Clinical features of COPD

Question 1

What is COPD defined as ?

Answer 1

Lung disease characterised by chronic lung airflow that interferes with normal breathing and is not fully reversible

Question 2

What is the epidemiology of COPD ?

Answer 2

1.2 million with diagnosis of COPD
2nd most common lung disease after asthma
~50% underdiagnosed 
Prevalence is increasing 
F>M

Question 3

What is the main cause of COPD ?

Answer 3

Smoking

Question 4

What are the effects of smoking ?

Answer 4

Greater decline in FEV1
<50% of smokers develop COPD
Environmental tobacco smoke may be factor
Smoking during pregnancy may affect foetal lung growth

Question 5

What rare disease can cause COPD (emphysema ) ?

Answer 5

Alpha-1-antitrypsin deficiency

Question 6

What is Alpha-1-antitrypsin deficiency ?

Answer 6

Rare inherited disease
AAT is a protease inhibitor made in liver
Limits damage caused by activated neutrophils releasing elastase in response to infection/ cigarette smoke
When absent/low-> alveolar damage and emphysema
Basal predominance to emphysema

Question 7

What are other aetiological factors of COPD ?

Answer 7

Pollution
Occupational exposures
Increasing age

Question 8

What are the symptoms of COPD ?

Answer 8

Cough
SOB
Sputum
Frequent chest infection
Wheezing 

Weight loss
Fatigue
Oedema in ankles

Question 9

What is useful findings in the history of COPD ?

Answer 9

Age >35
Smoking history
Onset/progression
Productive cough for 3 consecutive months for at least 2 years

Question 10

What are some examination findings in diagnosed COPD ?

Answer 10

Cyanosis 
Raised JVP
Cachexia 
Wheeze
Pursed lip breathing
Hyperinflated chest 
Use of accessory muscles
Peripheral oedema
Acute exacerbations

Question 11

What is the mMRC breathlessness scale ?

Answer 11

0- only breathless with strenuous exercise
1- SOB when hurrying on level ground/ walking up hill
2- on level ground, walk slower than people of same age because of breathlessness
3- I stop for a breath after walking ~100 yards or after a few minutes
4- I am too breathless to leave the house or I am breathless when dressing

Question 12

Is there any single test to diagnose COPD ?

Answer 12

No

Question 13

What criteria needs to be met to diagnose COPD ?

Answer 13

Typical symptoms
>35 years
Presence of risk factor (smoking or occupational exposure)
Absence of clinical features of asthma
AND
Airflow obstruction confirmed by post-bronchodilator spirometry

Question 14

What are the investigations of COPD ?

Answer 14

Airflow obstruction confirmed on spirometry:

- FEV1 reduced (70%)
- FVC usually reduced 
- FEV1/FVC (<0.7)

Chest X-ray:

- exclude alternative pathology + screen for malignancy 
- Hyperinflated lungs 
- Bulla
- Vascular hila 
- Flat diaphragm

Question 15

What is the severity scoring of COPD ?

Answer 15

Stage 1 - Mild - FEV1 80%
Stage 2 - Moderate - FEV1 50-79%
Stage 3 - Severe - FEV1 30-49%
Stage 4 - Very severe - FEV1 <30%

Question 16

If we are unsure if it is COPD what are other useful investigations ?

Answer 16

Pulmonary function tests:
- lung volumes: increased RV
increased TLC
RV/TLC >30%
- transfer factor: reduced gas transfer
reduced Dlco and Kco

Question 17

What are the clinical features differentiating COPD and asthma ?

Answer 17

COPD Asthma

Smoker/ ex-smoker - nearly all possibly
Symptoms <35yrs - rare often
Chronic productive cough - common uncommon
Breathlessness - persistent/progressive variable
Night time waking with SOB/wheeze - uncommon common
Diurnal or day-day variability of symptoms - uncommon common

Question 18

What is an acute exacerbation ?

Answer 18

Worsening of pre-existing symptoms

Question 19

What are the symptoms of an acute exacerbation ?

Answer 19

SOB
Wheeze
Chest tightness
Cough
Sputum- purulence/ volume 
In addition to above signs of severe exacerbation:
     - RR >25/min
     - accessory muscles in use 
     - purse lip breathing
     - cyanosis (SaO2 <92%)

Question 20

What are the causes of an acute exacerbation ?

Answer 20

Often viral

Sometimes bacterial secondary to viral infection

Question 21

What is the management of acute exacerbations in primary care ?

Answer 21

Change in inhalers (technique, device, add bronchodilator, increase or add inhaled steroid)
Oral steroids (Prednisolone tablets)
Antibiotics

Self- management for select patients

Question 22

What can trigger an acute exacerbation in secondary care ?

Answer 22

Viral/bacterial infection - most common

Sedative drugs, pneumothorax, trauma

Question 23

What is the management for Acute exacerbations ?

Answer 23

Oxygen
Nebulised bronchodilator
(B2 & anti-muscarinic) 				
Oral/IV corticosteroid +/- antibiotic
(IV aminophylline, respiratory stimulant, NIV)

Question 24

How can the severity of COPD be measured ?

Answer 24

Spirometry 
Nature and magnitude of symptoms 
    - MRC breathlessness scale 
History of moderate and severe exacerbations and future risk
Presence of co-morbidity

Question 25

What is respiratory failure caused by ?

Answer 25

Reduced V/Q- matched

Question 26

What is type 1 respiratory failure ?

Answer 26

Reduced pO2

Question 27

What is type 2 respiratory failure ?

Answer 27

Reduced pO2
Increased pCO2 (ventilatory drive)
- severe ventilatory problems can lead to reduced sensitivity of CO2 chemoreceptors in
medulla therefore some COPD patients develop a “hypoxic drive”

Question 28

What is Cor pulmonale ?

Answer 28

Right sided heart failure due to lung disease
Smoking, hypoxia
Tachycardia, oedematous, raised JVP, congested liver

Question 29

What is Secondary polycythaemia ?

Answer 29

Body produces increased erythropoietin in repsonse to low O2
Raised Hb levels
Raised blood viscosity

Question 30

What are some complications of severe COPD ?

Answer 30

Respiratory failure
Cor pulmonale
Secondary polycythaemia

Question 31

What is End stage COPD ?

Answer 31

Terminal illness
Unpredictable decline
Palliation of symptoms- breathlessness, anxiety
Social aspects- care, housebound, O2 at home