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COPD Flashcards

1
Q

What is COPD?

A

encompassing older terms ‘chronic bronchitis’ and emphysema; in vast majority of cases, caused by smoking

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2
Q

What are 4 clinical features typical of COPD?

A
  1. Cough: often productive
  2. Dyspnoea
  3. Wheeze
  4. In severe cases, right sided heart failure may devlelop causing peripheral oedema
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3
Q

What are the 4 investigations recommended to carry out in suspected COPD?

A
  1. Post-bronchodilator spirometry to demonstrate airflow obstruction
  2. CXR
  3. Full blood count to exclude secondary polycythaemia
  4. BMI calculation
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4
Q

What finding is expected to make a diagnosis of COPD from spirometry?

A

FEV1/FVC ratio <70%

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5
Q

What are 4 signs are you looking for on CXR in suspected COPD?

A
  1. Hyperinflation
  2. Bullae: if large, may sometimes mimic a pneumothorax
  3. Flat hemidiaphragm
  4. Also important to exclude lung cancer
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6
Q

What is used to categorise the severity of COPD? What are the 4 categories?

A

the FEV1

  1. Stage 1 - mild: FEV1 >80% of predicted
  2. Stage 2 - moderate: FEV1 50-79% of predicted
  3. Stage 3 - severe: FEV1 30-49% of predicted
  4. Stage 4 - very severe: FEV1 <30% of predicted
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7
Q

Why is measuring peak expiratory flow of limited value in COPD?

A

may underestimate degree of airflow obstruction

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8
Q

What classification would COPD be if post-bronchodilator FEV1/FVC is <0.7 but FEV1 is greater than 80%?

A

stage 1 - mild COPD

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9
Q

If a patient is asymptomatic but has FEV1/FVC <0.7 and FEV1 >80% what is the diagnosis?

A

no COPD - symptoms have to be present to diagnose in stage 1 patients

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10
Q

When do NICE recommend that a diagnosis of COPD is considered?

A

patient over 35 smoker/ex-smoker, symptoms such as exertional breathlessness, cough or regular sputum production

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11
Q

What are 4 non-pharmacolical elements of the management of COPD?

A
  1. Smoking cessation advice, including offering nicotine replacement therapy (varenicline or bupropion)
  2. Annual influenza vaccination
  3. One-off pneumococcal vaccination
  4. Pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (MRC grade 3 and above)
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12
Q

What is the first line treatment for all patients with COPD?

A

SABA (short-acting beta-2 agonist) OR SAMA (short-acting muscarinic antagonist)

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13
Q

What feature in COPD determines the management beyond first-line therapy?

A

Whether asthmatic features or features suggesting steroid responsiveness are present

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14
Q

After first line management, what is the next management that is considered for controlling COPD without asthmatic features/ features suggesting steroid responsiveness?

A
  • add LABA + LAMA
  • if already taking a SAMA, discontinue and switch to a SABA
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15
Q

What are 4 criteria suggested to determine whether a patient has ashtmatic/steroid responsive features?

A
  1. Any previous, secure diagnosis of asthma or of atopy
  2. Higher blood eosinophil count (FBC should be done for all patients)
  3. Substantial variation in FEV1 over time (at least 400ml)
  4. Substantial diurnal variation in peak expiratory flow (at least 20%)
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16
Q

After first line management, what are the next steps in management of COPD with asthmatic/steroid responsive features?

A
  • LABA + ICS
  • if remain breathless or have exacerbations (1 severe [hospitalisation] or 2 moderate in a year) LABA + ICS + LAMA
  • if already taking SAMA, discontinue and switch to a SABA
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17
Q

How do NICE recommend the delivery of drugs to treat COPD is achieved?

A

combined inhalers where possible

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18
Q

What are 4 potential further aspects of treamtent of COPD in some patients, beyond general management of all patients?

A
  1. Oral theophylline
  2. Oral prophylactic antibiotic therapy
  3. Mucolytics
  4. Cor pulmonale treatment
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19
Q

What are the only 2 situations when NICE recommends oral theophylline to treat stable COPD?

A
  1. After trials of short and long-acting bronchodilators
  2. People who cannot use inhaled therapy
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20
Q

When should the dose of oral theophylline be reduced, if used to treat stable COPD?

A

if macrolide or fluroquinolone antibiotics are co-prescribed

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21
Q

What is recommended for use as oral prophylactic antibiotic therapy?

A

azithromycin prophylaxis

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22
Q

When is oral prophylactic antibiotic therapy considered for the treatment of COPD?

