L5 COPD

Question 1

What is Cronic Obstructive Pulmonary Disease (COPD)?

Answer 1

Involves emphysema and chronic bronchitis and is characterised by reduced airflow in the lungs.
Generally affects middle aged and older people.
Smoking is major risk factor.
COPD is usually permanent and irreversible.

Question 2

Compare the inflammatory mediators present in asthma and COPD, and their response to corticosteroids.

Answer 2

ASTHMA: CD4+ T lymphocytes, B lymphocytes, mast cells and eosinophils.
COPD: macrophages and neutrophils.

Question 3

What are the symptoms of COPD?

Answer 3

Cough
Mucus production
Shortness of breath, particularly with exercise
Wheezing upon inhalation
Tightness in chest

Question 4

Which factors should be avoided, and what can worsen COPD?

Answer 4

Smoking cessation decreases rate of decline in lung function by 50%
Smoking, dust, fumes and pollutants must be avoided
respiratory infection can worsen progress of disease

Question 5

Define emphysema.

Answer 5

Alveolar enlargement caused by destruction of alveolar walls.
Abnormal accumulation of air in alveoli, due to reduced ability of the alveoli to recoil (loss of elasticity).
As ir continues to collect in the alveoli, they become enlarged, may break, or become damaged and form scar tissue.

Question 6

What is usually the first symptom of emphysema?

Answer 6

Shortness of breath during exertion.

Question 7

Describe the pathophysiology of emphysema.

Answer 7

Environmental insult such as tobacco smoke stimulates alveolar macrophages to produce chemokines to attract neutrophils.
Neutrophils and macrophages release proteinases that degrade elastin.
Alveoli degrade and coalesce to form enlarged airspaces typical of emphysema.
Also increase in mucous production and fibrosis.

Question 8

What is a genetic disorder that may lead to development of emphysema?
What is the normal role of the enzyme, and how does cigarette smoke affect it?

Answer 8

alpha-1 trypsin deficiency.
Usually neutralises proteases. Cig smoke can activate and attract inflammatory cells into the lung, and so promotes the release of proteases such as elastase.
Cig smoke also inactivates endogenous protease inhibitors including alpha-1 anti-trypsin, further supporting protease activity and increasing risk of tissue damage.

Question 9

What are the symptoms of emphysema?

Answer 9

Marked dyspnoea
later development of productive cough
rapid breathing (tachypnoea) with prolonged expiration
barrel chest
normal or elevated haematocrit
later development of ‘cor pulmonale’ (change in right ventricle due to respiratory disorder.

Question 10

What treatments are available for emphysema?

Answer 10

Smoking cessation
prophylactic Abx
bronchodilators
cautious oxygen administration

Question 11

What is the pathophysiology of chronic bronchitis?

Answer 11

Inflammation and swelling of the lining of the airways, resulting in airway narrowing and obstruction.
Production of mucous which can further obstruct the airways. Obstruction increases likelihood of bacterial lung infections.

Question 12

How is a clinical diagnosis of chronic bronchitis made?

Answer 12

Chronic cough with production of sputum for 3 or more months during 2 consecutive years, that cannot be attributed to another cause.

Question 13

What is the first symptom of chronic bronchitis?

Answer 13

Persistent, productive cough.

Question 14

What causes the airway obstruction in chronic bronchitis? What are the precipitating causes of CB?

Answer 14

Inflammation and thickening of the mucous membrane lining airways, colliery impairment and accumulation of mucous and pus.
precipitating causes include cigarette smoke, air pollutants and infection.

Question 15

What are the symptoms of chronic bronchitis?

Answer 15

Exercise intollerance
late dyspnoea
Wheezing
productive cough
Hypoxemia leacing to increased haematocrit and cyanosis
early col pulmonale

Question 16

Even though drugs do not modify decline in lung function in COPD, what benefits do they have?

Answer 16

Provide relief of symptoms
Improve exercise tollerance
Improve quality of life
Prevent or treat exacerbations and complications of COPD

Question 17

List treatments available for chronic bronchitis.

Answer 17

Bronchodilators (both relievers and controllers)
Expectorants
Postural drainage
Possible steroids (late in disease)
Possible antibiotics for acute exacerbations.

Question 18

List drugs for stable COPD

Answer 18

Short acting bronchodilators such as SA beta-2 agonists (salbutamol and terbutaline), and ipratropium (anticholinergic)
Long acting bronchodilators such as LABAs (salmeterol, eformoterol and indacaterol) and tiotropium.
Inhaled corticosteroids.
Theophylline.

Question 19

What benefits do short-acting bronchodilators have in COPD treatment? What are their limitations?

Answer 19

Releive symptoms, inprove exercise tollerance and used for initial COPD management. Anticholinergics may be preferred, because many COPD patients have concomitant coronary artery disease.
Most patients with COPD have chronic breathlessness and so SA relievers are less beneficial than LA drugs in COPD.

Question 20

What are the indications for use of indacarerol, its duration of action and common adverse effect?

