COPD Flashcards
What spirometry result is diagnostic of COPD
A) Pre-bronchodilator FEV1/FVC ratio <0.7
B) Post-bronchodilator FEV1/FVC ratio <0.7
C) Pre-bronchodilator FEV1/FVC ratio <0.8
D) Post-bronchodilator FEV1/FVC ratio <0.8
B) Post-bronchodilator FEV1/FVC ratio <0.7
How is COPD confirmed?
• The diagnosis of COPD requires spirometry to confirm the presence of persistent airflow limitation (post-bronchodilator FEV1 / FVC < 0.7) since spirometry is the most reproducible and objective measurement of airflow limitation available.
• COPD cannot be diagnosed on clinical features and / or chest x-ray findings alone.
• Emphysema may be present in the absence of airflow limitation. Complex lung function tests will aid this diagnosis.
• Many patients with COPD have some reversibility of airflow limitation (mainly FEV1) with bronchodilators.
However, reversibility alone does not equate to a
clinical diagnosis of asthma because the clinical features and pathophysiology of COPD and asthma overlap and both conditions can coexist in some patients
A 39 year old female smoker (20 pack year) has an ongoing cough the past few months. She is otherwise well with normal vitals and examination findings and no fevers, chest pain, haemoptysis or weight loss. You decide to perform a pre and post spirometry which she struggled with and her results show airflow limitation that’s not fully reversible - FEV1/FEV ratio <0.74 and FEV1 <82% predicted. What would be your next step in management
A) Advise her she likely has a post viral cough which should clear within the next few weeks
B) Request a CT chest and routine bloods
C) Consider referral for lung function testing
D) Prescribe amoxicillin as a trial and review her in a week
C) Consider referral for lung function testing
There is some risk with spirometry of over diagnosis in older people or under diagnosis in younger people,
especially when the FEV1 / FVC is close to 0.7. Consider referral for lung function testing at an accredited lung function testing laboratory if there is uncertainty, or the patient has difficulty performing the test.
Spirometry should be performed using standardised techniques
Perform pre- and post-bronchodilator spirometry to confirm COPD, which is characterised by airflow limitation that is not fully reversible (postbronchodilator FEV1 / FVC ratio < 0.7 and FEV1< 80% predicted).
Interpret borderline spirometry results with caution, particularly in older (> 65 years of age) and younger patients (< 45 years of age), or those without a history of smoking or exposure to occupational / environmental pollutants or dust
In patients with borderline spirometry, consider alternative diagnoses and investigate appropriately. Follow-up spirometry is also recommended
Which spirometry result would be most suggestive of asthma or co-existent asthma and COPD
A) FEV1 increase 12% and >160ml
B) FEV1 increase 10% and >200ml
C) FEV1 increase 10% and >300ml
D) FEV1 increase 12% and >400ml
D) FEV1 increase >12% and >400ml
Is it COPD or asthma?
- An FEV1 increase ≥ 12% and ≥ 200 mL constitutes a positive bronchodilator response. An FEV1 increase ≥400ml may suggest underlying asthma or coexistent asthma and COPD
- Asthma and COPD may co-exist. While a larger bronchodilator response may point to concurrent asthma or asthma-COPD overlap, a thorough history and further investigations may be needed to confirm this.
If the FEV1 response to bronchodilator is:
- ≥ 400 mL, consider asthma or asthma-COPD overlap
- < 400 mL (but ≥ 200 mL and ≥ 12%), consider asthma-COPD overlap or an asthma component depending on history and pattern of symptoms
What FEV1 would you expect in a COPD patient who becomes breathless walking on level ground, recurrent chest infections requiring PO corticosteroids and/or antibiotics and increased limitation of daily activities
A) 80% predicted
B) 64% predicted
C) 54% predicted
D) 38% predicted
C) 54% predicted
Guide to the severity of COPD:
Mild ≈ 60 - 80% predicted • few symptoms • breathless on moderate exertion • little or no effect on daily activities • cough and sputum production
Moderate ≈ 40 - 59% predicted
• breathless walking on level ground
• increasing limitation of daily activities
• recurrent chest infections
• exacerbations requiring oral corticosteroids +/or ABx
Severe < 40% predicted
• breathless on minimal exertion
• daily activities severely curtailed
• exacerbations of increasing frequency and severity
Which of these treatments may increase risk of pneumonia
A) Inhaled Terbutaline
B) Inhaled Corticosteroids
C) Inhaled LAMA/LABA dual therapy
D) Oral Montelukast
B) Inhaled Corticosteroids
There is evidence for an increased risk of pneumonia for patients treated with inhaled corticosteroids, however safety concerns should be balanced against the benefits of reduced exacerbations and reduced decline in quality of life
Avoid long-term (> 2 weeks) use of systemic corticosteroids
A COPD patient currently taking Atrovent when required presents for their GPMP and repeat spirometry shows a drop from 74% to 66% this past year. He’s noticed some more mucus being brought up each morning but no decline in SOB or daily activities.