A

for people who have had >3 exacerbations requiring steroid therapy, and at least 1 exacerbation requiring hospital admission in the previous year

should refer to specialist in respiratory medicine to consider this

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23
Q

How is prophylactic antibiotic treatment of COPD taken?

A

azithromycin 500mg three times per week

consider for a minimum of 6-12 months to assess evidence of efficacy in reducing exacerbations

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24
Q

What are 6 things that must be done before commencing a patient with COPD of prophylatic macrolides (e.g. azithromycin)?

A
  1. only if have optimised other pharmacological and non-pharmacological therapies including smoking cessation, optimised inhaler technique, airway clearance techniques and attendance and pulmonary rehabilitation course
  2. perform ECG to assess QTc interval
  3. Perform baseline LFTs
  4. Counsel about potential adverse effects including GI upset, hearing and balance disturbance, cardiac effects, resistance
  5. Arrange microbiological assessment of sputum before therapy (+ check for TB)
  6. CT thorax to exclude bronchiectasis
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25
Why should an ECG be done before starting prophylactic antibiotics for COPD?
to exclude QT prolongation, as azithromycin can prolong the QT interval
26
When should mucolytics be considered to treat patients with COPD?
in a person with stable COPD who develops chronic cough productive of sputum only continue if there is symptomatic improvement (e.g. reduction in frequency of cough and sputum production)
27
What should muclytics not be used to treat in COPD?
routine prevention of exacerbations
28
What is a risk of using ICS to treat COPD?
increased risks of pneumonia
29
Who is the only person who can start a patient on long-term oral steroid treatment for COPD?
respiratory specialist
30
What monitoring should be performed for patients taking prophylactic oral macrolides for COPD?
* LFTs 1 month after starting then every 6 months * ECG 1 month after starting to check for new QTc prolongation - stop if present
31
Should oral azithromycin taken prophylactically be stopped during an acute exacerbation of COPD?
no, unless another antibiotic with potential to affect QT interval has also been prescribed
32
What are 4 possible clinical signs of cor pulmonale in association with COPD?
1. Peripheral oedema 2. Raised jugular venous pressure 3. Systolic parasternal heave 4. Loud P2
33
What are 2 options for treatment of cor pulmonale in COPD and what are 3 things that are NOT recommended by NICE?
1. Loop diueretic for oedema 2. Consider long-term oxygen therapy ACE-inhibitors, CCBs and alpha blockers not recommended
34
What are 3 factors which may improve survival in patients with stable COPD?
1. Somking cessation - single most important intervention in patients who are still smoking 2. Long-term oxygen therapy in patients who fit criteria 3. Lung volume reduction surgery in selected patients
35
If patients are prescribed long term oxygen therapy (LTOT) to manage their COPD, how should it be used?
should breathe supplementary oxygen for at least 15 hours a day
36
What can be used to provide a fixed supply of oxygen for LTOT?
oxygen concentrators
37
What are 6 things to assess a patient with COPD for when considering prescribing LTOT?
1. Very severe airflow obstruction (FEV1 \<30% predicted). Assessment should be considered for patients with severe airflow obstruction (FEV1 30-49% predicted) 2. Cyanosis 3. Polycythaemia 4. Peripheral oedema 5. Raised jugular venous pressure 6. Oxygen saturations less than or equal to 92% on room air
38
What investigation should be performed when considering starting LTOT for a patient with COPD?
arterial blood gases should be measured on 2 occasions at least 3 weeks apart, in patients with stable COPD on optimal management
39
When should LTOT be offered to patients with COPD? 2 situations
PAtients with **_pO2 of \<7.3kPa_** **OR** those wiht a **_pO2 of 7.3-8_** kPa _and_ one of the following: 1. secondary polycythaemia 2. peripheral oedema 3. pulmonary hypertension
40
What do NICE advise about LTOT and smoking?
do not offer LTOT to people who continue to smoke despite being offered smoking cessation advice and treatment, and referral to specialist stop smoking services
41
What are 2 key things that should be part of the structured risk assessment before offering LTOT for COPD?
1. Risks of falls from tripping over equipment 2. Risks of burns and fires - increased if someone smokes in the home (including e-cigarettes)
42
What are 3 causes of COPD?
1. Smoking 2. Alpha-1 antitrypsin deficiency (suspect if \<40) 3. Occupational exposures: * cadmium (used in smelting) * coal * cotton * cement * grain
43
What is a fact illustrating the freqeuncy of acute exacerbations of COPD?
