Medicine- COPD + Pneumonia

Question 1

Which two of the following conditions typically characterize the pathophysiology underpinning COPD?

a) Bronchiectasis
b) Interstitial lung disease
c) Emphysema
d) Chronic bronchitis

Answer 1

c) Emphysema
d) Chronic bronchitis

Question 2

Which of the following are characteristic of Chronic Bronchitis?

a) Scarring of the lung parenchyma
b) Hypertrophy of mucus glands
c) Dilation of the alveoli following septal wall destruction
d) Permanent dilation of the bronchi

Answer 2

b) Hypertrophy of mucus glands

Question 3

Which of the following symptoms/signs is atypical of a patient presenting with COPD?

a) SOB
b) Dry cough
c) Hyperinflated chest
d) Fatigue

Answer 3

b) Dry cough

Question 4

What is ‘COPD’

Answer 4

Chronic Obstructive Pulmonary Disease (COPD) is an umbrella term referring to the obstructive airways disease of Chronic Bronchitis and Emphysema

Question 5

Define chronic bronchitis?

Answer 5

Chronic bronchitis is defined as a daily productive cough for 3 months of the year, over two consecutive years. It is characterised by hypertrophy and hyperplasia of the mucus glands within the bronchial tree. Bronchial wall inflammation and mucosal oedema are also typically observed.

Question 6

Define emphysema?

Answer 6

Emphysema is a disease of the terminal airways characterised by destruction of alveolar septal walls leading to dilation of the alveoli. The net result is air trapping.

Question 7

Symptoms of COPD

Answer 7

Typical symptoms of COPD include

• Daily productive cough
• Persistent and progressive breathlessness
• Chest tightness
• Fatigue

Typical signs associated with COPD include

• Cyanosis
• Expiratory wheeze
• Frequent respiratory tract infections
• Pursed lip breathing
• Accessary muscle use to breathe
• Ankle swelling

Question 8

When taking a history from a suspected COPD patient you have to screen the patient for risk factors.

What are they?

Answer 8

• Extensive history of cigarette smoking
• Chronic exposure to pollutants at work
• Alpha 1 Antitrypsin Deficiency

Question 9

What is a classic presentation of a COPD patient?

Answer 9

A classic presentation of a patient with COPD would be that of a smoker, presenting with progressive symptoms of breathlessness and a productive cough. The symptom of breathlessness is often worse on exertion.

They may also report having recurrent respiratory infections.

Question 10

Epidemiology of COPD?

Answer 10

• COPD tends to middle-aged adults and older.
• Those with a significant smoking history are at a much greater risk of developing COPD.
• Those with Alpha 1 Antitrypsin Deficiency.

Question 11

Ix for COPD?

Answer 11

Spirometry

Lung function test

CHest X ray

A1AT levels

Question 12

What would spirometry show on a COPD patient?

Answer 12

COPD would show an obstructive pattern of disease (FEV1/FVC ratio of < 0.7). In order to distinguish COPD from Asthma, you would test for reversibility, whereby the patient then uses a Salbutamol inhaler and spirometry is retested. In COPD, no significant change is observed, however in the case of Asthma, the condition is reversible

Question 13

What would lung function test show on a COPD patient?

Answer 13

shows airflow limitation with increasing disease severity and symptoms. The severity of a patient’s COPD can be staged using their FEV1 value (see table RIGHT)

Question 14

What does Chest X ray show on COPD patient?

Answer 14

COPD patients may have hyperinflated lungs

Question 15

What does A1AT levels in COPD patients?

Answer 15

if low, may explain the cause of the patient’s COPD

Question 16

Differentials for COPD

and how to differentiate them?

Answer 16

Asthma – the main differential to consider, however there are a number of factors that distinguish one condition from the other (summarised in the table RIGHT)

Heart failure – in a patient with HF, would expect SOB and ankle swelling, however also likely to report orthopnea, paroxysmal nocturnal dyspnea and may have basal crackles on auscultation

Bronchiectasis – would expect chronic production of large quantities of sputum. On examination, a patient with bronchiectasis may have coarse crackles and digital clubbing. Investigate with CT and CXR.

Question 17

What are the different stages of COPD in relation ot FEV1

Answer 17

Question 18

Difference in COPD and Asthma?

Answer 18

Question 19

What is management for COPD patients?

Answer 19

Smoking cessation first

Question 20

What are findings of COPD in a clinical examination?

