Respiratory: COPD I

Question 1

Define COPD [1]

Answer 1

Chronic obstructive pulmonary disease (COPD) involves a long-term, progressive condition involving airway obstruction, chronic bronchitis and emphysema. It is almost always the result of smoking and is largely preventable.While it is not reversible, it is treatable.

Question 2

Define chronic bronchitis [1] and emphysema [1]

Answer 2

Chronic Bronchitis- the presence of chronic productive cough and sputum for at least 3 months in each of two successive years

Emphysema involves damage and dilatation of the alveolar sacs and alveoli,

Question 3

Describe the typical presentation of a COPD patient

Answer 3

A typical presentation of COPD is a long-term smoker with persistent symptoms of:

• Shortness of breath
• Cough
• Sputum production
• Wheeze
• Recurrent respiratory infections, particularly in winter
• Barrel chested

Question 4

Which symptoms does COPD not cause? [4]

Answer 4

Clubbing
Chest pain
Haemoptysis
Chest pain

If have these, investigate other diseases

Question 5

Describe the pathophysiology of COPD [5]

Answer 5

Inflammation
- Inhalation of noxious particles or gases, such as cigarette smoke or occupational irritants, triggers an inflammatory response in the airways and lung parenchyma.
- Causes infiltration of neutrophils, macrophages, and lymphocytes, leading to the release of pro-inflammatory cytokines and chemokines.

Protease-Antiprotease Imbalance
- Causes an imbalance between proteases (e.g., neutrophil elastase, matrix metalloproteinases) and antiproteases (e.g., alpha-1 antitrypsin, tissue inhibitors of metalloproteinases)
- The excess protease activity degrades extracellular matrix components, leading to the destruction of lung parenchyma and the development of emphysema.

Oxidative Stress:
- Toxins induce ROS
- ROS causes direct cellular damage, impair antiprotease activity, and promote inflammation

Airway Remodeling
- thickening of the airway wall
- increased mucus production
- goblet cell hyperplasia

Alveolar Destruction
- destruction of alveolar walls, leading to the formation of larger, less efficient airspaces and a reduction in the surface area available for gas exchange.

Question 6

Explain genetic disorder can lead to early onset COPD? [1]

Answer 6

Alpha-1 antitrypsin deficiency:
- reduced inhibition of neutrophil elastase, leading to uncontrolled protease activity and lung tissue destruction

Question 7

What are the 5 grades of the MRC dyspnoea scale? [5]

Answer 7

• Grade 1: Breathless on strenuous exercise
• Grade 2: Breathless on walking uphill
• Grade 3:Breathlessness that slows walking on the flat
• Grade 4: Breathlessness stops them from walking more than 100 meters on the flat
• Grade 5: Unable to leave the house due to breathlessness

mMRC ≥2

Question 8

What investigations would you conduct for COPD? [7]

Answer 8

Spirometry:
- FEV1/FVC < 70%

Pulse ox:
- low oxygen saturation
- In patients with chronic disease, an oxygen saturation of 88% to 90% may be acceptable.

CXR:
- hyperinflation
- bullae
- flat hemidiaphragm

COPD Assessment Test (CAT) or Modified British Medical Research Council (mMRC)
- mMRC ≥2 or CAT score ≥10 indicates higher symptoms burden

FBC
- polycythaemia (raised haemoglobin due to chronic hypoxia),
- anaemia
- infection & WBC count

BMI:
- weight loss occurs in severe disease

Serum alpha-1 antitrypsin
- look for alpha-1 antitrypsin deficiency

Question 9

What are common ECG changes might you see in COPD patients? [4]

Answer 9

• Rightward deviation of the P wave and QRS axis
• Low voltage QRS complexes, especially in the left precordial leads (V4-6)
• With development of cor pulmonale, right atrial enlargement (P pulmonale) and right ventricular hypertrophy
• Arrhythmias including multifocal atrial tachycardia

Question 10

State how the different severity scores for COPD are calculated [4]

Answer 10

The severity can be graded using the forced expiratory volume in 1 second (FEV1):

