COPD

Question 1

A progressive disorder characterized by airway obstruction with 2 main things:

Answer 1

emphysema and chronic bronchitis

Question 2

in COPD - what is their:

FEV1?
FEV1/FVC ratio?

Answer 2

o FEV1 <80%

o FEV1:FVC ratio is <70%

Question 3

Emphysema?

Answer 3

enlarged distension of the air sacs with alveolar wall damage.

alveoli elastic recoil is absent

Question 4

COPD patients have a hyperinflated chest:

• what determines a hyperinflated chest?

Answer 4

• Hyperinflated chest = >6 anterior ribs above the diaphragm and increased radiolucency of the lungs

Question 5

what is chronic bronchitis?

Answer 5

Defined clinically as cough with sputum for at least 3 months in 2 successive years.

Question 6

2 types of COPD patients:

pink puffers and blue bloaters

• which one is overweight and cyanosed?
• which one is just (dyspnoea + cough) and which also has sputum?
• which one is hypercapnic?
• what type Resp failure is each one?

which one is predominantly emphysema and which is chronic bronchitis?

Answer 6

Pink puffers = thin and not cyanosed

Blue bloaters = overweight and cyanosed

• pink puffer = dyspnoea + cough
• blue bloater = dyspnoea + cough + sputum

Pink puffer = Type 1 resp failure
Blue bloater = Type 2 resp failure

Pink puffer = emphysema
Blue bloater = chronic bronchitis

Question 7

smoking accounts for ?

Answer 7

90% of patients (rarely alpha 1 antitrypsin deficiency)

Question 8

Mx for Chronic Stable COPD

Step 1 = start all patients on?

Step 2

a ) if FEV1 >50 = add what?
b) if FEV1 <50 = add what?

STEP 3

If still uncontrolled - a) patients can add? , b) patients can add?

Step 4

If a) patients still uncontrolled - add?

Answer 8

Step 1

Give SABA (salbutamol) or SAMA (ipratropium) inhaler

Step 2

a ) if FEV1 >50 = LABA (salmeterol)
b) if FEV1 <50 = LABA + ICS

or both sets can add LAMA instead and jump to Step 4 instead - LAMA + LABA + ICS

Step 3

a) LABA + ICS
b) LAMA (tiotropium) + LABA + ICS

Step 4

a) LAMA + LABA + ICS

Question 9

who should get long term oxygen therapy?

Answer 9

1. Clinically stable non-smokers with PaO2 <7.3kPa.
2. If PaO2 between 7.3-8 kPa + pulmonary HT, polycythaemia, peripheral oedema or nocturnal hypoxia.
3. Terminally ill patients.

Question 10

Acute Exacerbation of COPD

May be triggered by viral/bacterial infections. Present with increasing SOB, cough and wheeze.

ACRONYM

Need
Oxygen
Stay 
Alive 
And 
Ventilate

Answer 10

Nebulised salbutamol + ipratropium 
Oxygen therapy 
Steroids (IV hydrocortisone + oral prednisolone) 
Abx 
Aminophylline IV
NIV - BiPAP not CPAP

Question 11

what can severe COPD lead to as a result of pulmonary hypertension resulting in RV failure?

Answer 11

Cor pulmonale

Question 12

Signs of cor pulmonale?

Answer 12

tricuspid regurgitation
raised JVP
cyanosis
peripheral oedema

Question 13

COPD patients can have a influenza vaccine and pneumococcal vaccine:

which one is annual and which one is one-off?

Answer 13

annual influenza vaccination

one-off pneumococcal vaccination

Question 14

A 62-year-old woman with recently diagnosed chronic obstructive pulmonary disease (COPD) presents for review. Her FEV1 is 65% of the predicted value. She has managed to give up smoking and was prescribed a salbutamol inhaler to use as required. Despite this she is still symptomatic and complains of wheeze and shortness of breath. What is the most appropriate next step?

add ICS
add LAMA
add oral theophylline
add LABA + ICS

Answer 14

add LAMA

FEV1 needs to be <50 to get LABA + ICS

Question 15

A 62-year-old female is admitted with a suspected infective exacerbation of COPD. A chest x-ray shows no evidence of consolidation. What is the most likely causative organism?

