COPD

Question 1

State the symptoms of COPD.

Answer 1

Breathlessness
Cough (with sputum)
Wheeze on exertion 
Chest tightness
Weight loss / loss of muscle mass
Recurrent winter bronchitis
Peripheral oedema (cor pulmonale)
Symptoms are gradually progressive and worsening
No variability in symptoms

Question 2

what are risk factors for COPD?

Answer 2

Smoking
Chronic asthma
passive or maternal smoking 
Air pollution
Occupation (dust in coal mines)
alpha 1 anti trypsin deficiency

Question 3

what are the differentials of COPD?

Answer 3

asthma

bronchiectasis

Question 4

When diagnosing COPD, what is needed in the history?

Answer 4

Symptoms, age, smoking (if they do smoke, have ever smoked and for how long), recurrent chest infection / winter bronchitis, asthma as a child, if symptoms are worsening.

Question 5

Describe the essential investigations that are used to diagnose COPD.

Answer 5

spirometry - FEV1/FVC < 7.0 or < 80% predicted
pulmonary function tests
ABG
CXR
FBC
reversibility to bronchodilators 
ECG (if suspect cor pulmonale)

Question 6

When trialling a potential patient with COPD on bronchodilator and corticosteroid therapy, what are the doses / length of time prescribed?
And also how are these results interpreted?

Answer 6

(Baseline)
10 mins post neb 2.5-5mg salbutamol
30 mins post neb 2.5-5mg salbutamol + 500ug ipratropium

(Baseline)
30-40 mg prednisone needed daily for 2 weeks (0.6mg/kg)

Measure baseline and final FEV1
Significant reversibility = FEV1 > 200ml / > 15% baseline
Significant reversibility suggests asthma / asthmatic component
COPD = insignificant bronchodilator/steroid response

Question 7

Describe the useful investigations that can be carried out to help diagnose COPD.

Answer 7

Bedside: FBC, ECG, ABG, ESR.CRP

Sputum culture (if evidence of exacerbation)

Chest X-ray: hyperinflated lung fields, flattened diaphragm, bullae

Spirometry: FEV1/FVC < 0.7

Question 8

What signs should you look for in patients who may have COPD.

Answer 8

hyper resonant lungs on percussion
decreased cardiac dullness to percussion 
decreased breath sounds
prolonged expiration with wheeze
use of accessory muscles for breathing
pursed lip breathing 
barrel chest / hyper expanded chest
laryngeal descent
loss of muscle mass / weight loss
peripheral oedema , hepatomegaly, elevated JVP, loss of P2 (cor pulmonale)

Question 9

Describe the inhaled drug therapy which may relieve some symptoms of COPD.

Answer 9

Short acting Bronchodilators:
SABA- salbutamol
SAMA - ipratropium

Long acting bronchodilators
LAMA - long acting anti-muscarinic agents
LABA - long acting B2 agonists

High dose inhaled corticosteroids (ICS) and LABA
Relvar
Fostair MDI

Question 10

What are the differential diagnoses of COPD.

Answer 10

Lung cancer
Asthma
Left ventricular failure
Fibrosing alveolitis
Bronchiectasis
Rarities - TB and recurrent pulmonary emboli

Question 11

describe the pathophysiology in COPD.

Answer 11

increased airway resistance
enlargement of mucous secreting glands
remodelling of the airways
- alveolar walls are damaged resulting in fewer, larger alveoli
- bronchioles become narrowed and clogged with mucous

hypoxia and vascular bed changes resulting in pulmonary hypertension

Question 12

Pathophysiologically, what are the 3 main causes of airway limitation in COPD?

Answer 12

1. Loss of alveolar attachment of airways and loss of elasticity (due to emphysema) - This reduces elastic recoil so small airways collapse on expiration
2. Inflammation and scarring - causes small airways to narrow
3. Mucous secreting cells hyperplasia - blocks airways.

Question 13

describe some clinical differences between COPD and asthma.

Answer 13

COPD > 35yr olds where asthma occurs in any age
symptoms in COPD are persistent and progressive whereas in asthma they are intermittent and variable.
COPD there is no family history - Asthma there is usually history in the family
nocturnal symptoms are uncommon in COPD but common in asthma
cough in COPD is persistent and productive whereas in asthma it is intermittent and non productive

Question 14

how is the severity of COPD categorised?

Answer 14

Gold criteria - FEV1;
< 80% predicted = mild
< 50-79% predicted = moderate
< 30-49% predicted = severe
< 30% = very severe

Question 15

what is the criteria for putting a COPD on long term oxygen?

Answer 15

Pa02 < 7.3 Pka

or Pa02 7.3-8 Pka if there is polycythaemia, for pulmonate, nocturnal hypoxia or pulmonary hypertension.

Question 16

what do you assess in a patient for acute exacerbation COPD (AECOPD) ?

Answer 16

Increasing breathlessness
cough
sputum volume
sputum purulence
wheeze 
chest tightness

Question 17

when would you consider hospital admission in a patient with AECOPD?

Answer 17

tachypneoic
hypotensive
low oxygen saturation (< 90-92%)

Question 18

describe the ward assessments that have to be carried out if a patient is admitted with AECOPD.

Answer 18

Oxygen saturation 88-92%
Medication i.e. nebulised bronchodilators (if they cannot take inhalers) and corticosteroids
Antibiotics if there is infection (oral or IV)
Assess for respiratory failure (test arterial blood gas ABG) If in respiratory failure ventilation will be required.

Question 19

what does spirometry measurement of lung function involve?

Answer 19

FEV1 / FVC

Question 20

what is the normal FEV1 and FVC values?

Answer 20

FEV1 = 3.5- 4 litres
FVC = 5 litres
therefore FEV1/FVC should be 70-80% (> 0.7 - 0.8)

Question 21

what is obstructed lung disease defined as on spirometry?

Answer 21

FEV1/FVC < 70%

Question 22

what is the pathophysiology of chronic bronchitis causing obstruction in the large and small airways?

Answer 22

large airways:
- goblet cell and mucous gland hyperplasia.
- inflammation and fibrosis
small airways:
- goblet cells appearing
- inflammation and fibrosis sin long standing disease

Question 23

what are the 3 different pathological forms of emphysema?

Answer 23

centriacinar
panacinar
periacinar

Question 24

describe what periacinar emphysema is.

Answer 24

periacinar emphysema also known as bullous/bleb emphysema
lungs contain emphysematous bullae which are airfilled bullae >1cm.
the bullae are like the blebs which can develop just under the pleurae

Question 25

in emphysema (and therefore COPD), what does it show on CXR?

Answer 25

hyperinflated lung fields

Question 26

what is the definition of chronic bronchitis?

Answer 26

chronic sputum production for at least 3 consecutive months for 2 years

Question 27

why does cor pulmonale cause pulmonary hypertension?

Answer 27

hypoxia caused by cor pulmonale results in pulmonary vasoconstriction as well as;
pulmonary arteriole hypertrophy and intimal fibrosis
loss of capillary bed
secondary polycythaemia

Question 28

why does cor pulmonale result in shunt?

Answer 28

cor pulmonale results in hypoxaemia therefore shunt occurs due to pulmonary arteriole constriction to prevent blood flow to alveoli that don’t have oxygen

Question 29

what is FL02?

Answer 29

fraction of inspired air which is oxygen

Question 30

what is complicated chronic bronchcitis?

Answer 30

when the sputum becomes mucopurulent and is infected