Respiratory - COPD

Question 1

What is COPD?

Answer 1

Long-term progressive condition
- Airway obstruction
- Chronic bronchitis
- Emphysema

Treatable but not reversible

Question 2

What is chronic bronchitis?

Answer 2

Long-term symptoms of a cough and sputum production due to inflammation of the bronchi

Question 3

What is emphysema?

Answer 3

Damage and dilatation of the alveolar sacs and alveoli decreasing surface area for gas exchange

Question 4

How reversible is airway obstruction?

Answer 4

Minimally reversible, patients susceptible to exacerbations

Question 5

How does COPD present?

Answer 5

Long-term smoker with:
- SOB
- Cough
- Sputum production
- Wheeze
- Recurrent respiratory infections especially in winter

Question 6

What is the MRC Dyspnoea scale?

Answer 6

5-point scale for breathlessness
1- Strenuous exercise
2- Walking uphill
3- Breathlessness that slows walking on the flat
4- Can’t walk more than 100m
5- Can’t leave the house

Question 7

How is COPD diagnosed?

Answer 7

Clinical presentation
Spirometry

Question 8

What does COPD show with spirometry?

Answer 8

Obstructive picture

Little or no response to reversibility

Question 9

How is severity of COPD graded?

Answer 9

FEV1
Stage 1 (mild)- FEV1 more than 80% predicted
Stage 2 (moderate)- FEV1 50-79%
Stage 3 (severe)- FEV1 30-49%
Stage 4 (very severe)- FEV1 under 30%

Question 10

What other investigations are done for COPD?

Answer 10

BMI
CXR
FBC, for polycythaemia, raised Hb due to chronic hypoxia, anaemia and infection
Sputum culture
ECG
CT thorax
Serum alpha-1 antitrypsin
Transfer factor for carbon monoxide

Question 11

What is the long-term management of COPD?

Answer 11

Smoking cessation
Pneumococcal and annual flu vaccine
Pulmonary rehabilitation
Medical treatment

Question 12

What is pulmonary rehabilitation?

Answer 12

MDT approach to help improve function and QoL including exercise, lifestyle advice and education

Question 13

What is the initial medical treatment for COPD?

Answer 13

SABA (salbutamol)
SAMA (ipratropium bromide)

Question 14

What is the second step of COPD medical treatment determined by?

Answer 14

If there are asthmatic of steroid responsive features
- Previous asthma diagnosis
- Variation of FEV1 more than 400 mls
- Diurnal variation in peak flow
- Raised eosinophil count

No asthmatic or steroid features
- LABA
- LAMA
Anoro Ellipta

Asthmatic or steroid features
- LABA
- ICS
Fostair, Symbicort

Question 15

What is the final step for COPD management?

Answer 15

LABA
LAMA
ICS

Trimbow inhaler

More severe cases use
- Nebulisers
- Oral theophylline
- Oral mucolytics (carbocisteine)
- Prophylactic antibiotics e.g. azithromycin (will need ECG and liver function before starting)

Question 16

When is long-term oxygen therapy used?

Answer 16

Severe COPD
- Chronic hypoxia
- Polycythaemia
- Cyanosis
- Cor pulmonale

Cannot give to smokers due to fire risk

Question 17

What causes Cor pulmonale?

Answer 17

Pulmonary hypertension

Limits RV pumping into pulmonary arteries causing back-pressure into RA, vena cava and systemic venous system

Question 18

What conditions cause cor pulmonale?

Answer 18

COPD
PE
Interstitial lung disease
CF
Primary pulmonary hypertension

Question 19

What are the signs of cor pulmonale on examination?

Answer 19

COR PULM
Cyanosis
Oedema
Raised JVP

Parasternal heave
Underperfused
Loud second heart sound
Murmurs

Question 20

What is a common trigger of a COPD exacerbation?

Answer 20

Viral or bacterial infection

Question 21

What does an acute exacerbation of COPD look like on an ABG?

Answer 21

Low pH
Low pO2
Raised pCO2
Raised bicarbonate

Question 22

Why are the target sats 88-92% for COPD oxygen therapy?

Answer 22

Patients have chronic hypoxia

Sudden increase in oxygen will cause the respiratory drive to decrease

This causes a rise in carbon dioxide causing oxygen-induced hypercapnia

Can only increase oxygen sats to 94-98% if they do not retain CO2

Question 23

What masks are used for COPD oxygen therapy?

Answer 23

Venturi

Can deliver specific oxygen concentration

Question 24

What is the management of an acute exacerbation of COPD?

Answer 24

Inhalers or nebulisers
Steroids (prednisolone for 5 days)
Antibiotics if evidence of infection
Respiratory physiotherapy

Question 25

How are severe acute exacerbations of COPD managed?

Answer 25

IV aminophylline
Non-invasive ventilation
Intubation and ventilation and admission to ICU

Doxopram, respiratory stimulant if NIV or intubation not suitable

Question 26

What are the criteria for using non-invasive ventilation?

Answer 26

Persistent respiratory acidosis
Potential to recover

Question 27

What are the contraindications to NIV?

Answer 27

Untreated pneumothorax
Structural pathology in face, airway or GI tract

Question 28

When using NIV what must be done until acidosis resolves?

Answer 28

Hourly ABGs
IPAP increase until acidosis resolves