Haem influenza
Staph aureus
Strep pneumonia

Answer 15

Haem influenza

If the patient had pneumonia then Streptococcus pneumoniae would be the most likely causative organism. However, the chest x-ray shows no evidence of consolidation making a diagnosis of pneumonia unlikely.

Haemophilus influenzae is the most common cause of infective exacerbations of COPD

Question 16

most common cause of infective exacerbations of COPD?

Answer 16

Haemophilus influenzae

Question 17

A 54-year-old woman with chronic obstructive pulmonary disease (COPD) is prescribed an inhaled corticosteroid. What is the main therapeutic benefit of inhaled corticosteroids in patients with COPD?

reduced severity of exacerbations

slows decline of FEV1

reduced frequency of exacerbations

Answer 17

reduced frequency of exacerbations

COPD - reason for using inhaled corticosteroids - reduced exacerbations

Question 18

What is the main criteria for determining whether a patient with chronic obstructive pulmonary disease (COPD) should be offered long-term oxygen therapy?

Answer 18

COPD - LTOT if 2 measurements of pO2 < 7.3 kPa

Question 19

You are doing the annual review of a 72-year-old man with chronic obstructive pulmonary disease (COPD). Last year he had three exacerbations of his COPD, one of which resulted in him being hospitalised. Today his chest is clear and his oxygen saturations are 94% on room air. According to NICE guidelines, what treatment should you offer him?

home supply of oxygen 
home nebuliser 
home supply of Abx 
home supply of prednisolone 
home supply of prednisolone + Abx

Answer 19

home supply of prednisolone + Abx

In the 2010 NICE guidelines there is a recommendation that patients who have frequency exacerbations of COPD should be given a home supply of corticosteroids and antbiotics.

Question 20

You review a 60-year-old woman in the COPD clinic. She was diagnosed with COPD four years ago and is currently maintained on a salbutamol inhaler as required and a tiotropium inhaler regularly. She has recently managed to give up smoking and her latest FEV1 was 42% of predicted. Despite her current therapy she is have frequent exacerbations. What is the most appropriate next step in her management?

salmeterol inhaler 
salmeterol + fluticasone inhaler 
long term oxygen therapy 
betamethasome inhaler 
oral aminophylline

Answer 20

salmeterol + fluticasone inhaler

Question 21

Which one of the following interventions is most likely to increase survival in patients with COPD?

home nebuliser 
tiotropium inhaler 
long term steroid therapy 
smoking cessation 
long term oxygen therapy

Answer 21

smoking cessation

Question 22

You are reviewing the management of a number of patients with chronic obstructive pulmonary disease (COPD). Which one of the following factors should prompt an assessment for long-term oxygen therapy?

FEV1 54%
Hb 18.4 (high)
BMI 18
sats 93%

Answer 22

Hb 18.4 (high)

polycythaemia

Question 23

Nancy, 72, is diagnosed with chronic obstructive pulmonary disease (COPD). Despite using a short-acting beta agonist along with a short-acting muscarinic antagonist, she is still breathless at rest. Her current FEV1 is found to be 45%. Which of the following would be the most appropriate next step in her management?

LABA
ICS
ICS + LAMA
ICS + LABA
LABA + LAMA

Answer 23

ICS + LABA

Question 24

You are reviewing a patient with chronic obstructive pulmonary disease (COPD) who remains breathless despite using an ipratropium bromide inhaler as required. Her FEV1 is 40%. What are the two main options?

LABA or ICS
LAMA or LABA +ICS
LABA or LAMA
LAMA + ICS or LABA

Answer 24

LAMA or LABA +ICS