COPD

Question 1

how is COPD characterised?

Answer 1

life threatening lung disease
– Chronic
– Characterised by airflow obstruction
– Associated with an abnormal inflammatory response
– Not fully reversible
– Progressive i.e. worsens over time

Question 2

define COPD

Answer 2

Characterised by airflow obstruction. The airflow obstruction is usually progressive, not fully reversible, and does not change markedly over several months.
Obstruction is due to a combination of airway and parenchymal damage. The damage is the result of chronic inflammation that differs from that seen in
asthma, and is usually the result of smoking.

Question 3

who is COPD most common in?

Answer 3

65+

Question 4

when is COPD slightly reversible?

Answer 4

when there is an element of asthma

Question 5

can you get COPD if you never smoked?

Answer 5

yes- 12.2% have never smoked

Question 6

what are the signs and symptoms of COPD?

Answer 6

• Exertional breathlessness
• Chronic cough
• Regular sputum production
• Frequent winter ‘bronchitis’
• Wheeze
• Chest tightness
• Fatigue

Question 7

what are the possible complications of COPD?

Answer 7

• Cor pulmonale/heart failure
• Respiratory failure
• Sleep apnoea syndrome –prolonged
  pauses in breath whilst asleep
• Repeated respiratory infections particularly in the winter
• Osteoporosis

Question 8

who do you consider a disgnosis of COPD with?

Answer 8

– Over 35 and
– Smokers or ex-smokers
– Have any of the symptoms
* Exertional breathlessness
* Chronic cough
* Regular sputum production
* Frequent winter bronchitis
* Wheeze

Question 9

how would you diagnose someone without clinical symptoms of asthma?

Answer 9

– Chronic unproductive cough
– Significant variability in breathlessness
– Night time symptoms
– Significant diurnal or day to day variability in symptoms

Question 10

what should a patient be asked about if COPD diagnosis should be considered?

Answer 10

– weight loss
– effort intolerance
– waking at night
– ankle swelling
– fatigue
– occupational hazards
– chest pain
– haemoptysis.

Question 11

when do you preform a spirometry?

Answer 11

– at diagnosis
– to reconsider the diagnosis, for people who show an
exceptionally good response to treatment
– to monitor disease progression.

Question 12

how do you confirm the diagnosis of COPD with spirometry

Answer 12

Measure post-bronchodilator spirometry to confirm the
diagnosis of COPD.

Question 13

when s=would you think about alternative diagnosis in spirometry?

Answer 13

older people who have an FEV1/FVC ratio below 0.7 but do not have typical symptoms of COPD.

Question 14

what would show a restrictive effect in spirometry?

Answer 14

– FVC is reduced and the FEV1/FVC ratio is >80%
– The lung volume is reduced and the FEV1 and FVC are reduced proportionately

Question 15

when would spirometry show an obstructive effect?

Answer 15

Obstructive effect (e.g. asthma or COPD)
– FEV1 is reduced more than the FVC and the FEV1/FVC ratio is <80%
– FEV1 is less than 80% of predicted
– FVC can be near predicted

Question 16

what additional investigations should be done at the time of initial diagnostic evaluation?

Answer 16

a chest radiograph to exclude other
pathologies
– a full blood count to identify anaemia or
polycythaemia
– BMI calculated.

Question 17

what are the different measures on the dyspnoea scale?

Answer 17

1 Not troubled by breathlessness except on strenuous exercise
2 Short of breath when hurrying or walking up a slight hill
3 Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace
4 Stops for breath after walking about 100m or after a few minutes on level ground
5 Too breathless to leave the house, or breathless when dressing or undressing

Question 18

what are the aims of COPD management?

Answer 18

prevent symptoms and their recurrence
– Slow the progression of the disease
– Preserve optimal lung function (short and long term)
– Enhance quality of life

Question 19

what advice is given to COPD patients?

Answer 19

– stop smoking
– comply with medication
– take regular exercise/pulmonary rehabilitation
– attend for a regular influenza vaccination, and
a (once-only) pneumococcal vaccination

Question 20

what is offered in smoking cessation?

Answer 20

– NRT
– Varenicline
– Bupropion

Question 21

what pharmacological management is there for COPD?

Answer 21

• Bronchodilators
  – Beta2 receptor agonists, antimuscarinic
  agents, theophylline
• Corticosteroids
• Oxygen therapy

Question 22

when would you consider neubuisers?

Answer 22

for people with distressing
or disabling breathlessness despite maximal therapy using inhalers.

Question 23

when should you not continue nebulising therapy?

