COPD

Question 1

How do COPD patients present?

Answer 1

Chronic cough +/- sputum production
SOB
Recurrent lower respiratory tract infections
Symptoms being triggered by viral infections
Smoking history or air pollution exposure
>40 years of age

Question 2

Is spirometry diagnostic of COPD?

Answer 2

No!
Need clinical findings
Spirometry is only confirmatory testing

Vice versa, a patient can have “preserved” lung function on spirometry but be diagnosed with COPD based on history and clinical features/exacerbations

Question 3

List 3 things that reduce mortality in COPD

Answer 3

1) Supplemental oxygen in select populations
- Those with severe resting hypoxemia on RA (ABG PaO2 ≤55mmHg or SpO2 <88%; PaO2 ≤60% if pulmonary HTN/RHF )
- Must be worn continuously for at least 16-18 hours/day

2) Stop smoking

3) ?NIV
- Recommended if pCO2 >=52 when stable + nighttime hypoxemia SpO2 =<88%
- However evidence is mixed

Question 4

Can you rely on pulse oximetry readings in smokers?

Answer 4

No
Smokers can still be hypoxic despite normal resting O2 saturation because pulse oximeter cannot tell the difference between oxy and carboxyhaemoglobin

Need to check ABG

Question 5

Do inhalers improve mortality in COPD?

Answer 5

No
Only symptoms and exacerbations
Patients without symptoms/exacerbations can get away with ventolin PRN

Question 6

Can long-term azithromycin reduce exacerbation of COPD?

Answer 6

Yes

Consider in moderate/severe COPD (despite inhaler use)

Question 7

Which monotherapy inhaler should you NOT use in COPD?

Answer 7

Monotherapy ICS

Question 8

Which monotherapy inhaler should you NOT use in asthma?

Answer 8

Monotherapy beta-agonist

Question 9

What does a significant pre- and post-bronchodilatory spirometry suggest in COPD?

Answer 9

Shows how much room for improvement there is with the addition of inhaler therapies
Once COPD is well controlled, a significant post-bronchodilatory may be absent

COPD patients can have bronchodilatory response

Question 10

When should you suspect asthma COPD overlap?

Answer 10

Childhood asthma
Peripheral eosinophilia
Allergic triggers

Question 11

When to test for alpha-1-antitriypsin deficiency?

Answer 11

Can consider testing in emphysema which may be useful particularly for counselling family members

Question 12

What is considered a bronchodilatory response on spirometry?

Answer 12

200ml or 12% increase in FEV1 or FVC

Question 13

How to interpret spirometry in COPD?

5 steps

Answer 13

1) Look at the curve
- FEV1/FVC <70% should look curvilinear

2) FEV1/FVC ratio <70% = obstruction
3) Degree of obstruction is based on FEV1% predicted (predicted values are based on age, sex, and height)

4) Look at FVC
- If normal and all above suggests obstruction, you are done. Confirmed obstructive.
- If low, consider mixed obstructive restrictive picture but this needs full RFTs. A low FVC may also mean that the patient has so much air trapping that they couldn’t exhale long enough

5) Bronchodilator response (12% or 200ml increase in FEV1 or FVC)
- Gives you an idea of what optimal lung function could be with treatment

Question 14

COPD GOLD staging is based on…

Answer 14

FEV1% predicted
Exacerbation frequency and whether it leads to hospitalisation
Severity of dyspnoea symptoms (mMRC or CAT)

Question 15

What’s the BODE index?

