COPD Flashcards
In an obstructive airway disease, do patients struggle getting air into or out of the lungs?
- getting air out of the lungs is obstructed
- patients can inhale fine, but cannot exhale properly causing expiratory wheeze
- airways narrow and affect small, medium and larger parts of airways
In obstructive lung diseases, the elastic tissue in the lungs is affected. Are both recoil and compliance of lung tissue reduced in COPD?
- no
- recoil (ability of lungs to return to previous size and force air out is reduced
- compliance (stretching the lungs) is increased
What type of cells line the lumen of our airways?
1 - cuboidal epithelial cells
2 - transitional columnar epithelial cells
3 - ciliated pseudostratified columnar epithelial cells
4 - ciliated cuboidal cells
3 - ciliated pseudostratified columnar epithelial cells
Which of the following is NOT a layer of the mucosa that lines the airways?
1 - loose connective tissue
2 - goblet cells
4 - smooth muscle
5 - ciliated pseudostratified columnar epithelial cells
5 - basement membrane
4 - smooth muscle
Which of the following is NOT a layer of the submucosa that lines the airways?
1 - connective tissue
2 - smooth muscle
3 - bronchial mucinous glands
4 - basement membrane
4 - basement membrane
In the lining of the lumen, do goblet cells or bronchial mucinous glands secrete the majority of mucus in the lungs?
- bronchial mucinous glands
In obstructive lung disease we can see hyperinflation and trapping of air. Why does this occur?
1 - mucus is secreted causing mucus plugs
2 - reduced elastic recoil (snap back of lung tissue)
3 - small bronchi trap air (<2cm airways
4 - all of the above
4 - all of the above
- forced vital capacity may appear normal
COPD is an umbrella term. Which of the following does NOT come under the COPD umbrella?
1 - chronic asthma
2 - chronic bronchitis
3 - cystic fibrosis
4 - emphysema
3 - cystic fibrosis
COPD conditions are:
- obstructive lung diseases
- progressive airflow obstruction
- not fully reversible
- symptoms always present
All of the following are risk factors for COPD and contribute to the natural progression of COPD. What is the main cause that accentuates COPD?
1 - alpha 1 trypsin deficiency
2 - smoking
3 - asbestos
4 - occupation/pollution
5 - age >35 y/o
6 - asthma
2 - smoking
- 90% of COPD is caused by smoking
Calculate pack years:
- (no. cigs per day x years) / 20
- divide by 20 as packs contain 20 cigarettes
- e.g 10 cigs for 10 years = (10x10)/20 = 5 pack years
How can smoking increase risk of COPD?
1 - activates neutrophils in lungs
2 - elastase levels increase
3 - neutrophils cause inflammation
4 - all of the above
4 - all of the above
- essentially smoke irritates the lungs and causes reduced elasticity and inflammation
In spirometry, would we expect to see an increase of decrease in functional residual capacity (FRC) (remaining air in lungs at end of normal exhalation) in a patient with COPD?
- increase
- recoil = reduced (ability of lungs to snap back and exhale air)
- compliance = increased (stretching the lungs)
In spirometry, would we expect to see an increase of decrease in forced vital capacity (FVC) (air that can forcefully expired following maximum inhalation) in a patient with COPD?
- small reduction
- recoil is reduced so patient has to work harder to exhale air
In spirometry, would we expect to see an increase of decrease in forced expiratory volume in 1 second (FEC1) (air that can forcefully expired in 1 second following maximum inhalation) in a patient with COPD?
- significantly reduced
- airways are narrowed
In patients with asthma the FVC and FEV1 are reduced. What is the ratio that is diagnostic in patients with COPD?
1 - FVC/FEV1 <90%
2 - FVC/FEV1 <80%
3 - FVC/FEV1 <70%
4 - FVC/FEV1 <60%
3 - FVC/FEV1 <70%
In patients with COPD is the total lung capacity increased or decreased?
- increased
- lungs can become hyper inflated
What % of the UK is diagnosed with COPD?
1 - 2%
2 - 12%
3 - 20%
4 - 50%
1 - 2%
30,000 deaths/year in UK
The global initiative for COPD (GOLD) defines the severity of COPD. Which of the following is NOT part of this severity scale?
