COPD

Question 1

define chronic bronchitis

Answer 1

productive cough for at least 3 months per year for 2 consecutive years that cannot be explained by an alternative diagnosis

Question 2

define emphysema

Answer 2

permanent dilatation of pulmonary air spaces distal to the terminal bronchioles that is cuased by the destruction of the alveolar walls and pulmonary capillaries required for gas exchange

Question 3

endogneous risk factors

Answer 3

lung growth and development abnormalities - recurrent pulmonary infections, premature birth
a1-antitrypsin deficiency
airway hyperresponsiveness
antibody deficiency syndrome eg. IgA deficiency
primary ciliary dyskinesia

Question 4

presenting findings of COPD

Answer 4

chronic cough with expectoration especially in the morning
dyspnea and tachypnoea
pursed lip breathing
prolonged expiratory phase
end expiratory wheezing
crackles
muffled breath sounds
cyanosis
tachycardia

Question 5

features of advanced COPD

Answer 5

congested neck veins
baarrel chest
use of accessory respiratory muscles due to diaphraagmatic dysfunction
hyperresonant lungs
decreased breath sounds
right heart failure and cor pulmonale
weight loss and cachexia

Question 6

cor pulmonale

Answer 6

pulmonary heart disease
altered structure or impaired functioning of the right ventricle caused by a primary disorder of the respiratory system

Question 7

pink puffers

Answer 7

emphysema predominating
noncyanotic
cachectic
pursed lip breathing
mild cough

Question 8

blue bloater

Answer 8

chronic bronchitis predominating
productive cough
overweight
peripheral oedema

Question 9

a1-antitrypsin deficiency

Answer 9

deficiency of a protease inhibitor
presents with panacinar emphysema and cirrhosis
age of onset usually younger
often also have hepatic signs and symptoms related to hepatitis or cirrhosis

Question 10

centrilobular/centriacinar emphysema

Answer 10

most common type
seen in smokers
destruction of respiratory bronchiole (central portion of acinus) sparing distal alveoli
usually affects upper lobes

Question 11

panlobular/panacinar emphysema

Answer 11

rarer type
associated with a1-antitrypsin deficiency
characterised by destruction of entire acinus (respiratory bronchiole and alveoli)
usually affects the lower lobes

Question 12

initial tests for COPD

Answer 12

spirometry - FEV1/FVC ratio <0.7 after bronchodilator inhalation confirms the diagnosis
serum AAT level

Question 13

what finding on spirometry is diagnostic of COPD

Answer 13

FEV1/FVC ratio of less than 0.7

Question 14

restrictive lung disease

Answer 14

eg. pulmonary fibrosis
inability to inflate fully

Question 15

obstructive lung disease

Answer 15

eg. bronchial asthma, COPD
difficulty exhaling air

Question 16

assessment for respiratory failure

Answer 16

pulse oximetry: obtain in patients with signs of respiratory distress or signs of right heart failure
measure aat rest and on ambient air or usually oxygen prescription
ABG: obtain in patients with SO2 < 92% and/or acute illness

Question 17

ABG findings of COPD

Answer 17

may show hypoxemic resp failure (low PO2) with or without hypercapnic respiratory failure
(high PCO2)
chronic hypercapnia due to CO2 trpping is common in patients with severe COPD

Question 18

imaging

Answer 18

not required for diagnosis
signs of pulmonary hyperinlfation
- increased anteroposterior diameter (barrel chest)
- pushed down and flattened diaphragm
- horizontal ribs and widened intercostal spaces
- hyperlucency of lung tissue
- long and narrow heart shadow
signs of bullous emphysema: parenchymal bullae or pulmonary blebs

Question 19

lifestyle modifications for COPD

Answer 19

counsel on smoking cessation eg. varenicline, buproprion, nicotine replacement therapy, lozenges, transdermal patch, gum
encourage physcal activity to recduce the risk of acute exacerbations
educate on indoor air pollution, work related pollution
recommend vaccinations
pulmonary rehabilitation for symptomatic patients

Question 20

mild COPD

Answer 20

60-80% predicted FEV1 post bronchodilator
breathless on moderate exertion, few symptoms or effects on ADLs

Question 21

moderate COPD

Answer 21

40-59% predicted FEV1 increasing dyspneoa, breathless on the flat, increasing limitation of ADLs

Question 22

severe COPD

Answer 22

<40% predicted FEV1
dyspnoea on minimal exertion, ADLs severely curtailed

Question 23

pharmacotherapy for COPD

Answer 23

symptomatic bronchodilator: short acting bronchodilator SABA salbutamol and/or ipratropium used when needed
regular bronchodilator: long acting beta-2 agonist LABA added when frequent deterioration in symptoms prompts additional medication use

