Respiratory

Question 1

Define COPD.

Answer 1

COPD is an umbrella term for two disease phenotypes:

1. chronic bronchitis –> chronic, productive cough most days of the week for at least three months per year for the last TWO consecutive years
2. emphysema –> loss of elastic recoil leading to increased air trapping, hyperinflation and reduced surface area for gas exchange to occur

Both of these conditions are characterised by FEV1 / FVC < 70% with NO reversibility on lung function tests.

Question 2

What are the severity gradings of COPD?

Answer 2

Mild: between 60 to 80%

Moderate: between 40 to 60%

Severe: < 40%

Question 3

What are the two types of EMPHYSEMA?

Answer 3

PANACINAR
✔️ affects predominately non-smokers (alpha1-AT deficiency)
✔️ younger patients
✔️ lower-lobe involvement

CENTRI-ACRINOA
✔️ affects smokers
✔️ upper-lobe involvement

Question 4

Risk factors for COPD?

Answer 4

✔️ history of tobacco smoking (20+ pack year history)
✔️ history of second-hand smoke exposure
✔️ environmental pollution exposure
✔️ occupational exposure 
✔️ low birth weight
✔️ prematurity 
✔️ history of chronic lung disease
✔️ alpha-1 AT deficiency (family history of lung disease)

Question 5

Complications of COPD?

Answer 5

✔️ atrial fibrillation
✔️ right sided heart failure
✔️ pulmonary hypertension
✔️ lung cancer (non small cell lung cancer, squamous cell lung cancer)
✔️ secondary pneumothorax
✔️ respiratory failure

Question 6

What are the requirements for antibiotic therapy in IECOPD?

Answer 6

1. increased cough / dyspnoea
2. increased production of sputum
3. increased sputum purulence

Amoxicillin 500mg BD for 5 to 7 days.

Question 7

Outline appropriate lifestyle / non-pharmacological management options for COPD.

Answer 7

✔️ smoking cessation
✔️ chest physiological
✔️ vaccination (influenza, pneumococcal, shingles)
✔️ appropriate nutrition to avoid malnutrition –> significantly affects outcomes
✔️ appropriate physical activity
✔️ address co-morbidities (e.g. OSA, heart disease, GORD, depression)

Question 8

Outline appropriate pharmacological options for COPD.

Answer 8

STEP ONE (MILD COPD)
✔️ inhaled SABA, as required (e.g. salbutamol)

STEP TWO (MODERATE COPD)
✔️ inhaled LAMA / LAMA (e.g. tiotropium, salmeterol)

STEP THREE (SEVERE COPD)
✔️ ICS / LAMA / LABA

Indications for ICS therapy include:
✔️ severe COPD (FEV1 < 40% predicted value)
✔️ previous positive response to ICS
✔️ more than two exacerbations requiring oral corticosteroids in 12 months

Question 9

Indications for HOME OXYGEN THERAPY?

Answer 9

✔️ oxygen saturation < 88%
✔️ PaO2 < 55mmHg
✔️ PaO2 between 55 to 65 mmHg and symptomatic

Home oxygen should be left on for a minimum of 15 hours per day, as close to 24 hours per day as possible.

Question 10

Outline management of EXACERBATION OF COPD.

Answer 10

1. Antibiotic therapy, if required
   ✔️ increased / worsening cough or SOB
   ✔️ increased sputum production
   ✔️ increased sputum purulence

Amoxicillin 500mg BD PO for 5 to 7 days.

2. Oxygen if < 92%
   ✔️ 2L per minute
   ✔️ titrate for sats between 88 to 92%
3. Salbutamol (nebulised or inhaled)
   ✔️ 8 to 10 puffs of 100microg per puff
4. Ipatropium bromide (nebulised or inhaled)
   ✔️ 6 to 8 puffs of 21microg per puff
5. Oral corticosteroids
   ✔️ prednisolone 30 to 50mg PO for 7 to 14 days OR
   ✔️ hydrocortisone IV if oral not tolerable

Question 11

Define OBSTRUCTIVE SLEEP APONEA. What is the diagnostic criteria for OSA.

Answer 11

OSA is the most common sleep disorder characterised by multiple apnea / hypopnea events during the night leading to poor quality / non-restorative sleep, increased daytime sleeping and increased risk of numerous metabolic and systemic conditions.

If SYMPTOMATIC, > 5 AHI per hour is required on sleep study for diagnosis.

If ASYMPTOMATIC, >15 AHI per hour is required on sleep study for diagnosis.

Question 12

How is severity of OSA classified.

Answer 12

Severity of OSA is based on AHI per hour.

Mild: 5 to 15 events per hour
Moderate: 15 to 30 events per hour
Severe: > 30 events per hour

Question 13

Identify risk factors for OSA.

Answer 13

✔️ obesity 
✔️ male gender
✔️ increasing age
✔️ craniofacial abnormalities 
✔️ smoking or alcohol

Question 14

Outline clinical presentation of OSA.

Answer 14

✔️ increased day time sleepiness
✔️ poor-quality sleep / non-restorative / restless
✔️ observed choking, apnea or snoring during sleep
✔️ morning time headache
✔️ nocturia

Question 15

What do each of the components of STOP BANG stand for?

Answer 15

S - snoring
T - tired during the day
O - observed apnea / choking / snoring
P - pressure (being treated for HTN)

B - BMI > 35
A - age > 50 years
N - neck size large
G - gender (male)

Low risk 0 to 2
Moderate risk 3 to 4
High risk > 5

Question 16

Complications of OSA?

Answer 16

✔️ increased risk MVA 
✔️ HTN
✔️ metabolic syndrome + T2DM
✔️ right sided heart disease
✔️ atrial fibrillation
✔️ pulmonary hypertension
✔️ NAFLD