Chronic obstructive pulmonary disease

Question 1

Chronic bronchitis and emphysema

Answer 1

should be considered together

• as both conditions usually coexist to some degree in each patient.

An alternative, and preferable, term

—chronic obstructive airway or pulmonary disease (COPD)

• —is used to cover chronic bronchitis and emphysema with chronic airflow limitation.

Question 2

It is defined as

Answer 2

a preventable and treatable disease of persistent airflow limitation

• associated with an enhanced chronic inflammatory response to noxious particles or gases.

Question 3

Factors in causation

Answer 3

Cigarette smoking: usu. 20/d for 20 yrs

Air pollution

Airway infection

Familial factors: genetic predisposition

Alpha1-antitrypsin deficiency (emphysema)

Question 4

Symptoms

Answer 4

Onset in 5th or 6th decade

Main symptoms

• Excessive cough
• Sputum production (chronic bronchitis)
• Dyspnoea (chronic airflow limitation)

Wheeze (chronic bronchitis)

Chest tightness

Susceptibility to colds

Question 5

Investigations

Answer 5

Chest X-ray: can be normal (even with advanced disease) but characteristic changes occur late in disease.

Pulmonary function tests (spirometry is gold standard):

peak expiratory flow rate—low with minimal response to bronchodilator (not sensitive)

ratio FEV1/FVC—reduced with minimal response to bronchodilator

gas transfer coefficient of CO is low if significant emphysema

Blood gases:

• may be normal
• PaCO2↑ ; PaO2↓ (advanced disease)
• Gas transfer factor

Question 6

COPD is defined as

Answer 6

post-bronchodilator FEV1/FVC of < 0.70 (< 70%)

and

FEV1 < 80% predicted

Question 7

Management

Answer 7

Advice to the patient:

If you smoke, you must stop: this is the key to management

Avoid places with polluted air and other irritants, such as smoke, paint fumes and fine dust

Go for walks in clean, fresh air

A warm dry climate is preferable to a cold damp place (if prone to infections)

Get adequate rest

Avoid contact with people who have colds and flu

Question 8

Physiotherapy

Answer 8

Refer to a physiotherapist for:

• chest physiotherapy
• breathing exercises and
• an aerobic physical exercise program

Question 9

Drug therapy

Answer 9

Consider the use of bronchodilators (e.g. inhaled β2-agonists) and inhaled corticosteroids

• because of associated (often unsuspected) asthma.
• A carefully monitored trial of these drugs with FEV measurement is recommended.

Fixed dose combinations of LABA and inhaled corticosteroids ICS (Seretide, Symbicort or Flutiform)

• may be used for patient convenience.

Triple therapy with:

tiotropium (a long-acting muscarinic antagonist [LAMA]) plus an ICS/LABA agent

• is usual practice for moderate to severe COPD.

Question 10

Corticosteroids should be used routinely for?

Answer 10

Acute exacerbations. Use:

• prednisolone 30–50 mg (o)/d

If not tolerated orally use:

• hydrocortisone 100 mg IV 6 hrly (or equivalent dose of alternative steroid)

Question 11

The indication for antibiotic treatment is:

Answer 11

↑ cough and dyspnoea plus

↑ sputum volume and/or purulence

Use:

• amoxycillin 500 mg (o) tds for 5 d or
• doxycycline 200 mg (o) statim then 100 mg/d for 5 d