1 - Mild = FEV1 >95%
2 - Moderate = FEV1 50-79%
3 - Severe = FEV1 30-49%
4 - Very Severe = <30%
1 - Mild = FEV1 >95%
- mild is an FEV1 <80%
What is trypsin?
1 - enzyme that degrades proteins
2 - enzyme in coagulation cascade
3 - enzyme involved in bile synthesis
4 - enzyme involved in glycolysis
1 - enzyme that degrades proteins
Trypsin is an enzyme responsible for degrading proteins. What is alpha-1 antitrypsin?
1 - inhibits cytokines
2 - protease inhibitor
3 - inhibits scarring in the lungs
4 - HMG-CoA synthesis inhibitor
2 - protease inhibitor
- elastase is released by neutrophils in infection to kill pathogens, BUT also degrades elastin giving lungs elastic recoil
- alpha-1 antitrypsin inhibits elastase and stops elastin damage
- low levels of alpha-1 antitrypsin mean lungs are continually damaged and lungs lose elastic recoil
Which of the following forms of COPD can be caused by alpha-1 antitrypsin deficiency?
1 - causes emphysema (damaged alveoli)
2 - chronic bronchitis (damaged bronchi, main airways)
3 - bronchieltasis (smaller airways)
4 - all of the above
4 - all of the above
Bronchitis, which is inflammation of the upper airway bronchi that presents as a cough with mucus production, mucus plugs and an increased risk of infection. How long does this need to present for to be defined as acute bronchitis?
1 - <1 week
2 - <2 weeks
3 - <3 weeks
4 - <4 weeks
3 - <3 weeks
Chronic = lots of sputum production for >3months of the year for 2 years
Which of the following symptoms can patients with COPD present with?
1 - dyspnea (SOB)
2 - chronic/recurrent cough
3 - creamy sputum
4 - symptoms gradually become worse over time
5 - expiratory wheeze
6 - all of the above
5 - all of the above
SOB:
- asthma = SOB all time
- COPD = SOB on exertion
In addition to the typical symptoms of COPD, patients can also present with all of the following symptoms, but which is least likely?
1 - Weight loss, anorexia and fatigue
2 - Waking at night with SOB
3 - Peripheral oedema
4 - Migraines
5 - Chest pain – consider other causes
6 - Haemoptysis – consider other
7 - Reduced exercise tolerance
8- recurrent infections
4 - Migraines
Not a common presentation
Emphysema as a form of COPD. What is emphysema?
1 - damage to alveoli
2 - inflammation of alveoli
3 - inflammation of bronchi
4 - all of the above
1 - damage to alveoli
- distal to terminal bronchiole
Alveoli:
- damaged/destroyed
- become enlarged
- lose elasticity and become swollen
(collagen and elastin lost)
- reduction in surface area
- interstitium becomes fibrotic and reduces perfusion
In chronic bronchitis and emphysema, do both of these have damage to the interstitium?
- no
- typically emphysema gets fibrosis of the interstitium
- reduces O2 perfusion and increases CO2 retention
If the interstitium is damaged or blocked in COPD, does the transfer factor for carbon monoxide (TLCO/DLCO) increase or decrease?
- reduced
- CO cannot diffuse
In COPD, is there always airway remodelling?
- yes
- airway remodelling and emphysema are always present
What are large bullae?
1 - large mucus plugs
2 - deposits of elastase in alveoli
3 - an obstruction in the lungs
4 - alveoli sacs that have merged forming one large sac
4 - alveoli sacs that have merged forming one large sac
- damaged alveolar sacs
- small alveoli form one large sac called a bullae
- if a large bullae pops, this could lead to a secondary pneumothorax
In emphysema does surface area and perfusion increase or decrease?
- ⬇️ surface area
- ⬇️ perfusion
- can cause hypoxia and dysponea (SOB)
In COPD there is hyperplasia of goblet cells, which increases mucus production. Which can this lead to in the lung of a patient with chronic bronchitis?
1 - ⬆️ viscous mucus
2 - ⬆️ infection as mucus acts as a medium
3 - damaged cilia
4 - fixed airway obstructions
5 - all of the above
5 - all of the above
In COPD there is a reduction in elastic properties, how does this cause an increase in air trapping?