Stage 1 (mild):
- FEV1 more than 80% of predicted

Stage 2 (moderate):
- FEV1 50-79% of predicted

Stage 3 (severe):
- FEV1 30-49% of predicted

Stage 4 (very severe):
- FEV1 less than 30% of predicted

If the FEV1 is greater than 80% predicted but the post-bronchodilator FEV1/FVC is < 0.7 then this is classified as Stage 1 - mild. Symptoms should be present to diagnose COPD in these patients

Question 11

What is important to note about Stage 1 / mild COPD classification? [2]

Answer 11

If the FEV1 is greater than 80% predicted but the post-bronchodilator FEV1/FVC is < 0.7 then this is classified as Stage 1 - mild

symptoms should be present to diagnose COPD in these patients

Question 12

Which vaccines should COPD patients be offered? [2]

Answer 12

Patients should have the one off pneumococcal and annual flu vaccine.

Question 13

Label A-D for FEV1 (of predicted values) for COPD [4]

Answer 13

A: > 80%
B: 50-79%
C: 30-49%
D: < 30%

Question 14

Why is measuring PEF limited in COPD? [1]

Answer 14

Measuring peak expiratory flow is of limited value in COPD, as it may underestimate the degree of airflow obstruction.

Question 15

Describe the stepwise approach to treating COPD

Answer 15

First line treatment:
- SABA (salbutamol) or SAMA (e.g ipratropium bromide)

The next stage depends on whether the patient has asthmatic features / features suggesting steroid responsiveness

If NONE: use a combination:
- Add LABA AND LAMA regularly

If ASTHMATIC features:
- Add LABA & ICS regularly

Next stage for both:
- Use LABA AND LAMA AND ICS

Question 16

What are the determinants that decide if COPD is asthmatic or steroid responsive? [4]

Answer 16

• Previous diagnosis of asthma or atopy
• Variation in FEV1 of more than 400mls
• Diurnal variability in peak flow of more than 20%
• Raised blood eosinophil count

Question 17

Label A-E

Answer 17

Question 18

When is oral theophylline indicated for COPD treatment? [1]

Answer 18

NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy

Question 19

Polypharmacy of which drug classes with oral theophylline would cause the dose of theophylline to decrease [2]

Answer 19

the dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed

Question 20

Which antibiotic is given as oral prophylactic antibiotic therapy in some COPD patients? [1]

Answer 20

azithromycin prophylaxis is recommended in select patients

Question 21

Explain which further tests would you need to conduct if giving azithromycin prophylaxis? [4]

Answer 21

ECG:
- can cause QT prolongation

LFTs:
- Can cause liver injury

CT scan:
- to exclude bronchiectasis

Sputum culture:
- exclude atypical infections and tuberculosis

Question 22

Name a long-term risk of azithromycin use [1]

Answer 22

Long-term azithromycin use is associated with clinically significant hearing loss

Question 23

What need to consider before prescribig azithromycin in COPD patients? [1]

Answer 23

. Little evidence of treatment benefit is seen in
current smokers

Question 24

When are mucolytics indicated in COPD patients? [1]

Answer 24

Consider if have a chronic productive cough

Question 25

Name an example and describe the MoA of phosphodiesterase-4 (PDE-4) inhibitors in COPD

Answer 25

roflumilast:
- antiinflammatory and immunomodulatory effects in the pulmonary system due to increased levels of intracellular cyclic AMP

Question 26

When are roflumilast / PDE-4 inhibitors indicated in COPD treatment? [2]

Answer 26

FEV1 < 50%
AND
Ptx has two or more exacerbations in previous twelve months despitre triple therapy (LAMA; LABA & ICS)

Question 27

A 62-year-old man presents to his general practitioner (GP) with symptoms of exertional breathlessness, wheeze and cough. He has a 30 pack-year smoking history.

As part of the patient’s work-up, spirometry is requested:

FEV1/FVC ratio 0.61

Given the likely diagnosis, which of the following would be an appropriate first-line treatment?

Ipratropium

Formoterol

Salmeterol

Tiotropium

Beclometasone

Answer 27

Ipratropium

SAMA or SABA is first line COPD