COPD TFW

Question 1

What is COPD?

Answer 1

Chronic obstructive pulmonary disease (COPD) is a common, treatable (but not curable) and largely preventable lung condition.
It is characterised by persistent respiratory symptoms and airflow obstruction which is usually progressive and not fully reversible.

Question 2

State the risk factors for COPD

Answer 2

• Smoking – over 90% of cases are caused by cigarette smoking, nevertheless COPD can still affect those who have never smoked.
• Occupational dust (coals, grains, and silica), chemicals (welding fume, isocyanates and polycyclic aromatic hydrocarbons), noxious gases, and other particles.
• Indoor air pollution from burning fires, animal dung, crop residue, wood, and coal.
• Genetics – alpha1- antitrypsin deficiency (typically in young patients <45yrs) affects both smokers and non-smokers
• Lung development: Factors affecting lung growth and development in-utero (such as maternal smoking and pre-term birth) and in childhood (such as severe respiratory tract infection and passive smoking) have been associated with reduced lung function and potentially increased risk of COPD in adulthood.
• Asthma: adults with asthma had a 12-fold higher risk of developing COPD compared to those without asthma.

Question 3

COPD is the preferred term for chronic bronchitis, emphysema, and chronic obstructive airways disease. True/false?

Answer 3

True

Question 4

What is Emphysema?

Answer 4

pathological term referring to loss of parenchymal lung texture.

Question 5

What is Chronic Bronchitis?

Answer 5

clinical term referring to cough and sputum production for at least 3 months in each of 2 consecutive years.

Question 6

State complications associated with COPD

Answer 6

Reduced quality of life and increased morbidity and mortality — COPD was the fifth leading cause of disability adjusted life years lost worldwide in 2013.
Depression and anxiety — depression and anxiety are common comorbidities in people with COPD.
Cor pulmonale — right heart failure secondary to lung disease caused by pulmonary hypertension as a consequence of chronic hypoxia.
Frequent chest infections (including pneumonia).
Secondary polycythaemia — overproduction of red blood cells as a result of hypoxia.
Respiratory failure — due to increased airway resistance.
Pneumothorax — due to abnormal lung parenchyma and formation of bulla.
Lung cancer — COPD may increase the risk of lung cancer. The mechanism for this is unclear but may involve exposure to common risk factors (such as smoking), involvement of susceptibility genes, or impaired clearance of carcinogens.
Muscle wasting and cachexia — due to multiple factors including effects of disease (such as breathlessness and anorexia), increased nutritional requirements and psychological factors.
Muscle wasting and cachexia are associated with reduced exercise tolerance, poor health status and increased risk of mortality in people with COPD.

Question 7

How to diagnose COPD

Answer 7

Diagnosis of COPD is based on typical clinical features supported by spirometry.

Question 8

State the signs and symptoms of COPD

Answer 8

Suspect COPD in people aged over 35 years with a risk factor (such as smoking, occupational or environmental exposure) and one or more of the following symptoms:

Breathlessness — typically persistent, progressive over time, and worse on exertion.

Chronic/recurrent cough.

Regular sputum production.

Frequent lower respiratory tract infections.

Wheeze.

Question 9

State other symptoms which may present in COPD

Answer 9

Weight loss, anorexia and fatigue — common in severe COPD but other causes must be considered.
Waking at night with breathlessness.
Ankle swelling – consider cor pulmonale.
Chest pain – uncommon in COPD, consider other causes.
Haemoptysis – uncommon in COPD, consider other causes.
Reduced exercise tolerance.

Question 10

Spirometry requirement in COPD to confirm diagnosis

Answer 10

A post bronchodilator FEV1/FVC less than 0.7 confirms persistent airflow obstruction.

Consider other causes in older people without typical symptoms of COPD who have an FEV1/FVC ratio less than 0.7.
Consider COPD in younger people who have symptoms of COPD, even when their FEV1/FVC ratio is above 0.7.