Answer 20

Indicated for maintenance treatment of COPD only. has up to 24 hour duration of action, so only needs to be taken once daily.
Common adverse effect is a post inhalation cough.

Question 21

What is tiotropium, its dosage form and counselling.

Answer 21

Long acting anticholinergic bronchodilator used only for the maintenance of COPD. available as DPI (spiriva).
Should not be used for immediate relief of symptoms.
Powder should not come into contact with eyes. Tell doctor if you have eye pain, blurred vision or visual halos.

Question 22

Describe anticholinergic effects.

Answer 22

Anticholinergic inhalers alone are unlikely to cause anticholinergic effects, but the effects of many drugs together which have anticholinergic properties may summate.
Common effects include dry mouth, that irritation and dizziness. less frequent is blurred vision, and rare is urinary retention, constipation, closed angle glaucoma and palpitations.

Question 23

Describe the use of inhaled corticosteroids for stable COPD treatment.

Answer 23

May be added to LA bronchodilators in patients with 2 or more exacerbations per year.
Possibility of increased pneumonia in patients on inhaled corticosteroids needs investigation.
Macrophages and neutrophils are less responsive to corticosteroids so drug is of limited benefit. They do however decrease the frequency and severity of acute exacerbations of COPD.

Question 24

When is theophylline used for treatment of COPD?

Answer 24

Only used in patients who remain symptomatic despite optimal use of inhaled therapy.

Question 25

Describe the efficacy of combination therapy in COPD.

Answer 25

Bronchodilator effects of beta agonists, anticholinergic agents and theophylline are additive. Patients with severe COPD may benefit from combination therapy such as salbutamol and ipratropium.

Question 26

List types of drugs used for exacerbations of COPD.

Answer 26

SA bronchodilators such as SA beta-2 agonists, ipratropium and anticholinergic agents.
Oral corticosteroids.
Seretide.
Antibacterials
Aminophylline
Expectorants and mucolytics

Question 27

What benefits do oral corticosteroids have in COPD treatment?

Answer 27

Shorten recovery, reduce risk of early relapse and reduce severity of exacerbation.
Treatment exceeding 14 days provides no further benefit and increases adverse effects.

Question 28

When is sere tide indicated for use in COPD?

Answer 28

When there are repeated exacerbations that are inadequately controlled with beta-2 agonist therapy.

Question 29

When are antibacterials beneficial for COPD treatment? Which antibiotics can be used?

Answer 29

No evidence that they prevent COPD exacerbation, however they are beneficial during exacerbations with signs of infection.
Usually 5 days treatment with amoxycillin or doxycycline in people with penicillin allergy. Amoxyclav is an alternative.

Question 30

When can aminophylline be used in COPD treatment?

Answer 30

Not recommended for routine use in exacerbations, but considered as an adjunctive treatment if inadequate response to neb bronchodilators.

Question 31

Describe the efficacy of expectorants and mucolytics, aims of their use and examples.

Answer 31

Limited evidence for efficacy of expectorants and mucolytics. Mucolytics may have a small benefit in patients with a chronic productive cough.
The aim of mucolytic treatment is to reduce mucous viscosity and aid expectoration.
Evidence for the efficacy of acytylcysteine and bromhexine is limited.
Mucolytics may reduce the frequency and exacerbations in some patients with chronic bronchitis or COPD.

Question 32

List 4 other treatments for COPD.

Answer 32

Long-term oxygen therapy
Pulmonary rehab
Vaccines
Surgery

Question 33

Describe the use of long term oxygen therapy for COPD treatment.

Answer 33

O2 therapy for more than 15 hours per day.
Decreases mortality and complications in patients with chronic severe hypoxemia.
Also used for patients with pulmonary hypertension, peripheral odema (suggests heart failure) or polycthemia.

Question 34

What is the benefit of pulmonary rehabilitation in COPD patients.

Answer 34

Improves exercise capacity, dyspnoea and quality of life. May also decrease hospitalisation.

Question 35

Describe the use of vaccines in COPD.

Answer 35

Influenza vaccine reduces risk of COPD exacerbations, hospitalisation and death.
Pneumococcal vaccine: value of this vaccine is yet to be established.

Question 36

Describe the 3 types of surgery used in the treatment of COPD.

Answer 36

Done in selected patients for symptom relief.
BULLECTOMY: damaged lung sections are removed to allow neighbouring alveoli more room to expand and contract.
LUNG VOLUME REDUCTION: allows remaining healthier tissue to function better
LUNG TRANSPLANTATION

Question 37

Describe therapy for mild COPD.

Answer 37

Focus on active reduction of risk factors by vaccination and short-acting bronchodilators as needed.

Question 38

Describe therapy for moderate COPD.

Answer 38

Addition of one or more long-acting bronchodilators as needed, and inclusion of pulmonary rehabilitation.

Question 39

Describe therapy for severe COPD.

Answer 39

Addition of inhaled corticosteroids to treatments outlined for mild and moderate COPD.

Question 40

Describe therapy for very severe COPD.

Answer 40

Long term oxygen therapy in respiratory failure. Consideration of surgical treatments.