COPD

Question 1

Define COPD (including what it stands for)

Answer 1

Chronic Obstructive Pulmonary Disease

clinical syndrome characterised by chronic respiratory symptoms, structural pulmonary abnormalities (airways or alveoli or both) and lung function impairment

Question 2

What are the 2 (3) diseases under the umbrella term COPD?

Answer 2

chronic bronchitis
emphysema
(chronic asthma)

Question 3

Risk factors for COPD (host factors)

Answer 3

genetic (alpha-1-antitrypsin deficiency)
lung growth, low birth weight, age

Question 4

Risk factors for COPD (exposure)

Answer 4

tobacco smoke
biomass fuels, open fires
occupational dusts and exposures
chronic uncontrolled asthma
lower socioeconomic status

Question 5

What cell type is often raised in acute exacerbations of COPD and therefore what drug is given?

Answer 5

eosinophils
steroids

Question 6

Pathology of COPD

Answer 6

obstructive bronchiolitis

mucus hypersecretion

alveolar wall destruction

Question 7

What test is required for a diagnosis of COPD?

Answer 7

spirometry

obstructive pattern

Question 8

How does obstruction show on spirometry?

Answer 8

relatively normal FVC
reduced FEV1
FEV1/FVC ratio reduced (<0.7)

Question 9

What factors can influence spirometry?

Answer 9

height (tall people have larger lungs)
age (respiratory function declines with age)
sex (lung volumes smaller in females)
race (blacks and asians shown to have smaller lung volumes)
posture (little difference between sitting and standing, reduced in supine position)

Question 10

What improvement would show reversibility with spirometry?

Answer 10

pre-bronchodilator FEV1/FVC <70% predicted
post-bronchodilator increase 12% and at least 200ml

reversibility confirms asthma

Question 11

How is COPD classified?

Answer 11

classification of airflow limitation severity, based on post-bronchodilator FEV1

GOLD 1 = mild = FEV1>80% predicted

GOLD 2 = moderate = 50%<FEV1<80% predicted

GOLD 3 = severe = 30%<FEV1<50% predicted

GOLD 4 = very severe = FEV1<30% predicted

Question 12

Indicators to consider a diagnosis of COPD

Answer 12

dyspnoea that is progressive over time, worse with exercise, persistent

chronic cough

chronic sputum production (also consider bronchiectasis)

recurrent LRTIs

history of risk factors

family history of COPD

Question 13

What would you consider in a patient who presents uncharacteristically young with COPD symptoms?

Answer 13

alpha-1-antitrypsin deficiency

Question 14

Intrathoracic causes of chronic cough

Answer 14

asthma
lung cancer
TB
bronchiectasis
left heart failure
interstitial lung disease
cystic fibrosis
idiopathic cough

Question 15

Extrathoracic causes of chronic cough

Answer 15

chronic allergic rhinitis
post nasal drip syndrome
upper airway cough syndrome
gastroesophageal reflux
medication (eg. ACE inhibitors)

Question 16

Initial management of COPD

Answer 16

smoking cessation
vaccination - flu and pneumonia
active lifestyle + exercise
initial pharmacotherapy
manage comorbidities

Question 17

Pharmacological management of COPD

Answer 17

inhaled bronchodilators

LABA/LAMA combinations (increases FEV1, reduces symptoms, reduces exacerbation rate)

inhaled corticosteroids no longer first choice - studies have shown increased risk of pneumonia

Question 18

What are the indications for long term oxygen therapy (LTOT)?

Answer 18

ABGs measures on stable patients on 2 occasions at least 3 weeks apart

PaO2 < 7.3kPa irrespective of PaCO2 + FEV1 <1.5L

PaO2 7.3-8kPa + pulmonary hypertension, peripheral oedema or nocturnal hypoxaemia

patient must have stopped smoking

Question 19

How is long term oxygen therapy given and what is the goal?

Answer 19

use at least 15 hours/day at 2-4 litres/min

aim to achieve PaO2 >8kPa without an unacceptable rise in PaCO2

Question 20

Acute exacerbation of COPD symptoms/signs

Answer 20

increase in dyspnoea
increase in cough
increase in sputum volume/purulence

with or without symptoms of URTI

Question 21

Causes of COPD exacerbations

Answer 21

30-50% bacterial (haemophilus influenzae, streptococcus pneumoniae)

30% viral (rhinovirus, influenza)

Question 22

Manage of acute exacerbations of COPD

Answer 22

regular nebulisers (bronchodilators)

antibiotics

steroids (prednisolone 30mg 5-7 days)

?NIV (pH < 7.2)

Question 23

Aims of COPD treatment

Answer 23

reduce exacerbation rates
reduce decline in lung function
reduce mortality