COPD

Question 1

Define what COPD is

Answer 1

• It is a common progressive disorder characterised by airway obstruction (FEV1 < 80% & FEV1/FVC ratio < 0.7) with little or no reversibility.
• It encompasses both chronic bronchitis and emphysema

Question 2

What is COPD characterised by ?

Answer 2

• Characterised by airflow reduction that is in some patients partially reversible (with bronchodilators) but which progressively worsens as assessed by FEV1 and exacerbation of symptoms including cough and mucus production

Question 3

Define what chronic bronchitis is

Answer 3

• It is a clinical term defined clinically as cough and sputum production on most days for 3 months of 2 successive years.

Question 4

Define what emphysema is

Answer 4

• This is a pathological term defined histologically as enlarged air spaces distal to terminal bronchioles, with destruction of alveolar walls.

Question 5

What are the potential causes of COPD?

Answer 5

• Smoking! – 90% of cases
• Occupational exposure - cadmium (used in smelting), coal, cotton, cement, grain
• Genetics - alpha1-antitrypsin deficiency

Question 6

What are the general symptoms of COPD?

Answer 6

• Chronic cough: often productive (sputum production)
• Dyspnoea
• Wheeze

Question 7

What are the general signs of COPD?

Answer 7

• Tachypnoea – use of accessory muscles of respiration
• Hyperinflation
• Decreased cricosternal distance (<3cm)
• Decreased chest expansion
• Hyperresonant percussion note
• Quiet breath sounds
• Wheeze
• Cyanosis
• In severe cases, right-sided heart failure may develop resulting in peripheral oedema

Question 8

What features are generally suggestive someone has COPD rather than asthma:

Answer 8

• Age of onset > 35
• Smoker (active or passive)
• Or pollution related
• Minimal diurnal or day-to-day FEV1 variation

Question 9

How should you view COPD patients?

Answer 9

• As being on a spectrum with one side being chronic bronchitis and the other side being emphysema

Question 10

What are the signs/symptoms which would suggest more of a chronic bronchitis or emphysema aspect to someone’s COPD?

Answer 10

• Pink puffers have near normal PaO2 & a normal or low PaCO2. They are breathless but not cyanosed. They may progress to type I resp failure.
• Blue bloaters have a low PaO2 & a high PaCO2. They are cyanosed but not breathless. They may go on to develop cor pulmonale. They’re respiratory centres are insensitive to CO2 and they rely on hypoxic drive to maintain respiratory effort è supplementary O2 should be given with care (these are the ones a venturi mask is key for)

Question 11

What complications of COPD may arise?

Answer 11

• Acute exacerbations +/- infection
• Polycythaemia
• Respiratory failure
• Cor pulmonale (oedema, increased JVP)
• Pneumothorax
• Lung carcinoma

Question 12

What should be considered as the potential diagnosis in patients over 35 years of age who are smokers or ex-smokers and have symptoms such as exertional breathlessness, chronic cough or regular sputum production?

Answer 12

COPD

Question 13

What investigations should be done in someone with suspected COPD?

Answer 13

• CXR – hyperinflation (> 6 anterior ribs seen above hemidiaphragm), bullae, flat hemidiaphragm. Also, important to exclude lung cancer or other pathologies e.g. TB, bronchiectasis & HF
• FBC: to investigate for secondary polycythaemia caused by COPD, or anaemia

Question 14

What is the key investigation used to diagnose COPD?

Answer 14

• Spirometry (measured post-bronchodilator administration) – confirmation made if obstructive pattern seen – FEV1/FVC ratio < 70%

Question 15

How is the severity of COPD graded?

Answer 15

Question 16

What is the general management of COPD?

Answer 16

• Smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
• annual influenza vaccination
• one-off pneumococcal vaccination
• pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)

Question 17

What is 1^st line the treatment of COPD?

Answer 17

1^st line = a short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA)

Note - this is for patients with minimal symptoms, preserved lung function (FEV1 > 80% predicted) and few (if any) exacerbations, a SAMA or SABA should be prescribed as monotherapy (without the need for any other inhaled treatment)

Question 18

For patients who remain breathless or have exacerbations despite 1st line treatment of COPD, what does the next steps in treatment choice depend on ?

Answer 18

Whether the patient has ‘asthmatic features/features suggesting steroid responsiveness’ or not

Question 19

What different features/criteria can be used to determine if a COPD patient has asthmatic features suggesting steroid responsiveness or not ?

Answer 19

• Any previous, secure diagnosis of asthma or of atopy
• a higher blood eosinophil count (blood eosinophilia > 4%) - note that NICE recommend a full blood count for all patients as part of the work-up
• substantial variation in FEV1 over time (at least 400 ml)
• substantial diurnal variation in peak expiratory flow (at least 20%)

Note - in lectures this overlap of the 2 syndromes if referred to as ACO (asthma COPD overlap syndrome)

Question 20

What is the further treatment of COPD after 1st line treatment if they have No asthmatic features/features suggesting steroid responsiveness?

Answer 20

• 1^st line = add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA) + SABA (if already taking a SAMA stop and switch to SABA)
• 2^nd line = consider adding in ICS

Guidelines and licensing authorities generally indicate that co-administration of ICS should be considered in patients with FEV1 < 60% predicted (in a combination inhaler with a LABA) who experience frequent (≥2 per year) exacerbations

Question 21

What is the further treatment of COPD after 1st line treatment if they have asthmatic features suggesting steroid responsiveness?

Answer 21

• 1^st line = LABA + inhaled corticosteroid (ICS) (+ SAMA or SABA)
• 2^nd line = if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS (if already taking a SAMA, discontinue and switch to a SABA)

Question 22

What are the signs of an acute exacerbation of COPD?

Answer 22

• increase in dyspnoea, cough, wheeze
• there may be an increase in sputum suggestive of an infective cause
• patients may be hypoxic and, in some cases, have acute confusion

Question 23

What is the treatment of acute exacerbations of COPD?

Answer 23

• Give oxygen use a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92%
• 1^st line = Increase frequency of bronchodilator use and consider giving via a nebuliser (salbutamol & ipratropium) + Give prednisolone daily for 5 days
• Review if they need to be given antibiotics

Question 24

What Ix’s should be carried out in somoene with a possible exacerbation of COPD ?

Answer 24

• ABG’s
• CXR
• ECG
• Baseline bloods including CRP

Question 25

Why is it important to perform a CXR in someone with suspected exacerbation of COPD ?

Answer 25

**To look for signs of pneumonia, and** because they may have a pneumothorax which would influence their Mx.

Question 26

When should antibiotics be given in an acute exacerbation of COPD and what are the 1^st & 2^nd line choices:

Answer 26

Give antibiotics if ↑ sputum purulence. If no ↑ sputum purulence, then no antibiotics unless consolidation on CXR or signs of pneumonia * 1^st line = amoxicillin * 2^nd line = doxycycline

Question 27

What is the main causative organism of infective exacerbations of COPD?

Answer 27

* Haemophilus influenzae (most common cause)

Question 28

Even if a patient has COPD if they are critically ill (anaphylaxis, shock etc) how should oxygen be delivered?

Answer 28

* **It should be given via a reservoir mask at 15 l/min (high flow). Hypoxia kills.**

Question 29

Go over this summary slide