Question 24

regular bronchodilators that can be added in more severe disease

Answer 24

long acting anticholinergic tiotropium once daily
and then
fluticason propionate with salmeterol xinafoate

Question 25

oral medications for COPD

Answer 25

oral slow release theophylline
may be useful after trial of short and long acting bronchodilator or where no inhlater use is possible

Question 26

SABA

Answer 26

A class of bronchodilating medications with a short duration of action (< 6 hours). These medications also have a quick onset of action (1-5 minutes). Used to treat acute exacerbations of asthma and COPD. Usually administered via a nebulizer or metered-dose inhaler.

Question 27

LABA

Answer 27

A class of bronchodilating medications with a long duration of action (≥ 12 hours). Onset of action is variable (quick for formoterol, longer for salmeterol). Used for long-term control of symptoms of asthma and COPD. Usually administered via a nebulizer or metered-dosed inhaler.

Question 28

LAMA

Answer 28

A class of muscarinic antagonists that have a long duration of action (typically ≥ 12 hours). Used for maintenance therapy for asthma and chronic obstructive pulmonary disease. Examples include tiotropium, aclidinium, umeclidinium, and glycopyrrolate.

Question 29

SAMA

Answer 29

A class of muscarinic antagonists with an onset of action of 10-15 minutes and a short duration of action (4-6 hours). Used to treat acute exacerbations of asthma and COPD. Examples include ipratropium and aclidinium.

Question 30

ICS

Answer 30

inhaled corticosteroid eg. fluticasone

Question 31

other drugs for COPD

Answer 31

palliative pharmacotherapy for dyspnoea eg. opiates
mathyxanthines eg. theophylline, not recommended in australia

Question 32

LTOT

Answer 32

long term oxygen therapy
PaO2 < 55 mmHg or SaO2 < 88% at rest despite optimal medication
or pulmonary hypertension, CHF, polycythaemia
target O2 saturation >90%
continous oxygen therapy for > 15 hours/day
reevaluate after 60-90 days with ABG or pulse oximetry

Question 33

ventilatory support

Answer 33

continuous positive airway pressure is useful in patients with COPD and pbstructive sleep apnoea
long term noninvasive positive pressure ventilation may be considered in select patients with severe chronic hypercapnia

Question 34

surgical management

Answer 34

surgical bullectomy - in severe emphysema with hyperinflation and large bullae
lung volume reduction - for severe emphysema and hyperinflation without large bullae
lung transplantation

Question 35

complications of COPD

Answer 35

chronic respiratory failure
acute exaacerbation of COPD
cor pulmonale
secondary spontaneous pneumothorax due to rupture of bullae (especially in bullous emphysema)

Question 36

stepwise drug management of COPD

Answer 36

Question 37

multidisciplinary care team for COPD

Answer 37

GP
respiratory physician for advanced COPD
practice nurse for spirometry testing, inhaler education
pulmonary rehabilitation
physiotherapist for exercise training including airway clearance techniques
occupational therapist
speech therapist for swallowing difficulty
pharmacist

Question 38

use of SABA therapy for COPD

Answer 38

does not reduce the rate of decline
for as required therapy, use
salbutamol MDI with spacer or
terbutaline DPI

Question 39

use of LABA when SABA is not sufficient

Answer 39

LABA/LAMA plus SABA
for LABA: indacaterol DPI (only LABA available on the PBS as monotherapy for COPD)
for LAMA: tiotropium DPI

Question 40

use if long acting bronchodilator dual therapy when monotherapy is not sufficient

Answer 40

check inhaler technique first and other causes of breathlessness
fixed dose combination inhalers are avilable for dual therpy

Question 41

if dual therapy is insufficient

Answer 41

add an ICS, fixed done combination inhalers available
be aware that this increases the risk of pneumonia
consider referral to a respiratory physician

Question 42

role of SAMA in COPD

Answer 42

ipratropium is not usually used for symptom relief in COPD
contraindicated in patients using a LAMA, is more expensive than SABA, and may increase risk of cardiovascular events

Question 43

cor pulmonale

Answer 43

right ventricular hypertrophy nd dilation secondary to lung disease
should be considered in a patient who has COPD and any of the following:
- peripheral oedema
- raised JVP
- a systolic parasternal heave
- a loud pulmonary secondary heart sound

Question 44

pulmonary rehabilitation

Answer 44

effective intervention if the patient is motivated to reduce frequency of hospitalisations and exacerbations
involves exercise training, education, behaviour modification, outcome assessment