COPD

Question 1

COPD is like a combination of which two things?

Answer 1

Airway damage (bronchitis) + parenchymal damage (emphysema)

Question 2

FEV1:FVC should be what in COPD

Answer 2

<0.7

Question 3

If their FEV1 is >80% predicted normal can you diagnose COPD?

Answer 3

Only in the presence of resp symptoms

Question 4

What is the respiratory drive in COPD?

Answer 4

hypoxia (not hypercapnoea)

Question 5

What could be some causes other than smoking?

Answer 5

Noxious particles/gases- pollution or occupational

Question 6

Other risk factors?

Answer 6

alpha-1-anti trypsin

Asthma/recurrent resp infections

Women

Question 7

How do you calculate pack years?

Answer 7

(cigarettes per day /20) x number of years

Question 8

What is the diagnostic criteria

Answer 8

> 35y

+ risk factor e.g. smoking

+ wheeze/breathlessness/chronic cough/sputum production/winter ‘bronchitis’

Question 9

How do you confirm the diagnosis

Answer 9

post-bronchodilator spirometry (although this isn’t necessary)

Question 10

How do you categorise how severe COPD is?

Answer 10

> 80% mild

50-79% mod

30-49% severe

<30% very severe

But also consider clinical- frequency of exacerbation, breathlessness, exercise capacity, BMI, PaO2 on ABG, cor pulmonale

Question 11

What can you use to predict survival?

Answer 11

BODE index

BMI

(airflow) Obstruction (FEV1% after bronchodilator)

Dyspnoea (use MMRC scale)

Exercise capacity (6min walking distance)

Question 12

What do you need to consider in treatment other than inhalers?

Answer 12

Smoking cessation (the single most important intervention in patients who are still smoking)

Pneumococcal vaccine (one off) and annual flu vaccine

Pulmonary rehab (support and education from mdt) if indicated- offer to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)

Self-management plan

Optimise Rx for co-morbs

Question 13

What is the first line inhaled therapy?

Answer 13

SABA or SAMA

Question 14

If the person is still breathless/has exacerbations despite first line treatment, what do you do?

Answer 14

No asthmatic features/no steroid responsive features: offer LABA and LAMA

Asthmatic/steroid responsive features: consider LABA + ICS

Question 15

If the person with asthmatic features (step 2) is still breathless?

Answer 15

Offer LAMA+LABA+ICS (triple therapy. Use combined inhalers where poss)

Question 16

What are ‘asthmatic features’ or ‘features that suggest steroid responsiveness’?

Answer 16

Previous diagnosis or asthma or atopy

Higher blood eosinophil count

Variation in FEV1 over time (at least 400ml)

Diurnal variation in PEFR (at least 20%)

Question 17

Should oral theophylline be prescribed?

Answer 17

NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy.

The dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed.

Question 18

What are the features of cor pulmonale

Answer 18

peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2

Question 19

How do you treat the symptoms of cor pulmonale?

Answer 19

Loop diuretic for oedema

Consider LT O2 therapy

Question 20

Are ACE-inhibitors, calcium channel blockers and alpha blockers recommended?

Answer 20

No

Question 21

Which factors improve survival?

Answer 21

smoking cessation

Long term O2 therapy if fit criteria

Lung volume reduction surgery in selected patients

Question 22

Do you always continue the SABA in COPD?

Answer 22

Yes (?)

Question 23

Can you use a mucolytic for chronic productive cough?

Answer 23

Yes consider

Question 24

What advice do you give about exercise?

Answer 24

Work to their own level. Become a bit short of breath but don’t over stretch

If mobile, walk 20-30mins 3-4x per week

If immobile- upper limb

Question 25

How often should you follow up?

Answer 25

V severe- 6 monthly

Rest annual

Question 26

What should be included in COPD annual review?

Answer 26

Spirometry

BMI

MMRC dyspnoea scale (up a hill, 100m, can’t leave house etc)

Symptom control

Drug SEs

Complications e.g. cor pulmonale (do they get ankle swelling)

Inhaler technique

Mental health

In very severe- review spO2 - do they need referral for home O2 therapy?

?referral to resp/OT/social services

Question 27

what can be done to help manage exacerbations at home?

Answer 27

Give rescue meds- steroids and abx

Written action plan

Question 28

There is evidence of survival benefit if O2 therapy is used for ??? hours daily?

Answer 28

> 15

Question 29

Chronic hypoxaemia causes?

Answer 29

Slowly progressive pulmonary HTN–>RVH–>cor pulmonale–> secondary polycythaemia –> thrombosis

Question 30

How do you manage someone with what could be acute exacerbation COPD but no diagnosis in terms of oxygen?

Answer 30

If you suspect (e.g. >50yo smoker) same as you would for diagnosed- get ABGs!!

Question 31

Long term O2 therapy should be minimum ____/day?

Answer 31

15 hours

Incl overnight- hypoxaemia can worsen sleep

Question 32

In whom should you consider long term O2 therapy?

Answer 32

Very severe (<30% FEV1)

Cyanosis

Polycythaemia

Peripheral oedema

Raised JVP

SpO2 <92% on room air

Question 33

How do you asses the need for LTOT?

Answer 33

2 ABGs, >3 weeks apart in people with confirmed, stable COPD who are receiving optimum management

<7.3kPa O2

OR

<8kPa O2 and peripheral oedema/polycythaemia (haematocrit >55%)/pulmonary HTN

Question 34

What do you need to consider as a danger of LTOT?

Answer 34

If they smoke- fire

Question 35

If they are hypercapnic or acidotic on LTOT wyd?

Answer 35

refer to specialist for ? LT NIV

Question 36

When would you use short burst oxygen therapy?

Answer 36

Relief of SOB e.g. after exercise. Don’t need to be hypoxaemic

Question 37

How do you monitor LTOT?

Answer 37

ABGs (not SpO2)