Respiratory

Question 1

What generic measures should be taken for those with stable COPD?

Answer 1

• smoking cessation advice - offer nicotine replacement, varenicline or bupropion.
• Annual influenza vaccine
• one off pneumococcal vaccine.
• pulmonary rehab - for those who view themselves functionally disabled by COPD, usually MRC of 3 or more.

Question 2

Which Bronchodilators would you use for stable COPD patients?

Answer 2

• SABA or SAMA is first line.
• for those who remain SoB or have exacerbations despite these, the next step would depend on whether they have ‘asthmatic features/ features suggestive of steroid responsiveness’.

Question 3

How would you determine if a COPD patient has asthmatic/steroid responsiveness features?

Answer 3

• Any previous, secure diagnosis of asthma or atopy.
• Eosinophilia on FBC.
• Variation in FEV1 over time (at least 400ml)
• diurnal variation in PEF (at least 20%).

Question 4

for those COPD pts not stable on single SABA or SAMA and who don’t have asthmatic/steroid-responsive features, what other bronchodilator options would you consider next?

Answer 4

• Add on LABA + LAMA

a) if already on SAMA - discontinue and switch to SABA.

Question 5

for those COPD pts not stable on single SABA or SAMA and who DO have asthmatic/steroid-responsive features, what other bronchodilator options would you consider next?

Answer 5

• LABA + ICS
• if remains breathless/ has exacerbation with above: offer triple therapy of LABA + LAMA + ICS (if already taking SAMA, discontinue and switch to SABA).

Question 6

When do we consider oral theophylline in stable COPD patients?

Answer 6

• after trials of short and long-acting bronchodilator, or those who cannot use inhaled therapy.
• dose should be reduced if macrolide (e.g. clarithromycin, erythromycin, aithromycin) or fluoroquinolone (e.g. cipro, levofloxacin) abx are co-prescribed.

Question 7

When would you consider giving prophylactic antibiotics for COPD patients?

Answer 7

• Azithromycin is recommended in selected patients:
• pts shouldn’t smoke and have optimised treatment and still continue to have exacerbations.
• CT thorax to exclude bronchiectasis and sputum mcs to exclude atypical infections and TB.
• LFTs and ECG (to exclude long QT).

Question 8

How do we manage Cor pulmonale in COPD patients?

Answer 8

• use loop diuretics for oedema, consider long-term O2 therapy.
• ACEi, Ca-channel blocker, alpha-blockers not recommended.

Question 9

What factors improve survival in COPD patients?

Answer 9

• smoking cessation - most important.
• LTOT in pts who fit criteria.
• Lung volume reduction surgery in selected pts.