Management of COPD

Question 1

What is the effect of COPD on the population?

Answer 1

1 million patients in the UK + 2 million undiagnosed

30,000 annual mortality in UK

By 2020, will be 3rd leading cause of death in the world

Question 2

Summarise the typical presenting symptoms of COPD

Answer 2

Chronic Cough

Exertional Breathlessness

Sputum production

Recurrent chest infections (“Winter” Bronchitis)

Wheeze / chest tightness

> 35

Question 3

Summarise the signs on examination of COPD

Answer 3

Hyperinflated chest - “barrel chest”

Reduced chest expansion / shallow breaths

Prolonged expiration / wheeze

Respiratory failure:

• Tachypnoea
• Cyanosis
• Accessory muscle breathing
• Pursed lip breathing
• Peripheral oedema

Question 4

What are the investigations for COPD?

Answer 4

Spirometry
CXR

HRCT
Pulmonary function test
ECG

Full blood count
BMI
A1AT

Question 5

What are the main complications of COPD?

Answer 5

AECOPD
Pneumonia

Pneumothorax

Pulmonary hypertension
Cor pulmonale
Polycythemia

Macronutrient deficiency
Muscle atrophy, wasting

Depression

Question 6

How can COPD lead to AECOPD or Pneumonia?

Answer 6

Bronchitis aspect of COPD:

• Inflammation + loss of cilia means mucociliary escalator doesn’t work
• Mucous trapped in airways, serves as a nidus for infection

Infection leads pneumonia or acute exacerbation of COPD

Question 7

How can COPD lead to pneumothorax?

Answer 7

Emphysema aspect of COPD:

• Rupture of emphysematous bulla on the surface of the lungs
• This means inhaled air can leak out of the lungs into the pleural cavity and is trapped there

Question 8

How can COPD lead to macronutrient deficiency and muscle wasting?

Answer 8

COPD involves a chronic inflammation of the bronchioles etc

This means the lung is in a hypermetabolic state so lots of energy is used n shite

Also, respiratory problems cause those with COPD to become more inactive

Inactivity + hypermetabolic state = muscle wasting & deficiency

Question 9

How can COPD lead to Pulmonary hypertension?

Answer 9

Airway obstruction ∴ fuck ton of hypoxic alveoli

Pulmonary circulation’s response to hypoxia is arteriolar vasoconstriction to direct blood away from hypoxic area

Large amount of vasoconstriction in pulmonary circulation ∴ increased pressure ∴ pulmonary hypertension

Increased workload can cause Right heart failure ∴ Cor pulmonale

Question 10

How can COPD lead to Polycythemia?

Answer 10

Polycythemia = elevated volume of RBC’s in blood

Airway obstruction ∴ hypoxia

Kidney’s response to hypoxia = secrete more erythroprotein ∴ more RBC’s & HbA is made (excess)

Question 11

Summarise the aim of management of COPD

Answer 11

Prevent disease progression

Prevent exacerbations & complications

Relieve symptoms

Question 12

Summarise the non-pharmacological management for COPD

Answer 12

Smoking cessation - prevent disease progression

Vaccinations

• Pneumococcal
• Annual flu

Pulmonary rehab

Nutritional support

Psychological support

Question 13

What is the main therapy for COPD?

Answer 13

Inhalers

Question 14

What are the different types of inhalers for COPD

Answer 14

Short acting bronchodilators:

• SABA’s
• SAMA’s

Long acting bronchodilators:

• LAMA’s
• LABA’s

High dosage Inhaled Corticosteroids & LABA

Question 15

What is a SABA?

Answer 15

Short acting Beta2 agonist

Eg salbutamol or Terbutaline

Question 16

What is a SAMA?

Answer 16

Short acting anti muscarinic agent

Eg Ipratropium

Question 17

What is a LAMA?

Answer 17

Long acting anti muscarinic agent

Eg Umeclidinium or Tiotropium

Question 18

What is a LABA?

Answer 18

Long acting Beta2 agonist

Eg Salmeterol

Question 19

Give examples of High dosage ICS’s?

Answer 19

Relvar (Fluticasone/Valinterol)

Fostair MDI

Question 20

What is the inhaled treatment route for a patient with COPD with predominant breathlessness?

Answer 20

1) SABA (Salbutamol of Terbutaline)
2) SABA & LAMA (Umeclidinium or Tiotropium)
3) SABA & a LAMA/LABA combination (Salmeterol)

Question 21

What is the inhaled treatment route for a patient with COPD with exacerbations?

Answer 21

1) SABA + LAMA
2) SABA + LAMA/LABA combination
3) Review patient
4) SABA + LAMA/LABA/ICS triple combination

Question 22

What are the symptoms & signs of AECOPD?

Answer 22

Increasing breathlessness

Cough

Sputum volume

Sputum purulence

Wheeze

Chest tightness

Question 23

What is the treatment route for someone who presents with AECOPD?

Answer 23

Salbutamol and/or Ipratropium:
- inhaler or nebuliser

Steroids:
- Prednisolone 40mg 5-7 days

Antibiotics:
- If infection related symptoms (sputum stuff)

Question 24

If initial treatment of AECOPD doesn’t work, hospital admission should be considered

What signs would indicate that the patient with AECPOD need to go to hospital?

Answer 24

Tachypnoea

Low oxygen sats < 90-92%

Hypotension

Question 25

If a patient with AECOPD is admitted to hospital, what investigations should/can be done?

Answer 25

CXR 
ECG 
Full blood count 
Biochemistry & glucose 
Sputum culture, microscopy & sensitivity  
Blood culture 
Arterial blood gas 
Theophylline concentration

Question 26

What is the ward based management for someone who came in with AECOPD?

Answer 26

Oxygen - with target sats of 88-92%

Nebulised bronchodilators

Corticosteroids

Antibiotics - oral or IV

Arterial blood gas + clinical assessment for resp failure:
- If acute resp failure - patient put on Non-invasive ventilation