Answer 15

Predicts mortality, hospitalisation post lung volume reduction surgery
B - BMI
O - obstruction; FEV1% predicted
D - dyspnoea; mMRC dyspnoea scale
E - exercise; 6MWT

Question 16

Discuss the stepwise management for COPD management

Answer 16

1st line
- If the patient only has symptoms from a trigger (e.g. URTI), start with SABA or SAMA

2nd line

• For chronic symptoms, start with either a LAMA or LABA
• LAMAs outperform LABAs
• LABA/LAMA combination is associated with reduced rate of COPD exacerbations annually as compared to LABA/ICS
• Don’t use LAMA and SAMA together

3rd line

• Consider adding ICS for moderate/severe COPD however this should never be used as monotherapy (this is the opposite of asthma treatment in which LABAs should never be used as monotherapy and ICS are the cornerstone of therapy)
• ICS may increase the risk of pneumonia so not add unless exacerbations are frequent

Systemic steroids should not be used long-term

Pulmonary rehab can help with symptoms and functional improvement/ET and can reduce hospitalisation if patients have had an exacerbation within the last month

Long-term azithromycin (either low dose daily or 3 times/week) can reduce exacerbations but has the risk of adverse cardiac events due to QT prolongation or ototoxicity.

Question 17

Rx for COPD exacerbation

Answer 17

Prednisolone for 5/7
SABA with spacer or nebuliser

+/- abx for infective exacerbation
+/- BIPAP or intubation if T2RF

Question 18

Potential underlying aetiologies to consider in COPD exacerbation

Answer 18

PE
Viral infection
Environmental exposures

Question 19

When would you use abx in COPD exacerbation?

Answer 19

Fever
Raised inflammatory markers
Very unwell
Change in amount, colour, purulence of sputum
Consolidation on CXR (complicated by pneumonia)

Question 20

What abx to use and for how long in COPD exacerbation?

Answer 20

Mild: amoxycillin 500mg TDS or doxycycline 100mg BD
Severe: Ceftriaxone 1g + azithromycin 500mg

5-7 days

Question 21

Risk factors for COPD

Answer 21

Smoking
alpha-1 anti-trypsin deficiency
Dust and fume exposure, smoke from cooking
Bronchial hyperresponsiveness
Respiratory infections/mucous hypersecretion

Question 22

How do classify mild, moderate, severe COPD?

Answer 22

Mild: FEV 1 60-80% predicted
Moderate: FEV1 40-60% predicted
Severe: FEV1 <40% predicted

Question 23

IE COPD. List causative pathogens

1) Bacterial
2) viral

Answer 23

1) Haemophilus influenzae, strep pneumoniae, mycoplasma, moraxella, klebsiella, chlamydia, pseudomonas, staph
2) influenza, rhinovirus, RSV, metapneumovirus

Question 24

List non-infective causes of NIE COPD

Answer 24

PE
LVF
PTX
Anxiety
Sedation
Environmental pollution

Question 25

Acute rx exacerbation of COPD

Answer 25

• Oxygen, aim SpO2 88-92%
• Consider NIV +/- intubation in T2RF (pH <7.35, paCO2 >45)
• Steroids for 5 days
• Bronchodilators/burst therapy with salbutamol + ipratropium
• Abx

Question 26

Dose equivalent of 1mg dexamethasone

1) Methylprednisolone
2) Prednisolone
3) Hydrocortisone
4) Cortisone

Answer 26

1) 4mg
2) 5mg
2) 20mg
4) 25mg

Question 27

What’s a typical setting for biPAP for COPD exac?

Answer 27

10 (insp)/5 (exp)

5 exp keeps the alveoli opened, allows lung to get rid of CO2

Question 28

Is theophylline recommended in COPD management?

Answer 28

Oral bronchodilator

No

Question 29

What is the evidence behind the use of bronchodilators in COPD management?

Answer 29

Improves lung function and symptoms, and decreases exacerbations

?Maybe some mortality benefit

LAMAs are better than LABAs

Question 30

What is the evidence behind the use of ICS in COPD management?

Answer 30

Reduces exacerbations and symptoms, but not rate of decline in lung function or mortality

Indicated only in severe disease (FEV <50%) and a history of frequent exacerbations

Increase risk of pneumonia

Question 31

Any benefit with long-term oxygen therapy for nocturnal desaturation (not OSA)?

Answer 31

No

Improves quality of sleep and reduces ventricular premature contractions, but does not reduce mortality