Chronic Obstructive Pulmonary Disease (COPD)

Question 1

Respiratory risk factors

Answer 1

• Pre-existing respiratory disease (e.g. asthma, COPD)
• Family history of respiratory disease (e.g. cystic fibrosis, alpha-1 antitrypsin deficiency)
• Smoking
• Occupational exposure (e.g. coal mining, farming) to chemicals, dust and fumes
• Hobbies (e.g. bird keeping)
• A history of childhood respiratory infections
• Smoke exposure from coal or wood burning stove
• Air pollution
• Exposure to secondhand smoke- passive smoking
• People who have underdeveloped lungs
• Those who are age 40 and older as lung function declines as you age
• Allergies eg mould

Question 2

SOCRATES for COPD

Answer 2

SITE - location of the symptom eg pain
ONSET - how and when the symptom developed eg
• “Did the shortness of breath come on suddenly or gradually?”
• “When did the shortness of breath first start?”
• “How long have you been experiencing the shortness of breath?”
CHARACTER- specific characteristics of the symptom eg
• “How would you describe the shortness of breath?” (e.g. “tight chest”, “can’t take a deep breath”)
• “Is the shortness of breath constant or does it come and go?”
RADIATION- does the symptom move elsewhere eg
• “Does the chest pain spread elsewhere?”
ASSOCIATED SYMPTOMS- any other symptoms associated with the primary symptom eg
• “Are there any other symptoms that seem associated with the pain?” (e.g. fever in pneumonia, shortness of breath and haemoptysis in pulmonary embolism)
TIME COURSE- has the symptom changes over time eg
• “How has the shortness of breath changed over time?”
EXACERBATING OR RELIEVING FACTORS- does anything make the symptom worse or better eg
• “Does anything make the shortness of breath worse?” (e.g. exertion, exposure to an allergen, cold air)
• “Does anything make the pain better?” (e.g. rest, inhaler)
SEVERITY- ask patient to grade severity on a scale of 0-10 eg
• “On a scale of 0-10, how severe is the chest pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”

Question 3

Potential symptoms of COPD

Answer 3

• weight loss- hyperventilation burns more calories (non-exercise activity thermogenesis NEAT)
• Barrel chested

Question 4

Spirometry

Answer 4

• only accurate method of measuring the airflow obstruction in patients with COPD
• should be performed at the time of diagnosis and to reconsider the diagnosis, if patients show an exceptionally good response to treatment. It is also used to monitor the progression of the disease
• should be performed in patients with features suspicious of COPD. Specifically in those who are aged over 35, are current or ex-smokers (or have a history of exposure to other risk factors such as air pollutants), and who have a chronic cough and/or one of the other typical symptoms. Spirometry should be also considered in patients with chronic bronchitis. A significant proportion of these will go on to develop airflow limitation.
• Assessment is based on post-bronchodilator measurements. A diagnosis of airflow obstruction can be made for forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) less than 0.7 (ie 70%) and FEV1 less than 80% predicted.

Question 5

Classification of severity for COPD spirometer

Answer 5

Stage 1: mild - FEV1 is >80% predicted.
Stage 2: moderate - FEV1 is 50-79% predicted.
Stage 3: severe - FEV1 is 30-49% predicted.
Stage 4: very severe - FEV1 is below 30% predicted (or FEV1 less than 50% but with respiratory failure).

Question 6

Main investigation for COPD

Answer 6

Spirometer

Question 7

Investigations for COPD

Answer 7

• chest radiography (CXR) to exclude other pathologies.
• full blood count to identify anaemia or polycythaemia.
• BMI calculated
• Serial domiciliary peak flow measurements: to exclude asthma if diagnostic doubt remains.
• Alpha-1-antitrypsin: if early onset, minimal smoking history or family history.
• Measurement of carbon monoxide transfer factor: to investigate symptoms that seem disproportionate to the spirometric impairment.
• CT scan of the thorax: to investigate symptoms that seem disproportionate to the spirometric impairment, investigate abnormalities seen on a CXR and assess suitability for surgery- presence of emphysema on CT scan is an independent risk factor for lung cancer.
• ECG and echocardiography: to assess cardiac status if there are features of heart disease or pulmonary hypertension.
• Sputum culture: to identify organisms if sputum is persistently present and purulent- infections
• Oxygen saturation
• Chest x-ray- cough for more than 3 weeks
• FeNO- test for asthma

