COPD

Question 1

45yo male with chronic productive cough over the past three months. Over the last 2 years this has been episodic. He has been worked up with other causes ruled out. What is his most likely diagnosis?

Answer 1

Chronic bronchitis

Question 2

What is the definition of emphysema?

Answer 2

Abnormal and permanent enlargement of the air spaces distal to the terminal bronchioles that is accompanied by destruction of airspace walls.

Question 3

What is the physiology of chronic obstructive pulmonary disease?

Answer 3

Lungs too big = difficult getting air out

Therefore: Wheeze

Question 4

What is the most common cause of COPD?

Answer 4

Smoking

Question 5

List THREE risk factors for COPD

Answer 5

1. Smoking***
2. Alpha-1 antitrypsin deficiency (1%)
3. Environmental (air pollution, occupational exposure)

Question 6

You suspect your patient has Chronic Obstructive Pulmonary Disease. What FIVE questions would you ask on history?

Answer 6

• Do you smoke? (Pack years)
• Any history of environmental exposure to air pollution or occupational chemicals?
• Severity of dyspnea?
• Chronic cough?
• Sputum production?
• Wheeze?
• History of exacerbations - Frequency ER visits and Hospitalizations (severity)
• Evidence of complications - Righ Heart Failure=pedal edema, progressive weight gain
• Current or previous treatments? Inhalers, oral corticosteroids and antibiotics

Question 7

You suspect your patient has acute exacerbation of chronic obstructive pulmonary disease. List FIVE symptoms you would expect on history.

Answer 7

1. Increased sputum production
2. Dyspnea
3. Wheeze
4. Prolonged/Recurrent cough
5. Decrease exercise tolerance
6. Increase inhaler use

Question 8

You suspect your patient to have chronic obstructive pulmonary disease. How would you confirm this diagnosis?

Answer 8

Pulmonary Function Test (spirometry):

FEV1/FVC < 0.7

FEV1 < 80% predicted

Question 9

In your patient with COPD if you were to order lab work what would you order and why?

Answer 9

Hemaglobin - to rule out anemia or rule in COPD if polycythemia (hematocrit >56%)

alpha-1 antitrypsin if pt <45yo or strong FHx COPD

Question 10

Your patient has COPD and presents with increased dyspnea. Why would you order plain flim chest radiography?

Answer 10

Rule out comorbidities - DDx:

Bronchietasis, Cancer, Tubercolosis, Pneumonia, Pneumothorax, Congestive Heart Failure

Question 11

What are some indications for pulse oximetry and arterial blood gases?

Answer 11

Acute Exacerbation of COPD

O₂ Sat 92%

FEV1 <50% predicted

Question 12

You have just diagnosed your patient with COPD, list FIVE non-medical treatment options

Answer 12

• Smoking cessation = prevent progression & increase survival
• Encourage healthy diet
• Recommend updated vaccinations - annual influenza and pneumoccocal
• Recommend regular exercise
• Referral to respiratory technician OR Pulmonary Rehabillitation Personel

Question 13

List FOUR classes of medical treatment for COPD

Answer 13

• Short-acting ß₂-Agonists - salbutamol
• Short-acting anticholinergics - ipratropium
• Long-acting ß₂-Agonists - salmeterol/formeterol
• Long-acting anticholinergics - tiotropium

Question 14

How would you treat a patient with stable mild COPD?

Answer 14

Short-acting bronchiodilators:

• Anticholinergics - ipratropium prn
• ß₂-Agonists - salbutamol prn or terbutaline prn

Question 15

You start your patient on an anticholinergic inhaler, discuss potential side effects.

Answer 15

Dry mouth

Dilated pupils=mydriasis

Urinary retention

Glaucoma if in eye

Question 16

You have started your patient on a salbutamol inhaler as needed, what are some side effects you need to discuss?

Answer 16

Tremors

Nervousness

Tachycardia

Palpitations

Question 17

Your patient’s spirometry results show FEV1 = 60% predicted, what category of COPD is he in?

Answer 17

FEV1 50-80% predicted = Moderate-Severe

Question 18

How would you treat patients in the moderate-severe COPD class?

