COPD

Question 1

Define COPD?

Answer 1

Chronic, progressive lung disorder characterised by airflow obstruction, with Chronic Bronchitis and Emphysema

Question 2

What is Chronic Bronchitis?

Answer 2

Chronic cough and sputum production on most days for at least 3 months per year over 2 consecutive years

Question 3

What is Emphesema?

Answer 3

Pathological diagnosis of permenant destructive enlargement of air spaces distal to the terminal bronchioles

Question 4

What is the normal cause of COPD?

Answer 4

Bronchial and Alveolar damage is caused by environmental toxins (e.g. cigarette smoke)

Question 5

What is a rare cause of COPD?

Answer 5

a1 antitrypsin deficiency

Question 6

When would you consider a1 antitrypsin deficiency as a cause of COPD?

Answer 6

Though this is rare, consider it in young patients, who have never smoked, presenting with COPD type symptoms (and may have accompanying symptoms of cirrhosis)

Question 7

What occurs in Chronic Bronchitis?

Answer 7

Narrowing of the airways resulting in bronchiole inflammation (bronchiolitis)
Bronchial Mucosal Oedema
Mucous Hypersecretion
Squamous metaplasia

Question 8

What occurs in Emphysema?

Answer 8

Destruction and enlargement of alveoli
Leads to loss of elasticity that keeps small airways open in expiration
Progressively larger spaces develop called bullae (diameter > 1 cm)

Question 9

What is the epidemiology of COPD?

Answer 9

VERY COMMON (8% prevalence)
Presents in middle age or later 
More common in males - this may change because there has been a rise in female smokers

Question 10

What are the presenting symptoms of COPD?

Answer 10

Chronic Cough 
Sputum Production
Breathlessness 
Wheeze 
Reduced Exercise Tolerance

Question 11

What are signs of COPD you with see in a physical examination on inspection?

Answer 11

Respiratory Distress
Use of Accessory Muscles 
Barrel-shaped over-inflated chest 
Decreased cricosternal distance 
Cyanosis

Question 12

What are signs of COPD you with see in a physical examination on percussion?

Answer 12

Hyper-resonant chest

Loss of Liver and Cardiac Dullness

Question 13

What are signs of COPD you with see in a physical examination on ausculation?

Answer 13

Quiet Breath sounds
Prolonged expiration
Wheeze 
Rhonchi
Sometimes crepitations

Question 14

What are Rhonchi?

Answer 14

Rattling, continuous and low-pitched breath sounds that sound a bit like snoring
They are often caused by secretion in larger airways or obstructions

Question 15

What are crepitations?

Answer 15

Crepitation refers to situations where noises are produced by the rubbing of parts one against the other
Creaking

Question 16

What are the early signs of CO2 retention?

Answer 16

Bounding Pulse
Warm peripheries
Asterixis

Question 17

What are some of the late signs of CO2 retention?

Answer 17

Signs of right heart failure (cor pulmonale)
Right Ventricular Heave
Raised JVP
Ankle Oedema

Question 18

What would we see on a spirometry and in Pulmonary Function Tests in COPD?

Answer 18

Shows obstructive picture
Reduced PEFR
Reduced FEV1/FVC
Increased Lung Volumes 
Decreased CO gas transfer coefficient

Question 19

What would you see on a CXR for COPD?

Answer 19

May appear normal
Hyperinflation (> 6 anterior ribs, flattened diaphragm)
Reduced peripheral lung markings
Elongated cardiac silhouette

Question 20

What would you expect to see in bloods for COPD?

Answer 20

FBC - increased Hb and haematocrit due to secondary polycythaemia

Question 21

What might you see in ABG for COPD?

Answer 21

May show Hypoxia, normal/raised PCO2

Question 22

What would you check for on an ECG or an Echocardiogram for COPD?

Answer 22

Check for cor pulmonale

Question 23

When would we do Sputum and Blood cultures in COPD?

Answer 23

Useful in acute infective exacerbations

Question 24

When would we do a1 antitrypsin levels in COPD?

Answer 24

Useful in young patients who’ve never smoked

Question 25

What is the important first step in any management plan for COPD?

Answer 25

STOP SMOKING

Question 26

What Bronchodilators would you use in COPD?

Answer 26

Short-acting Beta-2 agonists (e.g. salbutamol)
Anticholinergics (e.g. ipratropium bromide)
Long-acting beta-2 agonists (if> 2 exacerbation per year)

Question 27

What steroids would you use in COPD?

Answer 27

Inhaled beclamethasone

Regular oral steroids should be avoided if possible

Question 28

When do we consider Inhaled Beclamethasone?

Answer 28

Considered in all patients with FEV1 < 50% of predicted or > 2 exacerbations per year

Question 29

What are the 2 other possible management options in COPD?

Answer 29

Pulmonary Rehabilitation

Oxygen Therapy - only for those who stop smoking

Question 30

When is Oxygen Therapy indicated?

Answer 30

PaO2 < 7.3 kPa on air during a period of clinical stability
PaO2 is &.3-8 kPa and signs of secondary polycythaemia, noctural hypoxaemia, peripheral oedema or pulmonary hypertension

Question 31

What is the treatment for Acute Exacerbations?

Answer 31

24% O2 via Venturi mask
Increase slowly if no hypercapnia and still hypoxic (do an ABG)
Corticosteroids
Start empirical antibiotic therapy if evidence of infection
Respiratory Physiotherapy to clear sputum
Non-invasive ventilation may be necessary in severe cases

Question 32

How do you prevent infective exacerbations?

Answer 32

Pneumococcal and influenza vaccination

Question 33

What are the possible complications of COPD?

Answer 33

Acute respiratory failure 
Infections 
Pulmonary Hypertension 
Right Heart Failure
Pneumothorax (secondary to bullae rupture)
Secondary Polycythaemia

Question 34

What is the prognosis for patients with COPD?

Answer 34

High Morbidity
3-year survival of 90% if < 60 years, FEV1 > 50% predicted
3-year survival of 75% if > 60 years, FEV1: 40-4(% predicted