one of the most common reasons why people present to hospital in developed countries
44
What are 4 signs of acute exacerbation of COPD?
1. Increase in dyspnoea, cough, wheeze 2. May be an increase in sputum suggestive of an infective cause 3. Patients may be hypoxic 4. In some cases may have acute confusion
45
What are the 3 most common _bacterial_ organisms that cause infective exacerbations of COPD?
1. **Haemophilus influenzae (most common)** 2. Streptococcus pneumoniae 3. Moraxella catarrrhalis
46
What proportion of COPD exacerbations are accounted for by respiratory viruses?
30%
47
What is the most important viral pathogen known to cause COPD exacerbations?
human rhinovirus
48
What are 4 aspects of the management of an acute exacerbation of COPD?
1. Increase frequency of bronchodilator use 2. Consider giving bronchodilator via nebuliser 3. Give prednisolone **30mg** daily for **5 days** 4. Antibiotics **only** if sputum purulent or clinical signs of pneumonia: amoxicillin or clarithromycin or doxycycline
49
What is the only situation when you should give antibiotics to treat an acute exacerbation of COPD?
if sputum is purulent or there are clinical signs of pneumonia
50
What are the 3 antibiotics, that the BNF recommends using one of which to treat an acute exacerbation of COPD (when clinically indicated)?
1. Amoxicillin 2. Clarithromycin 3. Doxycycline
51
What are 2 examples of SABAs?
salbutamol and terbutaline
52
What are 3 examples of LABAs?
salmeterol, formoterl, vilanterol
53
What is an example of a SAMA?
ipratropium bromide
54
What is an example of a LAMA?
aclidiunium bromide
55
What are 4 examples of combintion inhalers with LABA and ICS?
1. Fostair: formoterol + beclometasone 2. DuoResp Spiromax: formoterol + budesonide 3. Symbicort Turbohaler: formterol + budesonide 4. Seretide 500 Accuhaler: salmeterol + fluticasone
56
What are 3 options for interventions for smoking cessation?
1. Nicotine replacement therapy 2. Varenlicline 3. Bupropion
57
How should NRT/varenicline/bupropion usually be prescribed?
don't favour one over another; prescribe as part of commitment to stop smoking on or before a particular date (target stop date) prescription should only last 2 weeks after target stop date: usually after 2 weeks of NRT therapy, and 3-4 weeks for varenicline and bupropion
58
What should you do if a patient hasn't stopped smoking by their target date using NRT/ varenicline/ bupropion?
don't give further prescriptions unless demonstrated their quit attempt is continuiung if unsucessful, don't offer repeat prescription within 6 months unless special circumstances
59
Can you offer NRT/ varenicline/ bupropion in combination?
no
60
What are 3 adverse effects of nicotine replacement therapy?
1. Nausea and vomiting 2. Headaches 3. Flu-like symptoms
61
What forms of NRT should be prescribed and how?
* combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge, nasal spray) if show high dependence on nicotine or who have found single forms of NRT inadequate in past * otherwise single NRT form
62
What is the mode of action of varenicline?
nicotinic receptor partial agonist
63
When should patients be started on varenicline and how long should it continue for?
1 week before patient's target date to stop recommended course of treatment is 12 weeks - monitor regularly, only continue if not smoking
64
What is the most common adverse effect of varenicline?
nausea
65
What are 4 common side effects of varenicline?
1. Nausea 2. Headache 3. Insomnia 4. Abnormal dreams
66
What are 3 situations when varenicline should be used with caution or contraindicated?
1. caution if: history of depression or self-harm - risk of suicide 2. contraindicated in pregnancy 3. contraindicated in breast feeding
67
What is the mechanism of action of buproprion?
norepinephrine and dopamine reuptake inhibitor and nicotinic **antagonist**
68
When should bupropion be started?
1 to 2 weeks before target date to stop smoking
69
What is a rise associated with the use of bupropion?
small risk of seizures (1 in 1000)
70
What are 4 situations when bupropion is contraindicated?
1. Epilepsy 2. Pregnancy 3. Breast-feeding 4. Eating disorder - relative contraindication
71
What is recommended about smoking monitoring in pregnancy?
NICE recommended in 2010 all pregnant women should be tested using carbon monoxide detectors - some women find it difficult to say smoke due to pressure to stop all those who smoke, have stopped in past 2 weeks, or with CO reading of 7ppm or above should be referred to NHS Stop Smoking Services
72
What are 2 intervention options for smoking cessation in pregnancy?
1. First line: CBT, motivational interviewing, self-stuctured help and support from NHS Stop Smoking services 2. NRT: if above fails. remove patches before bed varenicline and bupropion contraindicated

GP (43 decks)

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