Chronic obstructive pulmonary disease

Question 1

COPD

Answer 1

Non-reversible, long term deterioration in air flow through lungs

Almost always the result of smoking

Question 2

Features

Answer 2

Dyspnoea

Cough- often productive

Wheeze

In severe cases right sided heart failure may develop resulting in peripheral oedema

Question 3

Dyspnoea scale

Answer 3

1- breathlessness on strenuous exercise

2- breathlessness on walking up hill

3- breathless that slows walking on the flat

4- stop to catch their breath after walking 100m on the flat

5- unable to leave house due to breathlessness

Question 4

Investigations

Answer 4

Post-bronchodilator spirometry demononstrates airflow obstruction (FEV1:FVC <70%)

Chest xray
- hyperinflation
- bullae
- flat hemidiaphragm
- exclude lung cancer

FBC to exclude secondary polycythaemia

BMI

Question 5

Severity

Answer 5

Stage 1 (mild): FEV1:FVC <70%, FEV1 >80%

Stage 2 (moderate): FEV1:FVC <70%, FEV1 50-79%

Stage 3 (severe): FEV1:FVC <70%, FEV1 30-49%

Stage 4 (very severe): FEV1:FVC <70%, FEV1 <30%

Question 6

General management

Answer 6

Smoking cessation advice

Annual influenza vaccination

One-off pneumococcal vaccination

Pulmonary rehabilitation if functionally disabled by COPD

Question 7

1st line treatment

Answer 7

SABA (salbutamol or terbatuline) or SAMA (ipratropium bromide)

Question 8

Step 2

Answer 8

No asthmatic or steroid responsive features
- LABA + LAMA

Asthmatic or steroid responsive features
- LABA + ICS

Step up to LABA + LAMA + ICS

Question 9

Additional options

Answer 9

Nebulisers

Oral theophylline

Oral mucolytic therapy

Long term prophylactic antibiotics

Long term oxygen therapy at home

Question 10

Asthmatic/ steroid responsive features

Answer 10

Previous, secure diagnosis of asthma or atopy

Higher blood eosinophil count

Substantial variation in FEV1 over time

Substantial diurnal variation in peak expiratory flow

Question 11

Causes of infective exacerbations

Answer 11

Bacteria: haemophilus influenzae (most common), streptococcus pneumoniae, moraxella catarrhalis

Respiratory viruses: 30% of exacerbations, human rhinovirus most important

Question 12

Features of acute exacerbations

Answer 12

Increase in dyspnoea, cough, wheeze

Increase in sputum suggestive of infective cause

May be hypoxic and have acute confusion

Question 13

ABG

Answer 13

Low pH with raised pCO2 suggest acutely retaining (respiratory acidosis)

Raised bicarbonate indicates chronically retaining CO2

Question 14

Treatment of exacerbation at home

Answer 14

Prednisolone 30mg OD 7-14days

Regular inhalers or home nebulisers

Antibiotics if evidence of infection

Question 15

Treatment of exacerbation in hospital

Answer 15

Nebulised bronchodilators

Steroids

Antibiotics if infection

Physiotherapy to help clear sputum

Question 16

Other options in severe exacerbations

Answer 16

IV aminophylline

NIV

Intubation and ventilation

Question 17

Oxygen therapy

Answer 17

Too much oxygen can depress respiratory drive

Use venturi mask to deliver specific percentage concentration of oxygen

If retaining aim 88-92%

If not retaining aim normal >94%