COPD

Question 1

What is COPD?

Answer 1

A progressive, irreversible obstructive disease - chronic bronchitis (cough > 3 months, 2 consecutive years) + emphysema

5% >45yrs

Question 2

Causes of COPD

Answer 2

Smoking (90%)
a1-antitrypsin deficiency
asthma

Question 3

Two types of COPD patients:

Answer 3

Pink puffer (emphysema) - increased alveolar ventilation + damaged capillary bed –> muscle waste + hyperventilate

Blue bloater (bronchitis) - reduced alveolar ventialtion + undamaged capillary bed –> increased residual lung volume + hypoventialte (rely on hypoxic drive for respiratory effort)

Question 4

Clinical presentation?

Answer 4

Productive cough - green, mucky phelgm
Dyspnoea - worse on exertion
Polyphonic wheeze, resonant on percussion
Reduced chest expansion and accessory muscle use

Question 5

Investigations?

Answer 5

Spirometry:
FEV1 (decreased)
FEV1/FVC (decreased)
TLC (increased)
RV (increased)

CXR
FBC (anaemia and ploycythemia)
BMI

ABG

Question 6

FEV1 and severity

Answer 6

80 = mild (stage 1)
50-79 = moderate (stage 2)
30-49 = severe (stage 3)
<30 = v. severe (stage 4)

Question 7

What investigation can be done to indicate prognosis?

Answer 7

BODE (BMI, airflow obstruction, dyspnoea and exercise capacity index)

Question 8

Outline the MRC dyspnoea scale

Answer 8

1 - breathless at strenuous exercise (everyone)
2 - Breathoess when hurrying up a slight hill
3 - Walks slower than most people, stops after 1 mile/15 mins at own pace
4 - Stops after 100m walking or a few minutes on level ground
5 - too breathless to leave house, SOB when getting dressed

Question 9

What could be seen on a CXR?

Answer 9

Hyperinflation (6 anterior ribs)
Large central pulmonary arteries
Bullae
Reduced peripheral vascular markings
Flat semi-diaphragm

Question 10

Where should a1-antitrypsin def. patients be treated?

Answer 10

At a specialist centre

Question 11

Smoking management

Answer 11

History in pack years (cigs per day/20 x years smoked)

Cessation:
Offer NRT - patches, gum etc
Varenicilline (treats narcotic addiction) or bupropion (treats smoking addictions)

Question 12

What vaccinations should be given to COPD patients?

Answer 12

Annual flu

Pneumococcal

Question 13

When should pulmonary rehabilitation be offered?

Answer 13

If hospitalised or functionally disabled (grade 3+)

Involves physical training, disease education and nutritional, psychological and behavioural intervention

Question 14

Inhaled medication ladder:

Answer 14

1. Short acting relief = SABA (salbutamol) or SAMA (isosorbide mononitrate)
2. Long-acting relief:
   FEV1 > 50% - use LABA (salmeterol) or LAMA (tiotropium bromide) aka spiriva
   FEV1<50% - use LABA + ICS (formeterol + beclamethasone)
3. LABA+ICS + LAMA
4. Nebuliser if dyspnoea despite maximal inhaled therapy
5. Combine with oral therapy:
   B2-agonist + theophylline or
   Anti-ACh + theophylline

Question 15

What can be used to treat chronic productive cough?

Answer 15

Mucolytic (carbocristine)

Question 16

When should oxygen therapy be considered?

Answer 16

O2 sats <92%, cyanotic
Raised JVP
PaO2 <7.3 when patient is well (or <8.3 + polycythemia, pulmonary HTN, peripheral oedema, O2 sats drop <92% for >30% night)

LTOT must be worn for 15-20 hrs to get maximum benefit

Question 17

Acute exacerbation of COPD management?

Answer 17

Bornchodilator - salbutamol 5mg and IB 500 ug
Oxygen
Prednisilone - 30mg dail for 7-14 days
Abx if sputum is puruelent
Physiotherapy using PEP
NPPV of persistent hypercapnia ventilatory failure

Question 18

Complications and red flags

Answer 18

Cor pulmonale
Pulmonary HTN –> RVF __> HF
Peripheral oedema, dyspnoea, increased JVP, nausea

Question 19

How can you differentiate from asthma?

Answer 19

Asthma has:

1. a large response to bronchodilators
2. a large response to 30mg PO red (2 weeks)
3. Seriel PEFR >20% diurnal variation

Nb. COPD is not reversible