COPD

Question 1

Which bugs most commonly cause an exacerbation of COPD

Answer 1

Bacteria:
- Haemophilus influenzae (most common cause)
- Streptococcus pneumoniae
- Moraxella catarrhalis

Viral
- Respiratory viruses (e.g. human rhinovirus)

Question 2

Clinical features of acute exacerbation of COPD

Answer 2

• dyspnoea
• cough
• wheeze
• more sputum/ change in colour
• hypoxia
• confusion

Question 3

how should an exacerbation of COPD be treated in the community?

Answer 3

• increase frequency of bronchodilator use
• consider giving via nebuliser
• prednisolone 30 mg daily for 5 days
• Oral antibiotics (amoxicillin or clarithromycin or doxycycline)

Question 4

What would make you consider admitting a patient with an exacerbation of COPD?

Answer 4

• severe breathlessness
• acute confusion
• cyanosis
• oxygen saturation <90%
• social reasons e.g. inability to cope at home
• significant comorbidity (such as cardiac disease or insulin-dependent diabetes)

Question 5

How should an exacerbation of COPD be managed when patients are admitted to hospital?

Answer 5

• Oxygen therapy (venturi mask)
• Nebulised SABA and SAMA (salbutamol and ipratropium)
• oral prednisolone or IV hydrocortisone
• IV theophylline
• NIV if T2RF

Question 6

At what pH can NIV be used?

Answer 6

respiratory acidosis
pH 7.25-7.35

*can be used if pH < 7.25 but need monitoring in HDU and a lower threshold for intubation

Question 7

Causes of COPD

Answer 7

Most common:
- Smoking

Genetic:
- Alpha-1 antitrypsin deficiency

Others:
cadmium (used in smelting)
coal
cotton
cement
grain

Question 8

Investigations if suspecting COPD

Answer 8

• spirometry (obstructive pattern)
• CXR: hyperinflation, bullae, flat hemidiaphragm
• FBC: exclude secondary polycythaemia

Question 9

In COPD the FEV1/FVC ratio is <70%. COPD is then graded based on the FEV1 % of predicted. Describe the 4 stages

Answer 9

> 80% Stage 1 - Mild
50-79% Stage 2 - Moderate
30-49% Stage 3 - Severe
< 30% Stage 4 - Very severe

Question 10

For how long should patients with LTOT be using supplementary oxygen?

Answer 10

for at least 15 hours a day

Question 11

When should you consider an LTOT assessment for patients with COPD?

Answer 11

very severe (FEV1 < 30%)
cyanosis
polycythaemia
peripheral oedema
raised JVP
O2 sats <92% on room air

Question 12

What investigation is used to assess patients for LTOT?

Answer 12

ABG on 2 occasions at least 3 weeks apart to assess accurate pO2

Question 13

What pO2 on ABG assessment should instigate LTOT

Answer 13

pO2 of < 7.3 kPa

OR a pO2 of 7.3 - 8 kPa and one of the following:
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension

Question 14

Before starting LTOT what must you ensure about the patients home environment?

Answer 14

Home risk assessment:
- risks of falls from tripping over the equipment
- risks of burns and fires
- ensuring neither the patient nor any family at home are smokers

Question 15

Non-pharmacological management of COPD

Answer 15

> smoking cessation
annual FLU vaccine
pneumococcal vaccine
pulmonary rehab

Question 16

First line COPD treatment

Answer 16

SABA (salbutamol) or SAMA (ipratropium)

Question 17

For patients who remain breathless or have exacerbations despite using short-acting bronchodilators, the next treatment step is determined by whether they have ‘asthmatic features’. Describe these features.

Answer 17

• previous diagnosis of asthma/atopy
• high eosinophil count
• variation in FEV1 over time (at least 400 ml)
• diurnal variation in peak flow

Question 18

If a patient has no asthmatic features/ features suggesting steroid responsiveness, what is the next step of treatment after short-acting bronchodilators?

Answer 18

LABA + LAMA

(if already taking a SAMA, discontinue and switch to a SABA)

Question 19

If a patient has Asthmatic features/features suggesting steroid responsiveness, what is the next step of treatment after short-acting bronchodilators?

Answer 19

LABA + ICS

then if necessary:
LABA+ICS+LAMA

Question 20

If swapped onto a LAMA, patients should discontinue a SAMA and be given a SABA instead. TRUE/FALSE?

Answer 20

TRUE

Question 21

When is oral theophylline considered

Answer 21

after unsuccessful trials of short and long-acting bronchodilators

OR people who cannot used inhaled therapy

Question 22

What prophylactic antibiotics can be used in COPD?

Answer 22

Azithromycin (only in selected patients)

Question 23

What investigations should be completed prior to starting a patient on prophylactic azithromycin?

Answer 23

LFTs

ECG to exclude QT prolongation

Question 24

Who should receive mucolytics?

Answer 24

Patients with chronic productive cough

Discontinue if symptoms do not improve with this

Question 25

In what patients are PDE-4 inhibitors (e.g. Roflumilast) recommended?

Answer 25

FEV1 <50% of predicted

> 2 exacerbations in past year despite triple inhaled therapy (LABA+LAMA+ICS)

Question 26

Clinical features of cor pulmonale

Answer 26

• peripheral oedema
• raised JVP
• systolic parasternal heave
• loud P2

Question 27

Management of cor pulmonale

Answer 27

• loop diuretic for oedema,
• consider long-term oxygen therapy (LTOT)
• ACEi, Ca2+ channel blockers and alpha blockers are not recommended by NICE

Question 28

In patients with stable COPD, what 3 interventions can improve survival

Answer 28

1. smoking cessation
2. LTOT
3. lung volume reduction surgery in selected patients