1 - compliance increases and lungs cannot stretch
2 - compliance decreases and lungs cannot force air out
3 - elasticity increases and air cannot be forced out of lungs
4 - elasticity decreases and air cannot be forced out of lungs
4 - elasticity decreases and air cannot be forced out of lungs
COPD causes:
- compliance is ok and lungs are compliant to air entering
- elastic recoil is required for lungs to return to normal size after inspiration
- reduced elastic recoil means lungs cannot force air out and air becomes trapped
Why can trapped air and reduced elastic properties of the lungs increase work of breathing?
1 - expiration is generally passive due to elastic recoil
2 - accessory muscles need to be used to exhale causing fatigue
3 - pursed lip breathing helps, but uses lots more energy and can cause weight loss
4 - all of the above
4 - all of the above
When performing a spirometry test on a patient with COPD, would there be a >15% improvement in FEV1, and what would the FEV1/FVC ratio be?
- no improvement in FEV1 as generally irreversible
- FEV1/FVC ratio is <70%
Which of the following is NOT typically a clinical sign of COPD?
1 - Cyanosis
2 - Raised JVP and/or peripheral oedema – evidence of cor pulmonale
3 - Cachexia
4 - Hyperinflation
5 - Use of respiratory accessory muscles
6 - Finger clubbing
7 - Wheeze or crackles
6 - Finger clubbing
Which 2 of the following may cause patients with COPD to experience flapping or muscle tremors?
1 - B agonist medication
2 - CO2 retention
3 - hypoxia
4 - mucus plugs
1 - B agonist medication
- chronic use of B2 agonist activate B2 receptors in skeletal muscle
2 - CO2 retention
Why might we see an increase in jugular venous pressure in patients with COPD?
1 - increased fluid retention in COPD
2 - increased pressure in the lungs
3 - B-blocker medication increase JVP
4 - cachexia causing poor venous return
2 - increased pressure in the lungs
- increased pressure forces blood back through pulmonary artery and into right side of the heart
- pressure in right side of heart increases
- right heart failure increases pressure that backs up to JVP via the superior vena cava
Would patients with COPD be more likely to develop type 1 or 2 respiratory failure?
- type 2 respirator failure
- ⬇️ PaO2
- ⬆️ PaCO2
Breathing difficulty is associated with severity of COPD, what is the method for classifying breathlessness?
1 - MRC scale
2 - CURB-65 score
3 - mMRC
4 - Rockwood score
3 - mMRC
= modified Medical Research Council Scale
Polycythaemia, which is high RBCs, can be common in patients with COPD. Why is this?
1 - COPD can cause sickle cell disease so increase RBCs to account
2 - COPD is associated with splenomegaly
3 - hypoxia degrades RBCs
4 - bone marrow increases RBCs in an attempt to increase O2 saturations
4 - bone marrow increases RBCs in an attempt to increase O2 saturations
- COPD = low PaO2
- bone marrow increases RBC production
- attempt to increase haemoglobin and increase O2 saturation
Cor pulmonale is an enlargement and failure of the right ventricle of the heart as a response to increased vascular resistance or high blood pressure in the lung. If cor pulmonale is suspected in patients with COPD, what are the 2 most common cardiac assessments?
1 - troponin
2 - ECG
3 - echocardiogram
4 - FBC
2 - ECG
3 - echocardiogram
- right ventricle failure and hypertrophy
What are 2 common assessments of quality of life in patients with COPD?
1 - COPD Assessment Test (CAT)
2 - CURB-65 score
3 - Rockwood score
4 - St. Georges Respiratory Questionnaire (SGRQ)
1 - COPD Assessment Test (CAT)
4 - St. Georges Respiratory Questionnaire (SGRQ)
What are predominant cells in COPD?
- neutrophils (N is closer to C than A in COPD and Asthma)
Which of the following are simple lifestyle advice that patients with COPD should receive?
1 - smoking cessation
2 - ⬆️ activity
3 - improved nutrition
4 - all of the above
4 - all of the above
In patients with a diagnosis of COPD, how often should they receive the pneumococcal vaccination?
