COPD

Question 1

What would be the first line treatment for a patient who has low SpO2 in COPD?

Answer 1

Venturi mask 28%

Question 2

What SpO2 do you aim to achieve in someone with COPD?

Answer 2

88-92%

Question 3

If someone with COPD has type 2 respiratory failure, and is on oxygen, what would you do next?

Answer 3

Know that range is 88-92%

Start NIV if acidotic
If not acidotic repeat ABG in 30-60 minutes

Question 4

How is the severity of COPD assessed?

Answer 4

FEV1 (% predicted)

Question 5

What is used to diagnose obstructive lung disease?

Answer 5

FEV1/FVC <0.7

Question 6

What is FVC (% predicted) used to diagnose?

Answer 6

The severity and diagnosis of restrictive lung diseases

Question 7

What are the features of an acute exacerbation of COPD?

Answer 7

Increase in dyspnoea, cough or wheeze
Increase in sputum suggestive of infective cause
Hypoxia and in some cases acute confusion

Question 8

What are the most common bacterial causes of infective exacerbations of COPD?
What is the most common viral cause?

Answer 8

Haemophilus influenzae
Streptococcus pneumoniae
Moraxella cattarrhalis

Rhinovirus

Question 9

What is the recommended treatment of acute exacerbation of COPD?

Answer 9

Increase freq. bronchodilator, consider nebuliser

Prednisolone 30 mg daily for 7-14 days

Give oral abx: amoxicillin or clarithromycin or doxycycline if sputum is purulent or there are clinical signs of pneumonia.

Question 10

What antibiotics are recommended first line for infective exacerbations of COPD?

Answer 10

Amoxicillin
Clarithromycin
Doxycycline

Question 11

What are the causes of COPD?

Answer 11

Smoking (Vast majority)
Alpha-1-antitrypsin deficiency

Cadmium (smelting)
Coal
Cotton
Cement
Grain

Question 12

What two older terms are encompassed in COPD?

Answer 12

Chronic Bronchitis

Emphysema

Question 13

What are the features of COPD?

Answer 13

Cough: often productive
Dyspnoea
Wheeze
Right-sided heart failure (may develop in severe cases, resulting in peripheral oedema)

Question 14

What are the investigations of COPD?

Answer 14

Post-bronchodilator spirometry: Obstructive pattern: FEV1/FVC < 70%

Chest x-ray

FBC: exclude secondary polycythaemia

BMI

Question 15

What changes may be seen on a chest x-ray in COPD?

Answer 15

Hyperinflation
Bullae: can mimic pneumothorax
Flat hemidiaphragm

Question 16

How is the severity of COPD categorised?

Answer 16

Using the FEV1

Question 17

How is stage 1 (mild) COPD defined?

Answer 17

FEV1 >80% predicted

Post-bronchodilator FEV1/FVC < 0.7 (same in all)

• symptoms should be present to diagnose COPD in these patients

Question 18

How is stage 2 (moderate) COPD defined?

Answer 18

FEV1 50-79% predicted

Post-bronchodilator FEV1/FVC < 0.7 (same in all)

Question 19

How is stage 3 (severe) COPD defined?

Answer 19

FEV1 30-49% predicted

Post-bronchodilator FEV1/FVC < 0.7 (same in all)

Question 20

How is stage 4 (very severe) COPD defined?

Answer 20

FEV1 <30% predicted

Post-bronchodilator FEV1/FVC < 0.7 (same in all)

Question 21

What patients should be considered for long-term oxygen therapy?

Answer 21

Very severe or severe disease
Cyanosis
Polycythaemia
Peripheral oedema
Raised JVP
Oxygen sats < or = 92% on room air

Question 22

How is assessment for long-term oxygen therapy done?

Answer 22

By measuring arterial blood eases on 2 occasions, 3 weeks apart in patients with stable COPD on optimal management

Question 23

Which patients should long-term oxygen therapy be offered to?

Answer 23

pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
peripheral oedema
pulmonary hypertension

Question 24

Who should long-term oxygen therapy not be offered to?

Answer 24

People who continue to smoke despite being offered smoking cessation advice and treatment.

Question 25

What should be considered in the risk assessment for long-term oxygen therapy?

Answer 25

RIsk of falls from tripping over equipment

Risk of burns and fires

Question 26

What are general management recommendations of COPD?

Answer 26

Smoking cessation
Annual influenza vaccine
One-off pneumococcal vaccine
Pulmonary rehabilitation (if view themselves as functionally disabled)

Question 27

What drugs are used for the management of stable COPD?

Answer 27

SABA or SAMA Bronchodilator therapy

Then, if the patient ‘has asthmatic features/features suggesting steroid responsiveness’:

LABA + ICS
then: LAMA + LABA + ICS

If no asthmatic features/features suggesting steroid responsiveness:

LABA + LAMA

Theophylline (specialist)

Mucolytics - in patients with a chronic productive cough

Question 28

What features would be suggestive of ‘has asthmatic features/features suggesting steroid responsive’?

Answer 28

Any previous, secure diagnosis of asthma or of atopy
A higher blood eosinophil count
Substantial variation in FEV1 over time (at least 400 ml)
Substantial diurnal variation in peak expiratory flow (at least 20%)

Question 29

What oral prophylactic antibiotic therapy is recommended?

Answer 29

Azithromycin prophylaxis

no smoking and otherwise optimised treatments

Question 30

What investigations are required before giving prophylactic antibiotics?

Answer 30

CT thorax - to exclude bronchiectasis
Sputum culture - to exclude atypical infections and TB
LFTs and ECG to exclude QT prolongation

Question 31

What are the features of cor pulmonale which can be seen in COPD?

Answer 31

Peripheral oedema
Raised JVP
Systolic parasternal heave
Loud P2

Question 32

How should cor pulmonale resulting from COPD be treated?

Answer 32

Loop diuretic for oedema

Consider long-term O2

Question 33

What factors improve survival in patients with stable COPD?

Answer 33

Smoking cessation
Long term O2 therapy - if fit criteria
Lung volume reduction surgery - if fit criteria