Chronic obstructive pulmonary disease (COPD)

Question 1

Define COPD

Answer 1

Chronic, progressive lung disorder characterised by airflow obstruction, with chronic bronchitis & emphysema

Question 2

Define chronic bronchitis

Answer 2

chronic cough & sputum production on most days for at least 3 months per year over 2 consecutive years

Question 3

Define emphysema

Answer 3

pathological diagnosis of permanent destructive enlargement of air spaces distal to terminal bronchioles

Question 4

Aetiology of COPD

2

Answer 4

Bronchial & alveolar damage is caused by environmental toxins (e.g. cigarette smoke)

RARE cause - α1 antitrypsin deficiency (consider in young people who don’t smoke)

Question 5

Aetiology of chronic bronchitis

4

Answer 5

Narrowing of the airways resulting in bronchiole inflammation (bronchiolitis)
Bronchial mucosal oedema
Mucous hypersecretion
Squamous metaplasia

Question 6

Aetiology of emphysema

3

Answer 6

Destruction & enlargement of alveoli
Leads to loss of elasticity that keeps small airways open in expiration
Progressively larger spaces develop called bullae (diameter > 1cm)

Question 7

Epidemiology of COPD

prevalence, age, gender

Answer 7

VERY COMMON (8% prevalence)
Presents in middle age or earlier
More common in males

Question 8

Presenting symptoms of COPD

5

Answer 8

Chronic cough
Sputum production
Breathlessness
Wheeze
Reduced exercise tolerance

Question 9

Signs of COPD on physical examination - inspection

5

Answer 9

Respiratory distress
Use of accessory muscles
Barrel-shaped over inflated chest
Decreased cricosternal distance
Cyanosis

Question 10

Signs of COPD on physical examination - percussion

2

Answer 10

Hyper resonant chest

Loss of liver & cardiac dullness

Question 11

Signs of COPD on physical examination - auscultation

5

Answer 11

Quiet breath sounds
Prolonged expiration
Wheeze
Rhonchi
Sometimes crepitations

Question 12

Signs of COPD on physical examination - CO2 retention

3 + 3 late stages

Answer 12

Bounding pulse
Warm peripheries
Asterixis

LATE stages:
Signs of heart failure
right ventricular heave
raised JVP
ankle oedema

Question 13

Investigations for COPD

7 types

Answer 13

Spirometry & pulmonary function tests
CXR
Bloods
ABG 
ECG & echocardiogram
Sputum & blood cultures
α1 antitrypsin levels

Question 14

Investigations for COPD - spirometry & pulmonary function tests
(4)

Answer 14

Shows obstructive picture -
Reduced PEFR
Reduced FEV1/FVC
Increased lung volumes
Decreased CO gas transfer coefficient

Question 15

Investigations for COPD - CXR

4

Answer 15

May appear NORMAL
Hyperinflation - >6 anterior ribs, flattened diaphragm
Reduced peripheral lung markings
Elongated cardiac silhouette

Question 16

Investigations for COPD - bloods

Answer 16

FBC - increased Hb & haematocrit due to secondary polycythaemia

Question 17

Investigations for COPD - ABG

Answer 17

may show hypoxia, normal/raised PCO2

Question 18

Investigations for COPD - ECG & echocardiogram

Answer 18

check for heart failure

Question 19

Investigations for COPD - sputum & blood cultures

Answer 19

for infective exacerbations

Question 20

Investigations for COPD - α1 antitrypsin levels

Answer 20

in young patients who gave never smoked

Question 21

Management of COPD

7 aspects

Answer 21

STOP SMOKING

Bronchodilators

Steroids

Pulmonary rehabilitation

Oxygen therapy

Treatment of acute exacerbation

Prevention of infective exacerbations

Question 22

Management of COPD - bronchodilators

3

Answer 22

Short acting β2 agonists - e.g. salbutamol

Anticholinergics - e.g. ipratropium bromide

Long acting β2 agonists (if >2 exacerbations per year)

Question 23

Management of COPD - steroids

2

Answer 23

Inhaled beclomethasone - if FEV1 < 50% predicted OR >2 exacerbations per year
Regular oral steroid should be avoided if possible

Question 24

Management of COPD - oxygen therapy

3

Answer 24

Only if stopped smoking
Indicated if:
PaO2 < 7.3 kPa on air during period of clinical stability
PaO2 7.3-8 kPa & signs of secondary polycythaemia, nocturnal hypoxaemia, peripheral oedema or pulmonary hypertension

Question 25

Management of COPD - acute exacerbation

6

Answer 25

24% O2 via Venturi mask
Increase slowly if no hypercapnia & still hypoxic (ABG)
Corticosteroids
Start empirical antibiotic therapy if evidence of infection
Respiratory physiotherapy to clear sputum
Non invasive ventilation may be necessary in severe cases

Question 26

Management of COPD - prevention of acute exacerbation

Answer 26

Pneumoccocal & influenza vaccination

Question 27

Complications of COPD

6

Answer 27

Acute respiratory failure 
Infections
Pulmonary hypertension
Right heart failure
Pneumothorax (2º to bullae rupture)
Secondary polycythaemia

Question 28

Prognosis of COPD

3

Answer 28

High morbidity
3 yr survival of 90% if < 60 yrs, FEV1 > 50% predicted
3 yr survival of 75% if > 60 yrs, FEV1 40-49% predicted

Question 29

Define rhonchi

Answer 29

rattling, continuous & low pitched breath sounds

Sound a bit like snoring
Caused by secretions in larger airways or obstructions