Chronic obstructive pulmonary disease

Question 1

What do these results show?

Answer 1

Obstructive pattern of spirometry

Prolonged expiratory phase

Question 2

What do these imaging results show?

Answer 2

Hyperexpanded lungs

Flattening of diaphragm

Chronic changes at bases

Question 3

What do these imaging results show?

Answer 3

Absense of normal lung

Bulla (holes) - alveolar destruction typical of emphysema

Question 4

What is COPD?

Answer 4

Preventable and treatable disease characterised by persistent, progressive airflow limitation (not fully reversible)

Enhanced chronic inflammatory response in the lungs to noxious gases/particles

Question 5

Why is there a rising prevelance of COPD?

Answer 5

Due to ageing population

Question 6

Complete the diagram on how COPD develops

Answer 6

Question 7

What are the 3 features of COPD?

Answer 7

Question 8

What is the pathophysiology of COPD in the airways?

Answer 8

Chronic inflammation

Increased number of goblet cells

Mucus cell hyperplasia

Fibrosis

Narrowing and reduction in the number of small airways

Airway collapse due to alveolar wall destruction in emphysema

Question 9

What is chronic bronchitis?

Answer 9

1. Chronic Bronchitis (large airways)

Chronic productive cough for three months in two successive years

Exclude other causes of chronic cough

Question 10

What is emphysema?

Answer 10

EMPHYSEMA (Alveolar)

Abnormal and permanent enlargement of the airspaces due to destruction of the alveolar airspace walls

Effects gas exchange

Question 11

What is small airways disease?

Answer 11

SMALL AIRWAYS disease

Wheeze

Question 12

What does this CT show?

Answer 12

Massive bulla

Question 13

What are the risk factors for COPD?

Answer 13

Question 14

How does a doctor take a smoking history?

Answer 14

Age started

Calculate pack year history

Times stopped and why failed quit attempt

Recreational drugs smoked (or other substances eg shisha)

Question 15

Complete the diagram on the consequences of COPD

Answer 15

Question 16

How is COPD diagnosed?

Answer 16

Symptoms (exertional breathlessness, productive cough, “winter bronchitis”, wheeze) + Risk factors (10 pkyr smoking history and age>35 years) + spirometry (FEV1/FVC <0.7)

Question 17

Draw what a flow-volume loop would look like in COPD

Answer 17

Question 18

How is there severity of COPD determined?

Answer 18

Question 19

What are the physical signs of COPD?

Answer 19

Barrel-shaped chest

(hyperresonant) percussion

Accessory muscles

Prolonged expiration

Pursed-lip breathing

Tripod position

Low BMI

Nicotine-staining

Question 20

What are the physiological effects of COPD?

Answer 20

Increased work of breathing

Reduced Exercise Tolerance

Impaired gas exchange

• Hypoxia
• Hypercapnia
• Raised pulmonary artery pressure
• RV dilatation, cor pulmonale
• Loss of Fat Free Mass

Question 21

How is chronic COPD managed?

Answer 21

• Stop smoking
• If symptomatic LABA/LAMA combined inhaler (eg. Duaklir)
• Flu vaccination
• Educate and Empower
• Treat exacerbations
• Pulmonary rehabilitation
• Think about the whole patient (bones, nutrition, mental health)
• (LTOT)

Question 22

What is pulmonary rehabilitation?

Answer 22

2x supervised sessions for 6 weeks

• Supervised exercise
• Education
• Psychosocial support/group work

Question 23

What are the treatments for COPD?

Answer 23

• Theophylline (oral phosphodiesterase inhibitor)
• Azithromycin 3x/week (anti-inflammatory antibiotic prophylaxis)
• Lung volume reduction surgery (valves/bullectomy)
• Lung transplantation

Question 24

What is an acute exacerbation?

Answer 24

Acute deterioration in symptoms requiring additional therapy

Question 25

How are acute exacerbations treated?

Answer 25

Mild (SABA)

Moderate (SABA +/- steroids +/- antibiotics)

Severe (Hospital admission) or ED attendance

Question 26

How would you treat this patient?

On assessment in ED she cannot speak in a full sentence so history taking is brief

RR 35

Oxygen saturations 83% on air, 90% on FiO2 0.28

Afebrile, CRP 22, WCC 13

Bp 130/70 PR 115 bpm

No chest pain, no haemoptysis, no peripheral oedema

Examination demonstrates scattered wheeze throughout her chest

Answer 26

• Antibiotics if signs of infection (sputa results)
• Oral steroids
• Target saturations 88-92% (controlled oxygen)
• Nebulisers (bronchodilate)
• Consider diuretics
• Nicotine replacement therapy/refer for smoking cessation

Question 27

What is the diagnosis?

COPD patient

On assessment in ED she cannot speak in a full sentence so history taking is brief

RR 35

Oxygen saturations 83% on air, 90% on FiO2 0.28

Afebrile, CRP 22, WCC 13

Bp 130/70 PR 115 bpm

No chest pain, no haemoptysis, no peripheral oedema

Examination demonstrates scattered wheeze throughout her chest

Answer 27

ED attendance due to progressive dyspnoea/hypoxia or signs of infection or signs of right heart failure

Severe exacerbation

Question 28

How can treatment fail?

Answer 28

1. Decompensated hypercapnic respiratory failure despite controlled oxygen and nebulised treatmentsà Non-Invasive Ventilation
2. Respiratory failure despite nebulised therapy and controlled oxygen and patient unable to tolerate NIVà Consider invasive mechanical ventilation
3. Respiratory failure on background of significant progressive decline over several months/years with no evidence of reversible event à palliate

Question 29

How can COPD symptoms be managed in palliative patients?

Answer 29

Oromorph

Lorazepam

Fan therapy

Oxygen therapy

CBT

Pacing/Breathing strategies

Hospice input