COPD pre work (+asthma)

Question 1

COPD pathophys

Answer 1

• Treatable (not curable)
• Largely preventable
• Perisstent resp symptoms- breathlessness, cough, sputum
• Airflow obstruction
• Progressive, not fully reversible
• Chronic inflam - usually caused by exposure to tobacco spoke (can also be envitonment and occupational)

Question 2

Symptoms to suspect COPD

Answer 2

• Breathlessness - progressive, persistent, worse on exertion
• Wheeze
• Chronic/recurrent cough
• Regular sputum
• Freq LRTI

Can get:
* Weight loss, anorexia, fatigue
* Waking at night due to breathlessness
* Ankle swelling
* Chest pain
* Haemoptysis
* Reduced exercise tolerance

Question 3

Examination signs of COPD

Answer 3

• Cyanosis
• Raised JVP +/- peripheral oedema - cor pulmonale?
• Cachexia
• Hyperinflation of chest
• Use of accessory muscles +/- pursed lips breathing
• Wheeze +/- crackles on ausc

Question 4

RF for COPD

Answer 4

• Smoking
• Occupational/environmental exposures - dusts, fumes/chemicals
• Air pollution
• Genetics - alpha 1 antitrypsin
• Lung development problems in utero and childhoof
• Asthma

Question 5

Spiro findings COPD

Answer 5

• post BDR of less than 0.7 FEV1/FVC

Question 6

CXR findings COPD

Answer 6

• Enlarged lung fields
• Flattened diaphragm
• Air pockets (bullae)

Question 7

FBC and COPD results

Answer 7

• Elevated Ht and Hb - chronic hypoxia
• Elevated RBC count
• Elevated WBC if infection/inflammation
• Can change platelet count

Question 8

What is COPD and steroid responsiveness/asthmatic features?

Answer 8

• Higher blood eosinophil count
• Diagnosis of asthma or atopy
• Substantial variation in FEV1 over time (at least 400mls)
• Substantial diurnal variation in PEFR (at least 20%)

Question 9

When can COPD with asthmatic features/steroid responsiveness occur?

Answer 9

• Confirmed asthma but continues to smoke
• Other atopic conditions and develops COPD
• Person with COPD has raised eosinophil count

Question 10

Other tests when COPD suspected

Answer 10

• Alpha-1-antitrypsin
• Heart disease investigations - ECG, NT-proBNP, echo
• Other lung disease - CT thorax, sputum culture
• O2 sats

Question 11

Complications of COPD

Answer 11

• Exacerbations
• Cor pulmonale - pulmonary HTN from hypoxia, inflammation, loss of alveolar capillaries
• T1RF/T2RF
• Psychological problems and loss of functional ability

Question 12

Aims of COPD treatment

Answer 12

• Reduce symptoms
• Reduce exacerbations
• Improve QoL
• Prevent deterioration of lung function

Question 13

General management COPD

Answer 13

• Holistic approach - control other resp and cardiac risk factors eg weight, diet, exercise
• Smoking cessation

Question 14

Non-pharmacological advice to offer in COPD

Answer 14

• Healthy diet and physical activity - British Lung foundation or NHS COPD page
• Stop smoking
• Pneumococcal and flu vaccines
• Pulmonary rehab
• Personalised self management plan
• Optimise treatment of co-morbidities

Question 15

Vaccinations for COPD

Answer 15

• Pneumococcal vaccine
• Annual influenza

Question 16

What is pulmonary rehab and when should it be offered, any scenarios where not appropriate?

Answer 16

• Refer if functionally disabled by COPD - MRC 3 or above
• OR recent hospitalisation for exacerbation
• Do not refer if unable to walk or have unstable angina or recent MI

Question 17

When should LTOT be commenced?

Answer 17

• Not without specialist assessment - treatment for HYPOXAEMIA and NOT breathlessness
• Can improve survival if chronic hypoxia

Refer if:
* O2 sats 92% or less breathing air
* Very severe FEV1 (less than 30% predicted) or severe (FEV30-49%) airflow obsruction
* Cyanosis
* Polycythaemia
* Peripheral oedema
* Raised JVP
* Refer for ambulatory if mobile outdoors
* Warn people not to smoke - explosion risk but do not withdraw

Question 18

Pharmacotherapy for COPD - initial

Answer 18

• Either SABA or SAMA

Question 19

Second line COPD treatment fir patients without asthmatic features/steroid responsivness

Answer 19

• Offer LABA and LAMA - discontinue SAMA if LAMA is given
• SABA is continued at all stages
• If symptoms persist, severe exacerbation or 2 moderate exacerbations, consider addition of ICS (trial for 3 months if just for symptoms, others review annually)

Question 20

Step up treatment for those with asthmatic features/steroid responsive COPD

Answer 20

• LABA and ICS
• Review ICS annually
• If severe exacerbations or 2 moderate within 1 yr/daily symptoms consider adding LAMA (remove SAMA if originally started)

Question 21

What is severe vs moderate COPD exacerbation?

Answer 21

• Severe - hospitalisation
• Moderate - systemic corticosteroids +/- antibacterial treatment

Question 22

Features of acute COPD exacerbation

Answer 22

• Wheeze
• Cough
• Worsening breathlessness
• Increased sputum volume/purulence
• Fever without obvious source
• URTI in last 5 days
• Increased RR or HR 20% above baseline

Question 23

Severe exacerbation COPD features

Answer 23

• Marked breathlessness and tachypnoea
• Pursed lips breathing and or use of accessory muscles at rest
• New onset cyanosis or peripheral oedema
• Acute confusion/drowsiness
• Marked reduction in ADLs

Question 24

What should you do whilst waiting for emergency services in acute COPD exacerbation?

Answer 24

• Give O2 and monitor with pulse oximetry
• Otherwise initially give O2 via venturi 24% at 2-3L/min or 28% at 4L/min or nasal cannula at 1-2L/min (if 24% venturi not available)
• Target O2 sats 88-92% usually BUT not always - if not retainer, normal sat target

Question 25

If someone does not require admission for COPD, what treatments should you offer?

Answer 25

* Advise to increase doses/freq of short acting bronchodilators (not exceeding max dose) * Consider oral corticosteroids for breathlessness that is interefering with daily activity * Consider need for abx - sputum colour change/increased thickness?

Question 26

Safety netting for someone not admitted with COPD exacerbation

Answer 26

* Symptoms worsen (eg sputum changes/thickens) * Systemically unwell * Symptoms do not improve within given timeframe

Question 27

Follow up for someone with COPD exacerbation

Answer 27

* Reassess if symptoms worsen rapidly/significantly at any time * Send sputum sample for culture and sensitivity if not improving on given abx * Follow up when stable (eg 6 weeks post exacerbation onset)