Answer 18

• Stable Mod-Severe = long-acting bronchiodilator (tiotropium) + SABA prn
• Mod-Severe with < 1 AECOPD/yr = Tiotropium + LABA + SABA prn
• Mod-Severe with Hx AECOPD = Tiotropium + LABA-ICS + SABA prn

Question 19

What is the spirometry criteria for severe COPD?

Answer 19

FEV1 < 30% predicted

Question 20

What should you consider in management of severe COPD?

Answer 20

• Long acting theophylline - need to monitor blood levels for toxicity.
• Referral to pulmonology

*Pts should be on regular tiotropium and LABA-ICS

Question 21

What are the indications for supplemental oxygen?

Answer 21

Stable COPD with hypoxemia:

• PaO2≤55mm Hg on ABG OR SaO2<88%
• PaO2 55-59mm Hg with bilateral ankle edema/cor pulmonale/polycythemia >56%

Question 22

Under what conditions would oxygen supplementation not be indicated?

Answer 22

• Respiratory arrest
• Hemodynamic instability
• High risk aspiration

Question 23

On physical examination what may be some signs of COPD?

Answer 23

• Hypoxia/cyanosis
• Hyperinflation: widened anteroposterior chest diameter, hyperresonance on percussion, and diminished breath sounds
• Cor pulmonale: accentuated second heart sound, peripheral edema, jugular venous distension, and hepatomegaly
• WOB: accessory respiratory muscles, paradoxical abdominal movement, increased expiratory time, and pursed lip breathing
• Wheeze
• Cachexia

Question 24

Your patient presents with acute exacerbation of COPD, what are the likely causes?

Answer 24

Viral Upper Respiratory Tract Infection (50%)

Bacterial (50%) - Streptococcus pneumonia, Haemophilus influenza, Moraxella catarrhalis

Severe = Klebsiella, Gram negatives e.g. Pseudomonas aeruginosa

Question 25

List FIVE instances where you would admit a patient with acute exacerbation of COPD

Answer 25

• Increasing intensity of symptoms or new physical signs
• Severe COPD with failure of AECOPD response to Tx
• Severe comorbidities
• Frequent AECOPD
• Older age with insufficient home support

Question 26

You have a patient with dyspnea, worsened sputum production and cough. How would you treat the patient?

Answer 26

• Dyspnea = SABA and anticholinergics
• oral corticosteroids (Prednisone 25-50mg po daily x 7-14d)
• Antibiotics b/c has 2/3:
  i) increase dyspnea/cough*
  ii) increase sputum*
  iii) sputum purulence

Question 27

You decide your patient with AECOPD is low risk and want to start antibiotics, which do you choose?

Answer 27

Low risk = ø O2, ø severe comorbidities (CHF/CAD), infrequent AECOPD (<3/yr):

• Doxycycline 100mg po daily x 7d
• Clarithromycin 1g po daily x 7d
• Amoxil
• Septra

Question 28

Your patient with AECOPD is high risk, and you would like to start antibiotics, what could you use?

Answer 28

High risk = severe comorbidities (CHF/CAD), >3 AECOPD/yr:

Amoxicillin-Clavulin 875mg po bid x 7d

Macrolide (Azithromycin/Clarithromycin)

Quinolone (Moxifloxacin 400mg po daily x 5d)

Question 29

You suspect your patient to have AECOPD, what investigations would you order and why?

Answer 29

• Pulmonary function tests (spirometry) if no previous spirometry
• Arterial Blood gas if SpO2 low
• White Blood Cell count = ?infection
• Blood culture = ?infection
• Hemaglobin = ?hemolysis 2° infection
• Chest X-ray = ?CHF/Pneumonia/Pneumothorax
• Sputum gram stain + culture if purulent with ABx in last 3months, poor lung function, frequent exacerbations

Question 30

Mr. Snook a 65yo male patient in your practice presents for refill of his medications, he has end-stage chronic obstructive pulmonary disease, but is stable. You should not forget to discuss ONE issue during this visit, what is it?

Answer 30

Re-evaluate and document is code status.

***You should periodically discuss and document his code status***