Answer 20

• General inspection – older patients, may be on oxygen therapy, may have inhalers at the bedside, may have a sputum pot.
• Inspection of the hands – tar staining of the fingers. Flapping tremor due to CO2 retention. Fine tremor may indicate salbutamol use.
• Palpation of pulse – pulsus paradoxus (whereby the wave volume decreases with inspiration).
• Inspection of the chest – may observe a ‘barrel chest’ due to hyperinflation.
• Auscultation of the chest – expiratory wheeze

Question 21

37 year old Mrs Jones presents to her GP with shortness of breath and a productive cough. The symptoms have worsened over the last few months, initially only present with exercise but now more frequent. Symptoms no worse at night. On taking her history, the GP finds: she has a 32 pack year smoking history and her mother had A1AT deficiency leading to liver cirrhosis. No other findings were noted.

Having considered other possible differentials (such as Asthma), the GP suspects a diagnosis of COPD. Which of the following points support the GP’s suspicion?

a) Symptoms no worse at night
b) Age 37 years old
c) Female
d) 32 pack year smoking history
e) Family history of A1AT

Answer 21

a) Symptoms no worse at night
b) Age 37 years old
d) 32 pack year smoking history
e) Family history of A1A

Question 22

Mrs Jones then undergoes spirometry testing with reversibility. She is found to have an FEV1 reading of 54% predicted and an FVC reading of 84% predicted giving an obstructive pattern of respiratory disease. No significant change was observed with Salbutamol use. Given that COPD is the correct diagnosis, which of the following classifications is correct?

a) Stage 1 - Mild
b) Stage 2 - Moderate
c) Stage 3 - Severe
d) Stage 4 – Very severe

Answer 22

b) Stage 2 - Moderate

Question 23

Mrs Jones is given the appropriate advice regarding initial management of COPD (i.e. smoking cessation etc). The GP then suggests starting inhaled therapies. Which of the following options is the most suitable inhaler therapy to start (on top of a Salbutamol PRN)?

a) LABA
b) Inhaled Corticosteroid
c) Theophylline
d) LABA and LAMA

Answer 23

d) LABA and LAMA

Question 24

What is the underlying pathophysiology of pneumonia?

a) Inflammation of the lung tissue due to infection
b) Obstruction of the airways
c) Inadequate blood supply (and thus perfusion) to the lung parenchyma

Answer 24

a) Inflammation of the lung tissue due to infection

Question 25

Which of the following symptoms would you NOT expect in a typical patient with Pneumonia

a) Fever
b) Purulent sputum
c) Dry cough
d) Malaise

Answer 25

c) Dry cough

Question 26

What is ‘Pneumonia’

Answer 26

Pneumonia is an acute lower respiratory tract infection (LRTI) that shows radiological change called consolidation.

Question 27

Pneumonia is broadly classified into 3 categories:

Answer 27

• Community Acquired Pneumonia (CAP)
• Hospital Acquired Pneumonia (HAP)
• Aspiration Pneumonia

Question 28

The most common microorganisms causing CAP are…..

Answer 28

Streptococcus Pneumonia, Haemophilus Influenza and Mycoplasma Pneumonia

Question 29

What is Hospital Acquired Pneumonia (HAP)?

Answer 29

HAP refers to a Pneumonia that occurs >48 hours following admission to hospital and/or if the patient was in hospital 2 weeks prior to onset.

Question 30

Example microorgansisms known to cause HAP include….

Answer 30

Staphylococcus Aureus, Pseudomonas, Klebsiella and C. Difficile.

Question 31

What is Aspiration Pneumonia

Answer 31

– Aspiration Pneumonia occurs when a foreign body enters the lungs and directly introduces bacteria to the environment. Individuals with decreased consciousness, oesophageal disease, neurological disease (particular affecting bulbar muscles) or poor dental hygiene are all at increased risk of aspiration and therefore aspiration pneumonia.

Question 32

Symptoms of pneumonia?

Answer 32

• There are a number of symptoms to look for in a patient with pneumonia, which can be broken down and considered in line with its definition.
• Symptoms of infection such as: Fever, Malaise, Anorexia Nervosa and Rigors.
• Symptoms of respiratory disease such as: Dyspnoea, Cough, Purulent Sputum, Pleuritic Chest Pain and Haemoptysis.

Question 33

What does a typical pneumonia patient present with on history ?

Answer 33

• Typically, a patient with Pneumonia will experience sudden onset dyspnea, a productive cough and non-specific infective symptoms with rapid disease progression.
• When taking a history from a patient with suspected Pneumonia,be sure to consider potential exposures (such as travel, animals, occupation etc) and also risk of aspiration (such as alcoholism, drug use, PMH of oesophageal disease and any loss of consciousness).

Question 34

What is epidemiology for pneumonia?

Answer 34

• As per the NHS website, Pneumonia affects approximately 8 in 1000 adults each year.
• Pneumonia is typically more prevalent in Autumn and Winter.

