COPD

Question 1

4 things on auscultation for COPD?

Answer 1

Quiet breath sounds
Polyphonic wheeze
Prolonged expiratory phase
Quiet heart sounds (lung is hyperinflated, muffling sound)
Crackles (chronic inflammation and mucus production)
Possibly irregular heart rhythm (AF, multifocial atrial tachycardia)

Question 2

Some things you may see on inspection in COPD?

Answer 2

Inhalers/Nebulisers
Sputum pot
Tar-stained fingers
Thin skin and bruising (disease and steroid use)
Proximal muscle wasting
Use of accessory muscles of respiration
Tachypnoea
Hyperexpanded chest
Prolonged expiratory phase
Pursed lip breathing

Question 3

Investigations to diagnose COPD and what are the results?

Answer 3

Spirometry

• -> FEV1/FVC < 70% of predicted
• -> FEV1 < 80% of predicted
• -> <15% reversibility of FEV1 (take inhaler and wait 15-30 minutes then try again)

Question 4

What are the 4 components of the BODE index which predict mortality?

Answer 4

BMI (high risk if < 19)

Obstruction (Degree of obstruction indicated by FEV1 as per cent of predicted)

Dyspnoea (i.e MRC score)

Exercise capacity (i.e from 6-minutes exercise test)

Question 5

5 complications of COPD?

Answer 5

Cor pulmonale
Polycythaemia (due to increased CO2 retention)
Pulmonary Hypertension
Pneumonia (loss of cough reflex)
Bronchiectasis
Pneumothorax (ruptured emphesymatous bullae)

Question 6

What scoring system used to predict morbidity and mortality from COPD?

Answer 6

BODE Index

Question 7

What scoring system used to categorise severity of COPD?

Answer 7

GOLD criteria

Question 8

What are some CXR findings you might see in COPD?

Answer 8

Lung hyperinflation
Flattened hemidiaphragm
Enlarged central pulmonary arteries
Decreased peripheral vascular markings
Presence of bullae

Question 9

What are the indications for long-term oxygen therapy?

Answer 9

1) Clinically stable non-smokers with PaO2 < 7.3kPa despite maximum treatment
2) If PaO2 is 7.3-8.0 kPa and pulmonary hypertension with cor pulmonale OR polycythaemia OR peripheral oedema OR nocturnal hypoxia
3) Terminally ill patients

Question 10

What is some lifestyle advice you can offer to a patient as a GP?

Answer 10

1) Stop smoking!
2) Exercise and maintain weight
3) Advise patient to go for annual flu and pneumococcal vaccination

Question 11

What sort of peak flow do you get in COPD?

Answer 11

Scalloped Peak flow (compromised mid-expiratory flow due to decreased elastic recoil)

Question 12

Define chronic bronchitis

Answer 12

o Defined clinically as the presence of a chronic productive cough for 3 months during each of 2 consecutive years (other causes of cough being excluded).

Question 13

Define emphysema

Answer 13

Defined pathologically as an abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis

Question 14

5 causes of COPD?

Answer 14

Cigarette smoking
Occupational dust
Air pollution
Passive smoking
Alpha1- antitrypsin deficiency

Risk factors:
HIV
Frequent childhood infections

Question 15

Two components of COPD?

Answer 15

Chronic bronchitis (not breathless but always cyanosed –> blue bloaters) and emphysema (not cyanosed but always breathless –> pink puffers)

Question 16

What are some potential complications with ventilation?

Answer 16

Ventilation-associated pneumonia

Pneumothorax from ruptured bullae

Question 17

What are some investigations you would do in acute exacerbations of COPD?

Answer 17

ABG (assess any form of Respiratory Failure)
CXR (Rule out pneumothorax or infection)
FBC
U + E
CRP
Blood culture (if pyrexial)
Sputum culture (if sputum purulent)

Question 18

Treatment for acute exacerbation of COPD?

Answer 18

1) Nebulised bronchodilators ie Salbutamol and ipratropium
2) Oxygen (if sats < 88%, aim for between 88 - 92%)
2) Steroids i.e IV hydrocortisone 200mg and oral prednisolone 30mg OD
3) Antibiotics i.e amoxicillin 500mg TDS PO

4) Chest physio for mucus expectoration

Question 19

What do you give to acute exacerbation of COPD patients who don’t respond to nebulisers or steroids?

Answer 19

Consider IV Aminophylline

• -> do not give loading dose to patients on maintenance methyxanthines (aminophylline, theophylline)
• -> ECG monitoring required

Question 20

What if all treatments for acute COPD don’t work?

Answer 20

Consider NIPPV
–> can give
respiratory stimulant i.e doxapram (IV in patients not suitable for mechanical ventilation)

If severely acidotic and type II respiratory failure
–> Consider intubation and ventilation

Question 21

What percussion note do you get with COPD?

Answer 21

Hyperresonant percussion note (because of chest hyperexpansion)

Question 22

What interventions will improve long term survival in COPD patients?

Answer 22

Smoking cessation (most impt)
Long term O2