1 - annually
2 - biannually
3 - every 3 years
4 - one off
4 - one off
In patients with a diagnosis of COPD, how often should they receive the influenza vaccination?
1 - annually
2 - biannually
3 - every 3 years
4 - one off
1 - annually
In COPD, once the following have been tried:
- stop smoking
- pneumococcal vaccinations
- influenza vaccinations
- pulmonary rehabilitation
- optimise treatment for comorbidities
Which 2 of the following can initially be offered as a reliever?
1 - Salbutamol (SABA)
2 - Salmeterol (LABA)
3 - Ipratropium (SAMA)
4 - Prednisolone (glucocorticoid)
1 - Salbutamol (SABA)
3 - Ipratropium (SAMA)
- can be either of these and it is used as PRN
In COPD, if a SABA or SAMA has been tried and patients are still having symptoms, which of the following could be the next step in the management for this patient?
1 - SABA +LABA
2 - LAMA and LABA
3 - LABA + ICS
4 - SABA and LAMA
2 - LAMA and LABA
OR
Could try adding in an ICS for 3 months if the patient doesn’t respond
BUT if patient improves, consider removing or titrating down steroid
If SABA +LABA OR LABA + ICS fails to relieve symptoms of COPD, what would be the next step in the management for this patient?
1 - SABA + LABA
2 - LAMA and LABA and ICS
3 - LABA + ICS + Phosphodiesterase inhibitors
4 - SABA + LAMA + leukotriene receptor antagonist
2 - LAMA and LABA and ICS
Some patients may benefit from the use of theophylline. Can this be prescribed by the GP?
- No
If patient needs this, they require a specialist referral
Theophylline competitively inhibits type III and type IV phosphodiesterase (PDE), the enzyme responsible for breaking down cyclic AMP in smooth muscle cells, possibly resulting in bronchodilation and smooth muscle relaxation.
In patients with COPD who have any of the following they should be admitted to hospital.
- severe breathlessness.
- unable to perform ADL
- deteriorating general condition
- rapid onset of symptoms.
- acute confusion
- impaired consciousness
- cyanosis.
- O2 saturation <90%
What should they be given asap?
1 - LABA
2 - oxygen
3 - air
4 - SABA
2 - oxygen
- O2 via a Venturi mask at 24% at 2-3 l/min OR Venturi 28% mask at a flow rate of 4 l/min OR nasal cannula at a flow rate of 1-2 l/min (if a 24% mask is not available).
- aim for sats of 88-92%
If patients with COPD have an acute exacerbation, which of the following are commonly performed?
1 - nebulised short acting B2 agonist (salbutamol) and Ipratropium (SAMA)
2 - oral prednisolone (30mg)
3 - controlled O2
4 - IV aminophylline
5 - antibiotics (Doxycycline)
6 - all of the above
7 - all of the above
Non-invasive ventilation may be given if patient not responding
In an acute exacerbation of COPD, what should the oxygen sats aim be?
1 - 88-92%
2 - 92-96%
3 - 90-98%
1 - 88-92%
If NOT a Co2 retained (type 1 respiratory failure) we can aim for sats of 94-98%, confirmed on an ABG)
Which of the following improves survival in COPD?
1 - long term O2 therapy
2 - SABA +LABA
3 - ICS
4 - LAMA + ICS
1 - long term O2 therapy
- long term O2 therapy
- non invasive ventilation
- lung volume reduction therapy
Which of the following are important to consider when discharging a COPD patient?
1 - nutrition
2 - smoking cessation
3 - appropriate inhaler and correct technique
4 - pulmonary rehabilitation
5 - palliative care
6 - vaccinations
7 - psychological support
8 - all of the above
8 - all of the above
If a patient presents to hospital with an admission of COPD, all of the following should be done asap, EXCEPT which one?
1 - chest X-ray
2 - ABG
3 - spirometry
4 - ECG
5 - FBC
6 - sputum sample culture
7 - blood sample culture
3 - spirometry
- important, but patient is unlikely to be able to do this
Which of the following empirical antibiotics is NOT considered in patients with a COPD exacerbation?
1 - vancomycin
2 - amoxicillin
3 - clarithyromyocin
4 - doxycycline
1 - vancomycin
- antibiotic given depends on the patient and local guidelines
