COPD

Question 1

What is COPD and what does in encompass?

Answer 1

Disease state characterised by airflow limitation that’s not fully reversible

Encompasses both emphysema and chronic bronchitis

Question 2

What is emphysema and how does it happen?

Answer 2

Disorder affecting alveoli, causing SOB.

Proteases break down alveolar walls (elastin, etc)→ loss of elastic recoil→ damaged alveoli. Over time, inner walls weaken and rupture→ larger air spaces (bullae) instead of many small ones

Question 3

What are bullae?

Answer 3

Air-filled space 1 cm in diameter within lung; has developed due to emphysematous destruction

Question 4

What is chronic bronchitis and how does it happen?

Answer 4

Bronchi become inflamed and scarred→ produce large amounts of mucus→ chronic cough and breathing problems

Question 5

What acid-base abnormality is commonly seen in COPD?

Answer 5

Fully compensated respiratory acidosis
- Normal pH
- High CO2
- High BE

Question 6

Pathophysiological changes due to COPD (due to repeated injury and repair)

Answer 6

• Airway narrowing and remodelling (epithelium, smooth muscle, etc thickens)
• Increased goblet cells
• Ciliary dysfunction
• Alveolar loss
• Vascular bed changes→ HTN
• Inflamm state (involv macrophages, neutrophils, leukocytes, eosinophils)

Question 7

Classification of COPD and respective FEV1%

Answer 7

Stage 1 (mild): >80%
Stage 2 (moderate): 50-79%
Stage 3 (severe): 30-49%
Stage 4 (very severe): <30 or <50 and resp failure

Question 8

Aetiology of COPD

Answer 8

• Smoking (main)
• Air pollution
• Indoor burning of biomass
• Occupational exposure to dusts, chemicals, fumes

Question 9

Risk factors for COPD

Answer 9

Smoking
Older age
Genetic factors; fam hx

Question 10

Signs and symptoms of COPD

Answer 10

Chronic productive cough + SOB + Wheeze (expiratory; polyphonic)

Barrel chest, decreased cricosternal distance, hyper-resonance

Asterixis, tachypnoea, cyanosis

Cor pulmonale: swollen ankles, raised JVP

Question 11

Investigations for COPD

Answer 11

O2 saturations; ABG

Spirometry: FEV1/FVC ratio <0.70 (obstructive)
- Performed after dose of short-acting inhaled bronchodilator

CXR: hyperinflation >6 anterior ribs, decreased lung markings, flat hemidiaphragms, air trapping

FBC (raised haematocrit, anaemia, possible increased WBC); ECG; sputum and blood culture

Question 12

COPD management: lifestyle modifications first which inclu..?

Answer 12

Smoking cessation
Avoid exposures
Immunisation (ie: flu, Streptococcus pneumonia, whooping cough, varicella-zoster, COVID19)
Pulmonary rehabilitation: education (inhaler technique) and exercise

Question 13

COPD management: first line pharmacological management, given to all patients for immediate sympt relief?

Answer 13

SABA/ SAMA

Inhaled salbutamol/ ipratropium

Question 14

COPD management: IF still limited by sympt or exacerbations despite initial SABA/ SAMA what next?

Answer 14

IF no asthmatic features→ LABA + LAMA
- Only add ICS IF sympt still impact quality of life/ 1-2 moderate or severe exacerbations in yr

IF asthmatic features→ LABA + ICS
- Only add LAMA IF sympt still impact quality of life/ 1-2 moderate or severe exacerbations in yr

Question 15

LABA examples?

Answer 15

Formoterol/ arformoterol

Question 16

LAMA examples?

Answer 16

Aclidinium/ glycoprronium

Question 17

ICS examples?

Answer 17

Budesonide/ flunisolide/ fluticasone/ mometasone

Question 18

COPD management: Other potential additional measures for ongoing COPD?

Answer 18

Consider adding:

Oxygen support
Roflumilast (oral phosphodiesterase-4 inhibitor)/azithromycin/ theophylline: consider if persistent symptoms and exacerbations
Mucolytic: consider if often produce thick sputum and have chronic bronchitis phenotype of COPD