RESP - A. DIAGNOSIS AND TREATMENT OF COPD-COVERED

Question 1

COPD key facts

Answer 1

• third leading cause of death worldwide
• most people >50

Question 2

what is COPD

Answer 2

• long term
• narrowing of airways, harder to breathe out, air is trapped
• affects lungs
• medical condition

Question 3

what happens in COPD

Answer 3

• lungs are inflamed, damaged, narrowed
• poorly reversible airflow obstruction
• abnormal inflam response
• progressive disease
• chronic inflam affects central and peripheral airways, lung parenchyma, alveoli, pulmonary vasculature
• repeated injury and repair = permanent structural and physiological changes
• narrowing and remodelling of airways, increased no. of goblet cells, enlargement of mucus-secreting glands of central airways, alveolar loss, vascular bed changes = pulmonary hypertension

Question 4

main effects of COPD

Answer 4

increased airway resistance due to:
- decreased elastic recoil
- fibrotic changes in lung parenchyma
- luminal obstruction of airways by secretions

expiratory flow limitation promotes hyperinflation (air gets trapped)
- causes hypoxia

Question 5

causes and risk factors of COPD

Answer 5

• tobacco smoking (particles damage airway linings)
• air pollution
• occupation
• genetics: alpha-1 antitrypsin deficiency
• age
• socioeconomic status
• asthma

Question 6

diagnosis of COPD

Answer 6

• symptoms, >1 of:
  persistent breathlessness
  wheeze
  chronic recurrent cough
  regular sputum production
  lower resp infections due to mucus
• risk factors
• age >35
• spirometry (FEV1/FVC <0.7) after bronchodilator
  (to confirm diagnosis) - no/limited bronchodilator reversibility
• BMI
• blood tests, chest x-ray for differential diagnoses
• occupation
• past
• socioeconomic status
• risk factors
• family history
• NO day to day variation in symptoms
• peak flow is not diagnostic for COPD

Question 7

GOLD?

Answer 7

• cough several times most days
• bring up phlegm or mucus most days
• get out of breath more easily than other that age
• older than 40
• current or ex-smoker

yes to ≥3 = ask doctor if have COPD

Question 8

3 ways to assess COPD severity

Answer 8

1. MRC dyspnoea scale
   - assesses breathlessness
2. SGRQ - questionnaire out of 100
3. pack years = no. of cigs per day x no, of years smoked / 20 (in pack)
   - chest radiography for fibrotic changes
   - FBC
   - BMI
   - serum alpha-1 antitrypsin
   - CT scan
   sputum culture

Question 9

aim of COPD treatment

Answer 9

• reduction in frequency and severity of symptoms and exacerbations
• improvement in exercise tolerance
• progression quality of life

VACCINATIONS

Question 10

COPD treatment

Answer 10

SABA OR SAMA

No asthmatic feature/no steroid responsiveness:
LABA and LAMA

Day-to-day symptoms that impact quality of life
3 month trial of LAMA and LABA and ICS
(no improvement revert to LABA and LAMA)

1 severe/2 moderate exacerbations within a year
LABA and LAMA and ICS

Asthmatic feature/steroid responsiveness:
LABA and ICS

Day-to-day symptoms that impact quality of life or 1 severe/2 moderate exacerbations within a year:
LABA and LAMA and ICS

Question 11

managing COPD

Answer 11

• long-term oxygen therapy
  severe COPD in non-smokers
  breathe for >15 hours/day
  ambulatory oxygen - exercise desaturation
• pneumococcal and influenza vaccines
• mucolytics (thinner mucus, easier to cough up) eg - carbocisteine
• prophylactic antibiotics eg - azithromycin
• mental health (shallow breathing from anxiety can make COPD worse)
• diet
  overweight: breathlessness worse
  underweight: weakens immune system
• smoking cessation
• med adherence
• avoid air pollution (air fresheners, dust, smoke, hairspray)

Question 12

COPD treatments

Answer 12

• keep adding therapies and optimising doses
• we want to slow the decline (faster than normal, asthma is normal decline)
• pulmonary rehabilitation
• active cycle breathing technique - clears airways if you produce a lot of phlegm

techniques:
- relaxed, slow, deep breathing
- breathing through pursed lips as if whistling
- breathing hard when doing a activity that needs a big effort
- paced breathing using a rhythm in time with the activity

Question 13

what is a COPD exacerbation (acute)

Answer 13

• flare-up
• worsening of symptoms
• worsening breathlessness
• cough
• increased sputum production
• change in sputum colour/thickness

Question 14

treatment of exacerbations

Answer 14

primary care:
- rescue medication: antibiotics and oral corticosteroids (doxycycline and prednisolone)
- increase freq/dose of SABA
- consider nebuliser

secondary care:
- hospital if severe symptoms
- if poor response to treatment
- red flags
- follow up within first week out of hospital

Question 15

prevention of exacerbations

Answer 15

• self-management plan made with HCP
• stop smoking
  annual health review
• rescue medication
• recognise signs of flare up