COPD

Question 1

Which features suggest an acute exacerbation of COPD

Answer 1

Worsening breathlessness 
Increased sputum volume and purulence 
Cough
Wheeze 
Fever
URTI in past 5 days 
Increased RR or HR

Question 2

Signs that indicate a severe exacerbation of COPD

Answer 2

Marked breathlessness and tachypnoea 
Pursed-lip breathing and/or use of accessory muscles at rest 
New-onset cyanosis or peripheral oedema
Acute confusion/drowsiness 
Marked reduction in ADLs

Question 3

When should hospital admission be considered for acute exacerbation of COPD

Answer 3

Severe SOB
Inability to cope at home
Rapid onset of symptoms 
Acute confusion
Cyanosis 
O2 sats less than 90%
Worsening peripheral oedema
New arrhythmia

Question 4

Management of acute exacerbation of COPD if hospital admission not required

Answer 4

Increase doses or frequency of SABA
If no contraindications, consider oral corticosteroids for people with significant increase in breathlessness
Consider antibiotics

Question 5

First choice oral antibiotics for acute exacerbation of COPD

Answer 5

Amoxicillin
Doxycycline
Clarithromycin

Question 6

What should be done if there is no improvement in symptoms on first choice antibiotic

Answer 6

Send a sputum sample for culture and susceptibility testing

Offer an alternative first choice antibiotic from different class

Question 7

Which antibiotic can be co-prescribed if the patient is at higher risk of treatment failure(previous or current culture with resistant bacteria)

Answer 7

Co-amoxiclav

Question 8

When should a sputum sample for culture and sensitivity testing be carried out

Answer 8

Not routinely

If symptoms have not improved following antibiotic treatment

Question 9

What should be done as follow up for all people who have had an exacerbation of COPD

Answer 9

Consider need for CXR if recurrent infections
Counsel with regard to medications
Consider need for referral to resp specialist and/or pulmonary rehab
Offer short course of oral corticosteroids and antibiotics if needed

Question 10

When should oral corticosteroids and oral antibiotics be prescribed as follow up for acute exacerbation of COPD

Answer 10

Have had an exacerbation within the last year, and remain at risk of exacerbations

Question 11

When should a patient with COPD be referred to a respiratory specialist

Answer 11

Diagnostic uncertainty
COPD is very severe or rapidly worsening
Age less than 40 yrs and family history of alpha-1-antitrypsin deficiency
Frequent infections

Question 12

When should a person with COPD be referred to pulmonary rehabilitation

Answer 12

Functionally disabled(MRC dyspnoea scale grade 3 or above)

Recent hospitalisation for an acute exacerbation

Question 13

When should COPD patients not be referred to pulmonary rehab

Answer 13

If unable to walk

Have unstable angina, or have had a recent MI

Question 14

Pharmacological intervention if person with COPD continues to be limited by symptoms or has exacerbations despite use of SABA

Answer 14

LABA plus a long-acting muscarinic antagonist (if no asthmatic features or features suggestive of steroid responsiveness)

LABA plus ICS if steroid responsive

Question 15

How is bronchodilator therapy administered for most patients

Answer 15

Hand-held inhaler

Spacer where appropriate

Question 16

Advice for usage of a spacer with a metered-dose inhaler

Answer 16

Administer drug by single actuations of MDI into spacer, inhaling after each actuation

Minimal delay between inhaler actuation and inhalation

Normal tidal breathing can be used

Repeat if a second dose is required

Question 17

Advice regarding spacer cleaning

Answer 17

Do not clean the spacer more than monthly, because more frequent cleaning affects their performance(because of build-up of static)

Hand wash using warm water and washing-up liquid, and allow the spacer to air dry

Question 18

Side effects of nebuliser therapy

Answer 18

Dry/irritated throat
Sneezing
Nosebleed
Nausea

Question 19

When should nebuliser therapy be considered

Answer 19

People with distressing or disabling breathlessness despite maximal therapy using inhalers

Question 20

When should the dose of theophylline be reduced in COPD patients

Answer 20

Should be reduced in people prescribed macrolide or fluoroquinolone antibiotics for an exacerbation

Question 21

When should theophylline(slow release) be considered in COPD management

Answer 21

After a short trial of short-acting and long-acting bronchodilators, or people who cannot use inhaled therapy

Question 22

Use of mucolytic therapy in COPD management

Answer 22

Consider if a person with stable COPD develops a chronic cough productive of sputum

Question 23

When should prophylactic antibiotic treatment for COPD be initiated in secondary care

Answer 23

For people with COPD who have had more than three exacerbations requiring steroid therapy and at least one exacerbation requiring hospital admission in the previous year

Macrolides should only be started following resp specialist referral

Question 24

Use of phosphodiesterase-4 inhibitors in COPD management

Answer 24

May be considered for severe disease with persistent symptoms and exacerbations

Must be initiated by a respiratory specialist

Question 25

What information should self-management plans offer for people with COPD

Answer 25

COPD and its symptoms
Non-pharmacological measures including diet, physical activity, pulmonary rehab, smoking cessation
Vaccinations
Appropriate use of inhaled therapies
Early recognition and management of exacerbations

Question 26

What is required for confirmation of COPD diagnosis

Answer 26

Spirometry

Post bronchodilator FEV1/FVC less than 0.7 confirms persistent airflow obstruction

Question 27

MRC dyspnoea scale grade 1

Answer 27

Not troubled by breathlessness except during strenuous exercise

Question 28

MRC dyspnoea scale grade 2

Answer 28

Short of breath when hurrying or walking up a slight hill

Question 29

MRC dyspnoea scale grade 3

Answer 29

Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace

Question 30

MRC dyspnoea scale grade 4

Answer 30

Stops for breath after walking about 100 m or after a few minutes on the level

Question 31

MRC dyspnoea grade 5

Answer 31

Too breathless to leave the house, or breathless when dressing or undressing

Question 32

Key indications for NIV

Answer 32

COPD with respiratory acidosis
Type II resp failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
Cardiogenic pulmonary oedema unresponsive to CPAP
Weaning from tracheal intubation

Question 33

Which medication can be used if unresponsive to NIV in severe cases

Answer 33

Doxapram - respiratory stimulant

Question 34

What is alpha-1 antitrypsin deficiency

Answer 34

Caused by a lack of a protease inhibitor (Pi) normally produced by the liver. The role of A1AT is to protect cells from enzymes such as neutrophil elastase.

It classically causes emphysema (i.e. chronic obstructive pulmonary disease) in patients who are young and non-smokers.

Question 35

Inheritance of A1AT

Answer 35

Autosomal recessive

Question 36

Features of A1AT

Answer 36

lungs: panacinar emphysema, most marked in lower lobes
liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children

Question 37

IX for A1AT

Answer 37

A1AT concentrations

spirometry: obstructive picture

Question 38

Mx of A1AT

Answer 38

no smoking
supportive: bronchodilators, physiotherapy
intravenous alpha1-antitrypsin protein concentrates
surgery: lung volume reduction surgery, lung transplantation

Question 39

Indications for long-term oxygen therapy in COPD

Answer 39

4 Bs

Blue (cyanosis, sp02 <92%)
Breathing (severe airway obstruction, FEV1 <30%)
Blood (secondary polycythaemia)
Ballooning (peripheral oedema, raised JVP, hepatomegaly)