Question 8

If COPD problem…. FEV1/FVC<

Answer 8

0.7

Question 9

If COPD problem… FEV1<

Answer 9

0.8

Question 10

Smoking cessation

Answer 10

local stop smoking services
• One-to-one and group stop smoking sessions - At first meeting with an adviser,talk aboutwhy you smoke and why you want to quit, as well as any attempts you’ve made to quit in the past; be able to decide on a quit date; offered a breath test,which shows the level ofcarbon monoxide in body
• Nicotine replacement products eg transdermal patches, gum, lozenges, inhalators, mouth and nasal sprays
• Medications eg Bupropion-SR, Varenicline
• weekly face-to-face or phone contact with adviser for the first 4 weeks after quitting smoking, then less frequently for a further 8 weeks. At each meeting, receive a supply of (or prescriptionfor) a stop smokingtreatment, and have carbon monoxide level measured.

Question 11

The 5 Rs

Answer 11

1. Relevance- why quitting is personally relevant
2. Risks- potential negative consequences of Tabasco use
3. Rewards- potential benefits of cessation
4. Roadblocks- identify barriers or impediments to quitting
5. Repetition- motivational intervention should be repeated every time the patient and clinician have an interaction

Question 12

The 5 As

Answer 12

1. Ask- identify and document tobacco use
2. Advise- in a clear, strong and personalised manner, urge tobacco user to quit
3. Assess- is the user willing to quit
4. Assist- use counselling and pharmacotherapy to help quit
5. Arrange- schedule follow-up contact

Question 13

Top tips for smoking cessation

Answer 13

• think when you’re likely to be tempted and come up with ways to overcome the urge
• Keep hands and mouth busy eg drink from a straw and gold drink in hand that usually holds a cigarette
• A craving can last 5 minutes so think of 5 minute strategies
• Make a list of reasons for quitting
• Reward yourself

Question 14

Health promotion

Answer 14

quick question at end of consultation by GP

Question 15

Nicotine replacement products

Answer 15

transdermal patches, gum, lozenges, inhalators, mouth and nasal sprays

Question 16

Treatments of COPD

Answer 16

• cessation of smoking
• Vaccination to reduces risk of developing serious complications if exposed to flu eg pneumonia and heart problems
• Pulmonary rehabilitation- lasts about 6-8 weeks. Involves physical exercise, breathing techniques and positions for when out of breath, how to manage stress, healthy eating, how to use inhalers and other medicines, why to do when unwell
• Oxygen therapy- helps improve persistently low blood oxygen levels which place a strain on your heart. Receive oxygen through one, or a combination, of: an oxygen concentrator (either portable or static for home use), oxygen cylinders (large or small that contain oxygen as a gas) or liquid oxygen (comes in a storage container, it is decanted and breathed in as a gas)
• Non-invasive ventilation- involves wearing a snug-fitting mask over your nose, or over your nose and mouth, connected to a machine that helps air get into your lungs. NIV supports your breathing to give your muscles a rest and helps you breathe out carbon dioxide.
• Lung volume reduction procedures- reduce amount of air trapped in the lungs (only effective for 1-2% of people of COPD and only effective for people with emphysema). May involve an operation to remove damaged lung or putting valves into the airways to block off the most emphysematous part.
• Lung transplant
• Medication
• Keep active to stay in shape and become out of breath less easily
• Create a self-management plan to monitor COPD and flare-ups

Question 17

Vaccination

Answer 17

reduces risk of developing serious complications if exposed to flu eg pneumonia and heart problems

Question 18

Pulmonary rehabilitation

Answer 18

lasts about 6-8 weeks. Involves physical exercise, breathing techniques and positions for when out of breath, how to manage stress, healthy eating, how to use inhalers and other medicines, why to do when unwell

Question 19

Oxygen therapy

Answer 19

helps improve persistently low blood oxygen levels which place a strain on your heart. Receive oxygen through one, or a combination, of: an oxygen concentrator (either portable or static for home use), oxygen cylinders (large or small that contain oxygen as a gas) or liquid oxygen (comes in a storage container, it is decanted and breathed in as a gas)

Question 20

Non-invasive ventilation

Answer 20

involves wearing a snug-fitting mask over your nose, or over your nose and mouth, connected to a machine that helps air get into your lungs. NIV supports your breathing to give your muscles a rest and helps you breathe out carbon dioxide.