What would be the best management option
A) Increase atrovent use to BD rather than PRN
B) Add salbutamol for PRN use and review in 4 weeks
c) Give short course of prednisolone and review in 4 weeks
C) Add regular formetorol to regime and review in 4 weeks
C) Add regular formetorol to regime and review in 4 weeks
Follow the stepwise management in COPD
Still mild symptoms
- START with short-acting relievers: (used as needed):
SABA (short-acting beta2agonist) OR SAMA (short-acting muscarinic antagonist)
ADD long-acting bronchodilators:
LAMA (long-acting muscarinic antagonist) OR LABA (long-acting beta2-agonist)
Consider need for combination LAMA/LABA depending on symptomatic response
Which one of these statements is incorrect:
A) Vaccination reduces the risks associated with influenza and pneumococcal infection
B) Influenza vaccination reduces the risk of exacerbations but not hospitalisation for COPD
C) Pneumococcal vaccination reduces the risk of exacerbations and hospitalisation, with no difference between vaccine types
D) Pneumococcal vaccination reduces the risk of exacerbations but not hospitalisation, with no difference between vaccine types
C) Pneumococcal vaccination reduces the risk of exacerbations and hospitalisation, with no difference between vaccine types
Vaccination reduces the risks associated with influenza and pneumococcal infection
Influenza vaccination reduces the risk of exacerbations but not hospitalisation for COPD
Pneumococcal vaccination reduces the risk of exacerbations but not hospitalisation, with no difference between vaccine types
Which statement is correct:
A) There is some risk with spirometry of over diagnosis in older people or under diagnosis in younger people
B) There is some risk with spirometry of over diagnosis in older and younger people
C) There is some risk with spirometry of under diagnosis in older people or over diagnosis in younger people
D) There is some risk with spirometry of under diagnosis in older and younger people
A) There is some risk with spirometry of over diagnosis in older people or under diagnosis in younger people
All patients with a diagnosis of COPD should have a post-bronchodilator spirometry test documented in their clinical record.
There is some risk with spirometry of over diagnosis in older people or under diagnosis in younger people, especially when the FEV1 / FVC is close to 0.7.
Consider referral for lung function testing at an accredited lung function testing laboratory if there is uncertainty, or the patient has difficulty performing the test.
Most patients with COPD have co-morbidities. Name the five most prevalent
A) Hyperglycaemia, atherosclerosis, hyperthyroidism, dyslipidaemia and osteoporosis
B) Hyperglycaemia, atherosclerosis, hypertension, dyslipidaemia and osteoporosis
C) Hyperthyroidism, osteoarthritis, hypertension, dyslipidaemia and osteoporosis
D) Hypothyroidism, atherosclerosis, hypertension, dyslipidaemia and rheumatoid arthritis
B) Hyperglycaemia, atherosclerosis, hypertension, dyslipidaemia and osteoporosis
Most patients with COPD have comorbidities. The five most prevalent comorbidities are hyperglycaemia, atherosclerosis, hypertension, dyslipidaemia and osteoporosis
Some of these comorbid conditions may also influence the outcome of COPD
COPD may increase the overall morbidity and mortality in excess of that related to the primary diagnosis
Reasons to refer to specialist respiratory services
Diagnostic uncertainty and exclusion of asthma.
Unusual symptoms such as haemoptysis.
Rapid decline in functional performance.
Persistent symptoms.
Frequent chest infections (i.e. more than annually).
Onset of ankle oedema.
Oxygen saturation, SpO2 < 92% when stable
(refer for assessment for long-term oxygen therapy)
Assessing suitability for pulmonary rehabilitation, if uncertain.
Bullous lung disease on CXR or CT.
COPD < 40 years of age.
Persistent dyspnoea, marked hyperinflation, severe airflow limitation or emphysema
Dyspnoea associated with chest tightness, anxiety or dizziness (refer for consideration of dysfunctional breathing*)
Daytime sleepiness, complaints by partner of
heavy snoring
What is the most important intervention to prevent worsening of COPD
Smoking cessation is the most important intervention to prevent worsening of COPD
Benefits of varenicline is smoking cessation
Based on a small number of trials, varenicline is more effective than nicotine replacement monotherapy but equally effective as a nicotine replacement combination therapy
What is the greatest risk factor for a further COPD exacerbation
A) An injury that now further limits mobility
B) A urinary tract infection
C) Increased daily smoking amount
D) A recent history of an exacerbation (within the last 12 months)
D) A recent history of an exacerbation (within the last 12 months)
A recent history of an exacerbation (within the last 12 months) is the greatest risk factor for a further exacerbation
Frequent exacerbations lead to faster decline in FEV1, impaired health status, and increased mortality
Prompt intervention for exacerbations improves recovery/quality of life and reduces hospitalisation
When should second dose pneumococcal vaccine (23vPPV) be given in a 66 year old with newly diagnosed COPD who received their first 23vPPV at 65 years old
A) At diagnosis
B) 68 year old
C) 70 years old
D) No need for a second dose
C) At 70 years old
For older adults who have already received an age-based first dose of 23vPPV at age 65 years (non Indigenous) or 50 years (Indigenous), a single revaccination dose of 23vPPV is recommended a minimum of 5 years after the previous dose
When should a newly diagnosed 42 year old indigenous receive their 23vPPV dose
A) At diagnosis
B) 45 years old
C) 50 years old
D) 65 years old
A) At diagnosis
For those with newly diagnosed COPD who have never received pneumococcal immunisation: a first dose of 23vPPV is recommended at diagnosis followed by up to two additional doses