Question 11

Consider alpha-1-antitrypsin deficiency if the person is younger than 40 years of age or has a family history when diagnosing COPD. True/false?

Answer 11

True

Question 12

State when to suspect cor pulmonale

Answer 12

Peripheral oedema.
Raised jugular venous pressure.
Systolic parasternal heave.
A loud pulmonary second heart sound (over the second left intercostal space).
Hepatomegaly.

Question 13

state the criteria for a stage 1(mild) airway obstruction?

Answer 13

FEV1 80% of predicted value or higher.

Question 14

state the criteria for a stage 2(moderate) airway obstruction?

Answer 14

FEV1 50–79% of predicted value.

Question 15

state the criteria for a stage 3(severe) airway obstruction?

Answer 15

FEV1 30–49% of predicted value

Question 16

state the criteria for a stage 3(very severe) airway obstruction.

Answer 16

FEV1 less than 30% of predicted value or FEV1 less than 50% with respiratory failure.

Question 17

List the differential diagnosis of chronic obstructive pulmonary disease (COPD)

Answer 17

• Asthma — COPD and asthma can be difficult to distinguish clinically and may co-exist.
  o Consider asthma if the person has a family history, other atopic disease, or nocturnal or variable symptoms, is a non-smoker, or experienced onset of symptoms at younger than 35 years of age.
• Bronchiectasis — clinical features include copious sputum, frequent chest infections, a history of childhood pneumonia, and coarse lung crepitations.
• Heart failure — clinical features include breathlessness when lying flat, a history of ischaemic heart disease, and fine lung crepitations.
• Lung cancer — consider if the person has a persistent cough, haemoptysis, weight loss, or persistent hoarse voice.
• Interstitial lung disease (such as asbestosis, pneumoconiosis, fibrosing alveolitis, or sarcoidosis) — clinical features include a dry cough and fine lung crepitations.
• Anaemia — clinical features include fatigue, breathlessness, and palpitations.
• Tuberculosis (TB) — clinical features include persistent productive cough, which may be associated with breathlessness and haemoptysis. May co-exist with COPD.
• Cystic fibrosis.
• Upper airway obstruction (for example tracheal tumour).

Question 18

State how to manage stable COPD with non-pharmacological therapy?

Answer 18

o Smoking cessation for those that are
smoking
o Pneumococcal and influenza vaccinations
o Pulmonary rehabilitation if indicated
o Self-management plan

Question 19

What tx option is suitable for a person who is breathless and has exercise limitation

Answer 19

Offer a short-acting beta-2 agonist (SABA) or short-acting muscarinic antagonist (SAMA) to use as needed to relieve breathlessness and improve exercise tolerance.

Question 20

State what to do If the person continues to be limited by symptoms or has exacerbations despite use of short-acting bronchodilators

Answer 20

Review to ensure that:
Non-pharmacological management is optimal and relevant vaccinations and smoking cessation support (if applicable) have been offered.
Symptoms are not due to another condition.

Question 21

State what to offer a person If they have no asthmatic features or features suggestive of steroid responsiveness:

Answer 21

Offer a long-acting beta-2 agonist (LABA) plus a long-acting muscarinic antagonist (LAMA).

Question 22

State what tx to offer If a person continues to have day-to-day symptoms adversely affecting quality of life

Answer 22

Consider a 3 month trial of LABA plus LAMA plus inhaled corticosteroids (ICS).

If there is no improvement at 3 months change back to LABA plus LAMA.

If symptoms have improved, continue with LAMA plus LABA plus ICS and review at least annually.

Question 23

State what tx to offer If a patient have asthmatic features or features suggestive of steroid responsiveness

Answer 23

Consider offering LABA plus ICS.

If the person continues to have day-to-day symptoms adversely affecting quality of life or has 1 severe (needing hospitalization) or 2 moderate exacerbations of COPD within a year, offer LABA plus LAMA plus ICS.