• In theory, Pneumonia can affect any individual; however, there are certain groups of the population that are at greater risk, these include:
-Young children and the Elderly

-Individuals who are immunosuppressed – for example those having chemotherapy to treat Cancer, on medication to suppress the immune system or those with HI

Question 35

Ix for pneumonia?

Answer 35

• Vital Signs
• Bloods
• FBC – increased WCC representing an active immune response.
• Blood culture – less common, typically only used if suspected Septicaemia (when the infection has spread from the lungs to the blood or vice versa)
• Sputum culture – test for the presence of microorganisms within the sputum.
• Chest X-Ray – assess for any radiological change on CXR (required in order to diagnose Pneumonia)

Question 36

Differentials for pneumonia?

Answer 36

• Lower Respiratory Tract Infection (LRTI) – same presentation as Pneumonia but shows no change on CXR.
• Asthma – unlike Pneumonia, you would expect Asthma to present with a long term history with slightly more episodic symptoms (which may include a dry cough). Can use Peak Expiratory Flow and Spirometry (obstructive in Asthma, restrictive in Pneumonia) to differentiate.
• Infective exacerbation of COPD – patient will present with the same infective signs and symptoms, may not necessarily show radiological change, PMH of COPD.

Question 37

Management for Asthma?

Answer 37

• The management of Pneumonia depends on its severity.
• Severity is scored using the CURB65 score; where each of the following criteria scores 1 point: • Confusion (new onset or worsened) • Urea >7mmol/L • Respiratory Rate >30/min • Blood pressure (low BP of either systolic <90mmHg or diastolic <60mmHg • 65+ years old
• CURB 1 – manage at home with oral Amoxicillin
• CURB 2 – consider hospital admission, manage with Amoxicillin and Clarithromycin
• CURB 3/4/5 – admit to hospital (and consider ICU admission if 4 or 5) and manage with IV co- amoxiclav and clarithromycin.
• Manage SpO2 with Oxygen therapy only if required to meet the SpO2 aim (88-92% in CO2 retainers such as a subset of those with COPD, otherwise 94-98%).

Question 38

What are findings for people with pneumonia on clinical examination?

Answer 38

• Inspection – use of accessary muscles to aid breathing, peripheral/central cyanosis, altered mental state.
• Reduced chest expansion on affected side.
• On percussion, dull note observed over the area of consolidation.
• On auscultation, bronchial breath sounds heard over the area of consolidation with added coarse crackles. Vocal resonance increased over area of consolidation.

Question 39

OSCE tips of pneumonia?

Answer 39

• When taking a history from a patient with suspected Pneumonia, be sure to ask about:
• Time frame • Symptoms (in detail) • Exposure to risks of Pneumonia

On examination, take time to assess the patient thoroughly and ensure the findings are accurate (e.g. distinguishing between coarse crackles and fine crackles).

Question 40

John is a 78 year old gentleman who has presented to his GP (with his wife who cares for him) with dyspnoea, a sharp stabbing chest pain on his right hand side and coughing up thick ‘mucky’ sputum. He has been feeling generally unwell and ‘not himself’. During the Hx, the GP finds that John is known to have dementia, had a PE in 2013 and was in hospital 10 days ago with a bout of diarrhoeal illness. No other findings to note.

The GP suspects that John has Pneumonia and admits him to hospital for investigation. Should the diagnosis be correct, which type is John’s Pneumonia likely to be?

a) CAP
b) HAP
c) Aspiration Pneumonia

Answer 40

b) HAP

Question 41

Upon arriving at A&E, 78 year old John was examined by the consultant and his blood’s were taken. He was found to have a dull percussion note, bronchial breathing and increased vocal resonance on the right hand side at the base of his back. His CXR showed consolidation in the same area. John was subsequently diagnosed with Pneumonia. His SpO2 were 94% on RA, RR 31, HR 96 and BP 93/58 . John did not appear any more confused than normal. His Urea was 7.3mmol/L and lactate 1.0mmol/L.

What is John’s CURB65 score?

a) 1 b) 2 c) 3 d) 4 e) 5

Answer 41

d) 4

Question 42

Given John’s CURB score of 4 and SpO2 of 94%, what would be the appropriate management plan (according to the guidance previously mentioned in the Presentation)?

a) Send home on oral Amoxicillin
b) Suggest that John should stay in hospital, give oral Amoxicillin, Clarithromycin and O2 Therapy.
c) Suggest that John should stay in hospital, give IV Co-amoxiclav and Clarithromycin.
d) Suggest that John should stay in hospital, give IV Co-amoxiclav, Clarithromycin and Oxygen Therapy.

Answer 42

c) Suggest that John should stay in hospital, give IV Co-amoxiclav and Clarithromycin.