COPD

Question 1

What is the biggest risk factor for COPD?

Answer 1

Smoking

Question 2

What evidence is there for corticosteroids in COPD?

Answer 2

NEJM 2014 - there was no difference in exacerbation rates between those who had corticosteroids withdrawn and those who remained on LABA and anticholinergic alone

Question 3

What is the “treatment ladder” for treatment of COPD?

Answer 3

SABA, LABA, anticholinergic, corticosteroid

Question 4

What non-pharmacological management options are there for COPD?

Answer 4

Pulmonary rehab, Pneumococcal and influenza vaccine, smoking cessation, oxygen (severe)

Question 5

When should you consider alpha 1 antitrypsin as a possible cause of COPD?

Answer 5

COPD/empysema under age 45
absent risk factors
empysema of lower lungs
unexplained liver disease
asthma with persistent air flow obstruction after treatment
C-ANCA vasculitis
necrotising panniculitis
family history

Question 6

Lung function test findings in COPD?

Answer 6

FEV1/FVC less then 0.7
Increased RV, FRC and TLC due to air trapping
Normal or decreased DLCO due to destruction of gas exchange units

Question 7

What is the main cell involved in the pathogenesis of COPD?

Answer 7

Macrophage

Question 8

What is centriacinar empysema associated with?

Answer 8

Smoking

Occurs in upper lobes and superior lower lobes

Question 9

What is panacinar empysema associated with?

Answer 9

Alpha 1 antitrypsin

Occurs predominately in lower lobes

Question 10

What are the GOLD stages for COPD?

Answer 10

1 = mild = FEV1 greater then 80% predicted but ratio less than 0.7
2 = moderate = FEV1 between 50-80% predicted
3 = severe = FEV1 30-50% predicted
4 = very severe = FEV1 less then 30% predicted

Question 11

What are the only 3 interventions shown to improve mortality in COPD?

Answer 11

Smoking cessation
Oxygen therapy for hypoxia
Lung volume reduction surgery
Some evidence that corticosteroids may have a mortality benefit - trend only, not significant

Question 12

What is the ladder of treatment in COPD?

Answer 12

PRN bronchodilators (B agonists, anticholinergics)
Add regular long acting B agonists
Add inhaled corticosteroids if symptoms not controlled or greater then 2 exacerbations per year
Triple therapy in severe disease - combination ICS + LABA + long acting anti-cholinergic + PRN SABA

Question 13

What is the drug with the best evidence for smoking cessation?

Answer 13

Varencicline

Followed by NRT then bupropion

Question 14

What is the concern with inhaled corticosteroid use in COPD?

Answer 14

Increases risk of pneumonia by x2 compared with salmeterol alone

Question 15

Who is a good candidate for lung volume reduction surgery?

Answer 15

those with upper lobe predominant disease and poor 6 minute walk test

Question 16

What makes up the BODE scoring system for COPD?

Answer 16

BMI
Airflow obstruction (FEV1)
Dysnoea
Excercise capacity (6MWT)

Question 17

12 month mortality after an exacerbation of COPD?

Answer 17

42%

Question 18

What is the genetic mutation in A1AT def?

Answer 18

mutation in SERPINA1 gene - codes for alpha-1-antitrypsin protein

Question 19

What causes the liver disease in A1AT?

Answer 19

Mutated alpha-1 antitrypsin protein cannot leave the liver - accumulates and causes liver failure

Question 20

What causes the lung disease in A1AT?

Answer 20

Low serum and alveolar levels of A1AT (as it is all stuck in the liver and cant escape). A1AT usually functions to protect the alveloli against proteases released from inflammatory cells - in its absence get progressive destruction of alveloar and empysema

Question 21

What are the main alleles causing disease in A1AT?

Answer 21

M normal phenotype
Z markedly reduced levels
S some reduced levels

Homozygote ZZ causes most disease
Carriers MS or MZ have only 35% action of A1AT but do not mainfest disease

Question 22

What is the inheritance of A1AT def?

Answer 22

autosomal co-dominant

- over 120 affected alleles

Question 23

What is the role for chronic antibotics in COPD?

Answer 23

1 year of macrolides showed a decrease in hospital admissions with exacerbations but increased rates of deafness and antibiotic resistance