COPD - Chronic Obstructive Pulmonary Disease

Question 1

What is COPD?

Answer 1

A non-reversible long-term deterioration in airflow through the lungs caused by damage to lung tissue.

Question 2

Why can COPD make someone more prone to infections?

Answer 2

Obstruction to airflow makes it difficult to ventilate the lungs.

Question 3

Risk Factors/Causes of COPD (2).

Answer 3

1. Smoking (increased levels of elastase and inhibits a-1 Antitrypsin).
2. a-1 Antitrypsin Deficiency (premature onset, liver cirrhosis, inherited disorder).

Question 4

Pathophysiology of COPD.

Answer 4

Chronic Bronchitis - Hypertrophy + Hyperplasia of mucus Glands in Bronchi resulting in Productive Cough for 3 consecutive months in 2 consecutive years.
Emphysema - Permanent Dilation of Airways Distal to Terminal Bronchiole and Destruction of Alveolar Walls.

Question 5

Clinical Presentation of COPD.

Answer 5

Stereotypical Patient : Long-Term Smoker with Chronic SOB, Cough, Sputum Production, Wheeze and Recurrent RTIs.

Question 6

What symptoms are very unusual in COPD?

Answer 6

1. Clubbing.
2. Haemoptysis.

Question 7

Grading of Dyspnoea.

Answer 7

MRC Dyspnoea Scale :
Grade I - Strenuous Exercise.
Grade II - Walking Up Hill.
Grade III - Walking Flat.
Grade IV - Stop to catch breath after walking 100m Flat.
Grade V - Unable to leave house.

Question 8

Diagnosis of COPD.

Answer 8

Clinical Presentation + Spirometry Above 35.

Question 9

What is seen on Spirometry of COPD? (3)

Answer 9

1. Obstructive Picture : FEV1/FVC Ratio < 0.7.
2. No Dramatic Response to Reversibility Testing with SABAs.
3. TLCO is reduced.

Question 10

Grading of Airflow Obstruction.

Answer 10

Compared to Predicted FEV1 :
Stage I - FEV1 > 80%.
Stage II - FEV1 is 50-79%.
Stage III - FEV1 is 30-49%.
Stage IV - FEV1 < 30%.

Question 11

CXR Findings of COPD (3).

Answer 11

1. Hyperinflation (> 6 anterior ribs).
2. Bullae - If Large, can mimic a Pneumothorax.
3. Flat Hemidiaphragm.

Question 12

Medical Management of COPD (4).

Answer 12

1. SABA or SAMA.
   2A : If Asthmatic/Steroid-Responsive = LABA + ICS (Fostair, Symbicort, Seretide) + (only SABA).
   2B : If Not Asthmatic/Steroid-Responsive = LABA + LAMA + (only SABA).
2. SABA + LAMA + LABA + ICS.
3. Additional Options.

Question 13

Features that are suggestive of Steroid Responsiveness or Asthma (4).

Answer 13

1. Previous Diagnosis of Asthma/Atopy.
2. Raised Eosinophil Count.
3. Substantial Variation in FEV1 (400ml +).
4. Substantial Diurnal Variation in PEF (>20%).

Question 14

Additional Medical Options in COPD (5).

Answer 14

1. Nebulisers of SABA.
2. Oral Theophylline.
3. Oral Mucolytic Therapy e.g. Carbocisteine.
4. Long-Term Prophylactic Antibiotics e.g. Azithromycin.
5. Long-Term Oxygen Therapy at Home.

Question 15

Indications of Long-Term Oxygen Therapy (LTOT) (5).

Answer 15

Severe COPD that causes :
1. Chronic Hypoxia (<7.3kPa alone or 7.3-8 + another condition).
2. Polycythaemia.
3. Cyanosis.
4. Heart Failure (Cor Pulmonale) - Peripheral Oedema, Raised JVP.
5. PEF < 30%.

Question 16

LTOT Use.

Answer 16

Patients should breathe supplementary Oxygen for at least 15+ hours a day. Assessment is done by measuring ABG on 2 occasions at least 3 weeks apart.

Question 17

Contraindication of LTOT.

Answer 17

Smoker.

Question 18

Contraindication of Prophylactic Antibiotic Therapy.

Answer 18

Smoker.

Question 19

Requirements for Prophylactic Antibiotic Therapy (3).

Answer 19

1. CT Thorax - Exclude Bronchiectasis.
2. Sputum Culture - Exclude Atypical Infections and TB.
3. ECG - Exclude QT Prolongation.

Question 20

Lifestyle Management of COPD (3).

Answer 20

1. Smoking Cessation.
2. Pneumococcal and Annual Flu Vaccine.
3. Pulmonary Rehabilitation (MRC3+).

Question 21

Which factors can improve survival in COPD patients? (3)

Answer 21

1. Smoking Cessation.
2. LTOT.
3. Lung Volume Reduction Surgery.

Question 22

Indications of Surgery in COPD (4).

Answer 22

1. Upper Lobe Predominant Emphysema.
2. FEV1 > 20% Predicted.
3. PaCO2 > 7.3kPa.
4. TICO > 20% Predicted.