COPD

Question 1

An 82 year female presents with progressive dyspnoea over a period of 6 months. She can now walk only 200m before having to stop to catch her breath. She smoked 1 pet of cigarettes daily until she turned 70. How would you manage her?

Answer 1

Impression
Given progression SOBOE/dyspnoea in setting of significant smoking history, am concerned about COPD as provisional diagnosis. Given patients age and smoking status also would like to rule out malignancy as a cause of this presentation.

Other DDx to consider include;

• Resp: Bronchitis, ILD, asthma exacerbation
• Cardiac: heart failure, ACS

Goals

• Initially rule out resp distress and HD instability, then. thorough Hx/Ex/Ix
• Diagnostic Ix with spirometry
• Treat with S/LABA and anticholinergics, consider ICS

Question 2

COPD - Assessment

Answer 2

Assessment
- A to E initially, focussing on A and B primarily, assessing for evidence of resp distress and need for intervention I/E supplemental 02, taking into consideration their P02 (may be chronic C02 retainers)

Question 3

COPD - History

Answer 3

History

• sx: characterise exercise intolerance, baseline function. progression.
• Assoc: pain, SOBOE, cough, production? orthopnoea? PND?
• malignancy: fevers, night sweats, weight loss, other mass effects (neurological, etc).
• RISKS: smoking, age, fam Hx, male gender, occupational exposures
• Meds, allergies, PMHx
• SNAP
• Sociocultural - how is she coping at home, need for

Question 4

COPD - Examination

Answer 4

Examination

• General appearance + vitals
• Cardioresp: widespread wheeze, reduced air entry, over-expansion and reduced chest expansion, dullness to percussion for masses
• systems review: mets

Question 5

COPD - Investigations

Answer 5

Investigations
Key/diagnostic
- spirometry: obstructive pattern, partially/not reversible with bronchodilators <0.7 FEV1:FVC ratio
- peak flow limitation for age and gender

Bedside: CXR (hyperinflation, reduced lung markings), sputum sample and MCS
Bloods: FBC, BNP, Trops,
Imaging: CT chest, staging CT, HRCT chest?

Utilise GOLD severity scoring system for management categorisation

Question 6

COPD - Management

Answer 6

Management (FOR COPD)
Acute
- SABA +/- LABA +/- LAMA
- ICS
- ABx coverage if infective exacerbation

Ongoing
Non-pharm
- ?home 02 (meet stringent criteria)
- ACAT referral - OT for home mods etc
- Chest physio, respiratory CNC
- Smoking cessation (if relevant)

Pharm
- As per acute regime, and depending on symptom control, severity, rate of relapse etc