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Question 1

COPD initial treatment

Answer 1

General management
>smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
annual influenza vaccination
one-off pneumococcal vaccination
pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)

Bronchodilator therapy
a short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is first-line treatment
for patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by whether the patient has ‘asthmatic features/features suggesting steroid responsiveness’

Question 2

COPD Asthma Like Criteria

Answer 2

any previous, secure diagnosis of asthma or of atopy
a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)

Question 3

COPD after initial treatment

Answer 3

No asthmatic features/features suggesting steroid responsiveness
add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA)

Asthmatic features/features suggesting steroid responsiveness
LABA + inhaled corticosteroid (ICS)
if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS
NICE recommend the use of combined inhalers where possible

Oral theophylline
NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy
the dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed

Question 4

Cor pulmonale

Answer 4

features include peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2
use a loop diuretic for oedema, consider long-term oxygen therapy
ACE-inhibitors, calcium channel blockers and alpha blockers are not recommended by NICE

Question 5

Obstructive lung disease

Answer 5

FEV1 - significantly reduced
FVC - reduced or normal
FEV1% (FEV1/FVC) - reduced

Asthma
COPD
Bronchiectasis
Bronchiolitis obliterans

Question 6

Restrictive lung disease

Answer 6

FEV1 - reduced
FVC - significantly reduced
FEV1% (FEV1/FVC) - normal or increased

Pulmonary fibrosis
Asbestosis
Sarcoidosis
Acute respiratory distress syndrome
Infant respiratory distress syndrome
Kyphoscoliosis e.g. ankylosing spondylitis
Neuromuscular disorders

Question 7

Acute asthma attack categorisation

Answer 7

Moderate
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm	

Severe 
PEFR 33 - 50% best or predicted
Can't complete sentences
RR > 25/min
Pulse > 110 bpm	

Life threatening
PEFR < 33% best or predicted
Oxygen sats < 92%
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma

Question 8

COPD LTOT Criteria

Answer 8

LTOT should be offered to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
nocturnal hypoxaemia
peripheral oedema
pulmonary hypertension