Answer 23

reduction in symptoms
– an increase in the ability to undertake activities of daily living
– an increase in exercise capacity
– an improvement in lung function

Question 24

why is long term use of oral corticosteroids not recommended for patients with COPD?

Answer 24

side effects
* Monitor people who are having long-term oral corticosteroid therapy for osteoporosis, and give them appropriate prophylaxis. Start prophylaxis without monitoring for people over 65.

Question 25

when should theophylline be given?

Answer 25

should only be used after a trial of short-
acting bronchodilators and long-acting bronchodilators, or for people who are unable to use inhaled therapy, as
plasma levels and interactions need to be monitored.

Question 26

when should you reduce the dose of theophylline?

Answer 26

Reduce the dose of theophylline for people who are having an exacerbation if they are prescribed macrolide or fluoroquinolone antibiotics (or other drugs known to
interact).

Question 27

when are oral mucolytics used?

Answer 27

or people with
a chronic cough productive of sputum.

Question 28

what oral prophylactic antibiotics should be given with COPD?

Answer 28

azithromycin (usually 250 mg 3 times a week)

Question 29

when should oral prophylactic antibiotics be given?

Answer 29

– do not smoke and
– have optimised non-pharmacological management and inhaled
therapies, relevant vaccinations and (if appropriate) have been
referred for pulmonary rehabilitation and
– continue to have 1 or more of the following, particularly if they
have significant daily sputum production:
– frequent (typically 4 or more per year) exacerbations with sputum
production
– prolonged exacerbations with sputum production
– exacerbations resulting in hospitalisation.

Question 30

what is the purpose of monitoring oxygen saturation of arterial blood?

Answer 30

Used to monitor patients progress and during exacerbations
* SpO2
* Normal 97-99%
* Refer to specialist services if Sp02 <92% on
one or more occasion

Question 31

what do the peripheral arterial chemoreceptors respond to?

Answer 31

respond to changes in CO2 and O2 and the pH of arterial blood. Afferents from the carotid body increase their rate of discharge significantly as PO2 falls

Question 32

what do central chemoreceptors respond to?

Answer 32

respond to changes in the pH of the
CSF resulting from alterations in PCO2
* Increased PCO2 results in an increase in the PCO2 of the CSF and the hydration reaction for carbon dioxide is driven to the right:
CO2 + H2O ↔ H+ + HCO3-
* As a result, the pH falls in proportion to the rise in PCO2 and stimulates the chemoreceptors

Question 33

when should you be cautious with oxygen in COPD?

Answer 33

some patients with COPD have reduced alveolar ventilation with a low Pa02 and a high PaC02. They may be cyanosed but not breathless. Their respiratory centres are relatively insensitive to C02 and they rely on hypoxic drive to maintain
respiration

Question 34

when should emergency oxygen be used?

Answer 34

For most patients with known chronic obstructive pulmonary disease (COPD) or other known risk factors for hypercapnic respiratory failure (eg, morbid obesity, chest wall deformities or neuromuscular disorders), a target saturation
range of 88–92% is suggested pending the
availability of blood gas results.

Question 35

why is the target for oxygen sat 88-92%?

Answer 35

In some people, uncontrolled oxygen therapy may reduce the depth and
frequency of breathing, leading to a rise in blood carbon dioxide levels and
a fall in the blood pH (acidosis). Controlled oxygen therapy must therefore
be administered by a delivery device and at a flow rate that helps the
oxygen saturation to be maintained between 88% and 92%.

Question 36

define exacerbation

Answer 36

A sustained worsening of the patient’s symptoms from his or her usual stable state that is beyond normal day-to-day variation, and is acute in on set

Question 37

what are the symptoms of exacerbation?

Answer 37

– Worsening breathlessness/dyspnoea
– Cough
– Increased sputum production/sputum volume
– Change in sputum colour

Question 38

how does one self manage exacerbations?

Answer 38

Give people at risk of exacerbations a course of antibiotic and corticosteroid tablets to keep at home.
* Encourage people at risk of having an exacerbation to respond quickly to the symptoms of an exacerbation by:
– starting oral corticosteroid therapy (unless
contraindicated) if increased breathlessness
interferes with activities of daily living
– starting antibiotic therapy if their sputum is purulent
– adjusting bronchodilator therapy to control symptoms.

Question 39

define pulmonary rehab

Answer 39

Pulmonary rehabilitation is defined as a multidisciplinary programme of care for patients with chronic respiratory
impairment that is individually tailored and designed to optimise each patient’s physical and social performance and autonomy.

Question 40

what does pulmonary rehabilitation include?

Answer 40

– Multidisciplinary interventions
– Physical training
– Disease education
– Nutritional, psychological and behavioural intervention