%

Question 5

How is stable COPD managed?

Answer 5

1st line:
SABA / SAMA

2nd line: 
If no asthmatic features: 
- SABA + LABA + LAMA 
If asthmatic features: 
- SABA + LABA + ICS
or if this doesn't control symtpoms 
- SABA + LABA + LAMA + ICS

3rd line: 
Oral theophylline (if inhalers cannot be tolerated / not effective) 

Oral prophylactic antibiotics
- Azithromycin in selected patients

Mucolytics can be considered in patients with a chronic productive cough

Cor pulmonale:

• loop diuretic for oedema
• consider long term oxygen therapy

Question 6

What are classified as asthmatic features in COPD?

Answer 6

Any previous diagnosis of asthma or atopy

A higher blood eosinophil count

Substantial variation in FEV1 over time (at least 400ml)

Substantial diurnal variation in peak expiratory flow (at least 20%)

Question 7

What are the features of cor pulmonale?

Answer 7

• Peripheral oedema
• Raised JVP
• Systolic parasternal heave
• Loud P2

Question 8

What interventions may improve survival in patients with stable COPD?

Answer 8

Smoking cessation
Long term oxygen therapy
Lung volume reduction surgery

Question 9

When should long term oxygen be considered for patients with COPD?

Answer 9

Very severe airflow obstruction (FEV1 < 30%)
Cyanosis 
Polycythaemia 
Peripheral oedema 
Raised JVP 
O2 sats <= 92% on room air

Question 10

What test is used to determine if long term oxygen should be given?

Answer 10

ABG on 2 occasions at least 3 weeks apart

Question 11

When should long term oxygen therapy be given?

Answer 11

If pO2 < 7.3

or

If pO2 7.3-8 +
secondary polycythaemia or
peripheral oedema or
pulmonary hypertesnion

Question 12

What are causes of COPD?

Answer 12

The main cause is smoking

Alpha-1 antitrypsin deficiency

Casmum 
Coal 
Cotton 
Cement 
Grain

Question 13

What are the most common bacterial organisms to cause acute COPD exacerbations?

Answer 13

Haemophilus influenzae (most common)

Streptococcus pneumoniae

Moraxella catarrhalis

Question 14

What are the most common viral causes of acute COPD exacerbations?

Answer 14

Human rhinovirus

Question 15

How are acute exacerbations of COPD managed?

Answer 15

Increase frequency of bronchodilater + consider nebuliser

Oral prednisolone 30mg daily for 5 days

Oral antibiotics should only be given if sputum is purulent or if there are clinical signs of pneumonia
- 1st line antibiotics: amoxicillin, clarithromycin, doxycycline

Question 16

What is the pharmacology of salbutamol?

Answer 16

Beta receptor agonist

• short acting inhaled bronchodilator
• relaxes bronchial smooth muscle through effects on beta 2 receptors

Question 17

What is the pharmacology of corticosteroids?

Answer 17

Anti-inflammatory action - used as a maintance therapy in respiratory disorders

Question 18

What is the pharmacology of ipratropium?

Answer 18

Blocks the muscarinic acetylcholine receptors

• Short acting inhaled bronchodilator
• Relaxes bronchial smooth muscle

Question 19

What is the pharmacology of methylxanthines (eg. theophylline)?

Answer 19

Non-specific inhibitor of phosphodiesterase resulting in an increase in cAMP

Question 20

What is the pharmacology of monteleukast?

Answer 20

Blocks leukotriene receptors

Useful in aspirin-induced asthma