COPD

Question 1

What are the features of COPD?

Answer 1

cough: often productive
dyspnoea
wheeze
in severe cases, right-sided heart failure may develop resulting in peripheral oedema

Question 2

What will post-bronchodilator spirometry to demonstrate?

Answer 2

airflow obstruction: FEV1/FVC ratio less than 70%

Question 3

What will CXR demonstrate?

Answer 3

hyperinflation
bullae: if large, may sometimes mimic a pneumothorax
flat hemidiaphragm
also important to exclude lung cancer

Question 4

Why is an FBC performed in COPD?

Answer 4

exclude secondary polycythaemia

Question 5

How is the severity of COPD is categorised?

Answer 5

using the FEV1

Question 6

What is Stage 1 COPD

Answer 6

Stage 1 - Mild
< 0.7 FEV1/FVC
> 80% FEV1 (of predicted)

Question 7

What is Stage 2 COPD

Answer 7

Stage 2 - Moderate
< 0.7 FEV1/FVC
50-79% FEV1 (of predicted)

Question 8

What is Stage 3 COPD

Answer 8

Stage 3 - Severe
< 0.7 FEV1/FVC
30-49% FEV1 (of predicted)

Question 9

What is Stage 4 COPD

Answer 9

Stage 3 - End stage
< 0.7 FEV1/FVC
<30% FEV1 (of predicted)

Question 10

How useful is PEF in COPD?

Answer 10

Measuring peak expiratory flow is of limited value in COPD, as it may underestimate the degree of airflow obstruction.

Question 11

What are the causes of COPD?

Answer 11

Smoking!

Alpha-1 antitrypsin deficiency

Other causes
cadmium (used in smelting)
coal
cotton
cement
grain

Question 12

General management of stable COPD?

Answer 12

> smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
annual influenza vaccination
one-off pneumococcal vaccination
pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD

Question 13

What is the first line treatment of stable COPD?

Answer 13

SABA/SAMA

Question 14

What is the second line treatment of stable COPD?

Answer 14

No asthmatic features/features suggesting steroid responsiveness LABA + LAMA

Asthmatic features/features suggesting steroid responsiveness
LABA + inhaled corticosteroid (ICS)

Question 15

What is the third line treatment of stable COPD?

Answer 15

triple therapy i.e. LAMA + LABA + ICS

if already taking a SAMA, discontinue and switch to a SABA

Question 16

What is the indication for prophylactic antibiotic therapy in COPD?

Answer 16

patients should not smoke, have optimised standard treatments and continue to have exacerbations

Question 17

What is the reccomended for prophylactic antibiotic therapy in COPD?

Answer 17

azithromycin

Question 18

What are the prerequisites for azithromycin treatment in COPD?

Answer 18

CT thorax (to exclude bronchiectasis) and sputum culture (to exclude atypical infections and tuberculosis)
LFTs and an ECG to exclude QT prolongation (azithromycin can prolong the QT interval)

Question 19

What factors improve survival in patients with stable COPD?

Answer 19

smoking cessation - the single most important intervention in patients who are still smoking
long term oxygen therapy in patients who fit criteria
lung volume reduction surgery in selected patients

Question 20

What are the features of cor pulmonale?

Answer 20

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

Question 21

What is the management for cor pulmonale?

Answer 21

loop diuretic for oedema (furosemide, bumetanide)

consider long-term oxygen therapy

Question 22

What are the features of an acute exacerbations of COPD?

Answer 22

increase in dyspnoea, cough, wheeze
there may be an increase in sputum
patients may be hypoxic
in some cases have acute confusion

Question 23

What are most common bacterial organisms that cause infective exacerbations of COPD?

Answer 23

Haemophilus influenzae (most common cause)
Streptococcus pneumoniae
Moraxella catarrhalis

Question 24

What % of acute exacerbations of COPD are caused by viruses?

Answer 24

30%

rhinovirus being the most important pathogen

Question 25

all patients with an exacerbation of COPD should receive antibiotics

Answer 25

false

oral antibiotics ‘if sputum is purulent or there are clinical signs of pneumonia’

Question 26

How should acute exacerbations of COPD be managed?

Answer 26

increase frequency of bronchodilator use and consider giving via a nebuliser
give prednisolone 30 mg daily for 5 days
one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.

Question 27

When should long-term oxygen therapy be offered in COPD patients?

Answer 27

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 28

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

Answer 28

true

Question 29

risks of falls from tripping over the equipment should be carried out before offering LTOT

Answer 29

true
also the risks of burns and fires, and the increased risk of these for people who live in homes where someone smokes (including e‑cigarettes)

Question 30

What are oxygen saturation targets for acutely ill patients?

Answer 30

94-98%

patients at risk of hypercapnia (e.g. COPD patients): 88-92%

Question 31

Outline emergency oxygen therapy for COPD patients

Answer 31

prior to availability of blood gases, use a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis
adjust target range to 94-98% if the pCO2 is normal

Question 32

Outline emergency oxygen therapy for acutely unwell patients (non-COPD)

Answer 32

initially be given via a reservoir mask at 15 l/min

94-98% target