Case 2 - COPD

Question 1

Other than smoking, other causes of COPD?

Answer 1

• Inhaled illicit drugs
• Pollution
• Smoke exposure - coal/wood burning stove
• Chronic bronchitis
• Genetic - alpha 1 antitrysin deficiency

Question 2

What is COPD?

Answer 2

• Airflow obstruction
• Progressive
• Not fully reversible
• predominantly caused by smoking

Question 3

Pathophyisology of COPD

Answer 3

• Ephysema and chronic bronchitis =
• Mucous gland hyperplasia
• Loss cilia function
• Emphysema - alveolar wall destruction causing enlarged air spaces distal to terminal bronchiole
• Chronic inflammtion - macrophages and neutrophils –> fibrosis of small airways

Question 4

Management of COPD outpatient

Answer 4

COPD care bundle:
* Smoking cessation
* Pulmonary rehabilitation
* Bronchodilators
* Antimuscarinics
* Steroids
* Mucolytics
* Diet
* LTOT - if suitable
* Lung volume reduction surgery - if appropriate

Question 5

Who manages someones COPD?

Answer 5

MDT approach

Question 6

3 things used to manage COPD which improve mortality

Answer 6

• Smoking cessation
• LTOT
• Lung volume reduction surgery

Question 7

Why do we use LTOT for COPD?

Answer 7

• Extended hypoxia –> renal and cardiac damage
• Prevent this using LTOT

Question 8

Criteria for LTOT

Answer 8

• pO2 consistently below 7.3kPa OR below 8kPa with polycythaemia, peripheral oedema or pulmonary HTN
• No CO2 retention
• O2 needs balanced with loss of independence and loss activity

NOT a treatment for breathlessness, treat hypoxia instead

Question 9

What does pulmonary rehabilitation aim to do?

Answer 9

• Stop cycle of inactivty
• When breathless people do not exercise =
• You do less = muscles weaken
• = get more breathless
• = feel depressed and avoid activity even more

Question 10

What does pulmonary rehab stop?

Answer 10

• Inactivity
• Social isolation

Question 11

What does pulmonary rehabilitation involve?

Answer 11

6-12 week programme of supervised, unsupervised exercise, nutritional advice, disease education and peer support

Question 12

Two types of COPD exacerbation

Answer 12

Infective - change in sputum volume/colour, fever, raised WCC +/- CRP
Non-infective

Question 13

Overall manageemnt of COPD exacerbation

Answer 13

ABCDE
* Oxygen - sats aim for 94-98% unless evidence of acute or previous T2RF - then change to 88-92%
* NEBs - salbutamol and ipratropium
* Steroids
* Abx if raised CRP/WCC or purulent sputum
* CXR

Question 14

What to consider if T2RF and pH 7.25-7.35?

Answer 14

NIV - eg BiPAP

Question 15

What medication to consider if steroids and NEBs and O2 not helping exacerbation?

Answer 15

• IV aminopylline? - not a lot of evidence for this

Question 16

What to consider if pH on ABG is <7.25?

Answer 16

ITU referral - invasive ventilation may be needed

Question 17

Dose of steroid in COPD exacerbation

Answer 17

30mg oral prednisolone (is 40 in asthma)

Question 18

What must we get before commencing NIV?

Answer 18

CXR - check if any untreated pneumothorax - contraindication for NIV

Question 19

Contraindications for NIV

Answer 19

• Untreated pneumothorax
• Impaired consciousness (GCS <8)
• Upper airway secretions
• Facial injury
• Long term hypoxia
• Vomit
• If agitated

Question 20

What is lung volume reduction surgery?

Answer 20

• Used when localised emphysema to lobe - heterogenous emphysema
• Removal of part of lung to make overall lung better
• Use CT scan to determine if suitable

Question 21

Why is smoking cessation encouraged in COPD?

Answer 21

SLOWS rate of decline of FEV1
At any age you give up

Question 22

LTOT minimum amount of time per day for benefits

Answer 22

16 hrs per day

Question 23

Stepway management of COPD

Answer 23

1. SABA or SAMA
2. LABA + ICS- if suggest will be steroid responsive - if still nothing –> LAMA, LABA and ICS
3. If no steroid responsiveness try LABA and LAMA