Question 21

Lung volume reduction procedure

Answer 21

reduce amount of air trapped in the lungs (only effective for 1-2% of people of COPD and only effective for people with emphysema). May involve an operation to remove damaged lung or putting valves into the airways to block off the most emphysematous part.

Question 22

Medications for COPD

Answer 22

Bronchodilator
Steroid inhalers

Question 23

Treating COPD flare ups

Answer 23

• steroid tablets
• Antibiotics
• Mucolytics - make phlegm thinner and easier to cough up.

Question 24

Brinchodilators

Answer 24

type of medicine you inhale, usually with an inhaler. They make breathing easier by relaxing the muscles in your airways helping them to open up.

Question 25

Short-acting bronchodilator

Answer 25

used if only become out of breath when active- effects are immediate and last for 4-6 hours

Question 26

Long-acting bronchodilator

Answer 26

used if breathless everyday. Take longer to have an effect but last 12-24 hours. 2 main types: long-acting anti-muscarinic (LAMA) and long-acting beta agonist (LABA). Most people with COPD who are breathless will benefit from taking both kinds. Sometimes they come in separate inhalers and sometimes in combinations. You may get on better with one or another combination, but in general they are all thought to be equally effective.

Question 27

Steroid inhalers

Answer 27

help reduce inflammation and swelling in your airways. You’ll usually be given a combination inhaler (two or three medicines in one inhaler) with one or two bronchodilators and a steroid.

Question 28

Dry powder inhalers

Answer 28

breathe in as hard as you can then hold your breath for ten seconds

Question 29

Soft mist inhalers

Answer 29

produce an aerosol but use spring power instead of propellant- easy breathe

Question 30

Pressurised metered dose inhalers

Answer 30

produce a puff of medication like an aerosol - use a slow deep breath in and hold your breath for up to ten seconds- CHEAPEST

Question 31

Inhaler with a spacer

Answer 31

these attach to pressurised metered dose inhalers (MDIs) to help you breathe in the drug more effectively. ‘tidal breathing’ or the ‘multiple breath’ technique. This is usually recommended if you can’t hold your breath for five seconds after using your inhaler or if you are having an asthma attack. For most adults and older children, your spacer can be used with a mouthpiece, but a spacer with a mask may be given to you if you cannot put your lips around the mouthpiece to form a tight seal.

Question 32

How to use a spacer

Answer 32

1. hold your inhaler upright and take the cap off. Check there’s nothing inside the mouthpiece. Shake it well. If your spacer has a valve, make sure the valve is facing upwards.
2. Put your inhaler into the hole at the back of the spacer. If the mouthpiece of your spacer has a cap, take it off.
3. Sit or stand up straight and slightly tilt your chin up as it helps the medicine reach your lungs.
4. Put your lips around the mouthpiece of the spacer to make a tight seal. Press the canister on the inhaler once to release the medicine and breathe in and out slowly and steadily into the spacer five times. Remove the inhaler and spacer from your mouth.
5. If you’ve been prescribed a second puff, keep the spacer away from your mouth, wait a minute and shake the inhaler again. Then repeat the steps.
6. When you’ve finished, take the inhaler out of the spacer and replace the caps on both the inhaler and the spacer.
7. If you’ve used an inhaler that contains steroids, rinse your mouth with water and spit it out to reduce the chance of side effects.

Question 33

Nebulisers

Answer 33

these devices turn the medicine into a mist that you can breathe in. They’re normally only used in an emergency when you need large doses of inhaled medicine, such as during a flare-up.

Question 34

What percentage of medication enters the lungs when using a spacer

Answer 34

85%

Question 35

Tidal breathing and a spacer

Answer 35

With tidal breathing your spacer should make a clicking sound as the valve opens and closes.