chronic obstructive pulmonary disease

Question 1

what is COPD? 2

Answer 1

• preventable and treatable disease characterised by persistent progressive airflow limitation (not fully reversible)
• enhanced chronic inflammatory response in the lungs to noxious gases/ particles
• rising prevalence due to ageing population

Question 2

how can airways narrow? 3

Answer 2

• large airway inflammation- chronic inflammation of the bronchi causing inflammation and changes to the mucocilliary escalator, often resulting in a chronic cough (chronic bronchitis)
• emphysema- airways collapse due to destruction of alveolar walls- may lead to bullae
• small airways- due to bronchoconstriction and inflammation; duration and severity are risk factors for development of airway remodelling and COPD

Question 3

what happens to the airways in COPD? 6

Answer 3

• chronic inflammation
• increased number of goblet cells
• mucus cell hyperplasia
• fibrosis
• narrowing and reduction in the number of small airways
• airways collapse due to alveolar wall destruction in emphysema

Question 4

what do symptoms we need to diagnose COPD? 3

Answer 4

• chronic bronchitis= chronic productive cough for three months in 2 successive years, exclude other causes of chronic cough
• emphysema (alveolar)= abnormal and permanent enlargement of the airspaces due to the destruction of the alveolar airspace walls- effect gas exchange
• small airways disease= wheeze

Question 5

what are the risk factors for COPD? 8

Answer 5

• cigarette smoke
• occupational dust and chemicals
• environmental tobacco smoke
• indoor and outdoor air pollution
• genes
• infections
• socio-economic status
• ageing populations

Question 6

describe smoking history and COPD? 4

Answer 6

• age started
• calculate pack year history (smoking 20 cigarettes per day for a whole year)
• times stopped and why the attempt to quit failed
• recreational drugs smoked (or other substances e.g. shisha)

Question 7

how do we make a COPD diagnosis? 3

Answer 7

• symptoms (exertion breathlessness, productive cough, wheeze)
• risk factors (10 packs year smoking history and age over 35)
• spirometry (FEV1/FCV<0.7)

Question 8

what are the physical signs of COPD? 8

Answer 8

• barrel-shaped chest
• hyper resonant percussion
• accessory muscles
• prolonged expiraltion
• pursed lip breathing
• tripod position
• low BMI
• nicotine staining

Question 9

what are the physiological effects of COPD? 4

Answer 9

• increased work of breathing
• reduced exercise tolerance
• impaired gas exchange- hypoxia, hypercapnia, raised pulmonary artery pressure, RV dilation
• loss of fat free mass

Question 10

how do you manage chronic COPD? 7

Answer 10

• stop smoking
• if symptomatic LABA/LAMA combined inhaler
• flu vaccination
• educate and empower
• treat exacerbations
• pulmonary rehabilitation
• think about the whole patient (bone, nutrition, metal health)

Question 11

what is pulmonary rehabilitation? 4

Answer 11

• 2x supervised sessions for 6 weeks
• supervised exercise
• education
• psychological support/ group work

Question 12

name some additional treatments for COPD? 4

Answer 12

• theophylline (oral phosphodiesterase inhibitor)
• azithromycin 3 x a week (anti-inflammatory antibiotic prophylaxis)
• lung volume reduction surgery (valves/bullectomy)
• lung transplantation

Question 13

what is an acute exacerbation of COPD? 4

Answer 13

• acute deterioration in symptoms requiring additional therapy
• mild (SABA)
• moderate (SABA + steroids + antibiotics)
• severe (hospital admission)

Question 14

describe the events of a severe COPD exacerbation? 7

Answer 14

• ED attendance due to progressive dyspnoea/ hypoxia or signs of infection or signs of right heart failure
• antibiotics if there are signs of infection (sputa results)
• oral steroids
• target saturations 88-92% (controlled oxygen)
• nebulisers (bronchodilate)
• consider diuretics
• nicotine replacement therapy/ refer for smoking cessation

Question 15

what happens if treatment for COPD fails? 3

Answer 15

• decompensated hypercapnic respiratory failure despite controlled oxygen and nebulised treatments –> non-invasive ventilation
• respiratory failure despite nebulised therapy and controlled oxygen and patient unable to tolerate NIV–> consider invasive mechanical ventilation
• respiratory failure on background of significant progressive decline over several months or years with no evidence of reversible event–> palliate

Question 16

explain symptom control for COPD? 7

Answer 16

• oromorph
• lorazepam
• fan therapy
• oxygen therapy
• CBT
• pacing/breathing strategies
• hospice input