COPD (RESP)

Question 1

Define chronic obstructive pulmonary disease.

Answer 1

Heterogeneous progressive lung disease characterised by chronic respiratory symptoms and airflow limitation that is not fully reversible

Question 2

What does COPD encompass? (3)

Answer 2

• chronic bronchitis - chronic narrowing of airways defined clinically as a productive cough on most days for at least 3 months per year for 2 consecutive years
• emphysema - permanent destructive enlargement of air spaces distal to the terminal bronchioles
• bronchiolitis (small airways disease)

Question 3

Define chronic bronchitis (COPD).

Answer 3

Chronic narrowing of airways defined clinically as a productive cough on most days for at least 3 months per year for 2 consecutive years

(Exposure to irritants –> hypertrophy and hyperplasia + increased mucus production –> obstruction)

Question 4

Define emphysema (COPD).

Answer 4

Permanent destructive enlargement of air spaces distal to the terminal bronchioles

(Inflammatory reaction to irritants –> enzymes break down collagen and elastin –> alveoli enlarge and lose recoil elasticity that keeps them open)

Question 5

What is the bronchial and alveolar damage in COPD caused by?

Answer 5

Environmental toxins (cigarette smoke, dust, NO2) –> activates innate and adaptive immune responses to long term exposure to noxious particles and gases

Question 6

Describe compliance and resistance of the lungs in COPD.

Answer 6

• increased resistance to airflow in small conducting airways
• increased compliance of lungs
• progressive airflow obstruction

Question 7

Describe the epidemiology of COPD. (3)

Answer 7

• M>F
• age >65
• smokers

Question 8

What are the main causes of COPD? (3)

Answer 8

• smoking - most common
• exposure to air pollution
• alpha-1-antitrypsin deficiency (in younger non-smoker patients)

Question 9

How can alpha-1-antitrypsin deficiency cause COPD?

Answer 9

• inhibited action of neutrophil elastase –> emphysema
• may be accompanied by symptoms of cirrhosis

Question 10

What condition, other than COPD, is alpha-1-antitrypsin deficiency a risk factor for?

Answer 10

Hepatocellular carcinoma

Question 11

What management can be done in late stage alpha-1-antitrypsin deficiency?

Answer 11

Lung volume reduction surgery

Question 12

What are some signs and symptoms of COPD?

Answer 12

• progressive SOB
• wheeze
• chronic cough
  
  • productive, white/clear sputum (yellow = exacerbation/infection)
• sputum production
• reduced exercise tolerance
• dyspnoea and tachypnoea
• cyanosis
• low oxygen sats <92%
• late stage - raised JVP, peripheral oedema

Question 13

What are some clinical findings on inspection of a COPD patient? (6)

Answer 13

• respiratory distress
• use of accessory muscles (tripod position)
• pursed lip breathing
• barrel-shaped, over-inflated chest
• decreased cricosternal distance
• cyanosis

Question 14

What are some clinical findings on palpation of a COPD patient?

Answer 14

Reduced chest expansion bilaterally

Question 15

What are some clinical findings on percussion of a COPD patient? (2)

Answer 15

• hyper-resonant chest
• loss of liver and cardiac dullness

Question 16

What are some clinical findings on auscultation of a COPD patient? (6)

Answer 16

• distant (quiet) breath sounds
• prolonged expiration
• wheeze
• rhonchi - rattling, continuous and low-pitched breath sounds (like snoring) due to secretions/obstructions
• crepitations
• coarse crackles

Question 17

What are some signs of CO2 retention in COPD? (3)

Answer 17

• bounding pulse
• warm peripheries
• asterixis (hand flap)

Question 18

What are some signs of late stage COPD (Cor Pulmonale)? (3)

Answer 18

• right ventricular haeve
• raised JVP
• ankle oedema

Question 19

What are some non-modifiable risk factors for COPD? (4)

Answer 19

• male sex
• advanced age
• white ancestry
• genetic factors / developmentally abnormal lung

Question 20

What are some modifiable risk factors for COPD? (4)

Answer 20

• smoking - makes cilia short and less mobile
• occupational exposure (dust, chemicals, vapours, fumes, gases)
• environmental (tobacco smoke, air pollution, indoor solid fuel burning)
• Fx or PMHx of chronic lung disease

Question 21

What are the gold standard investigations for COPD?

Answer 21

Spirometry and pulmonary function tests

Question 22

What are the first-line investigations for COPD?

Answer 22

• spirometry
• standardised symptoms score
• pulse oximetry
• ABG
• CXR
• FBC

Question 23

What does (post-bronchodilator) spirometry + pulmonary function tests show for COPD?

Answer 23

• FEV1/FVC ratio <0.7
• no bronchodilator reversibility (unlike asthma)
• significantly reduced FEV1 (<80% predicted), slightly reduced/normal FVC
• TLC normal/high

Question 24

How can COPD be classified by severity based on FEV1?
(FEV1/FVC<0.7 for all)

Answer 24

• GOLD 1 (mild): FEV1>80% predicted + symptoms
• GOLD 2 (moderate): 50%<FEV1<79% predicted
• GOLD 3 (severe): 30%<FEV1<49% predicted
• GOLD 4 (very severe): FEV1<30% predicted

Question 25

What does a chest x-ray show for COPD? (7)

Answer 25

- hyperinflation (>6 anterior ribs seen above diaphragm) - flat hemidiaphragm - reduced peripheral lung markings - large central pulmonary arteries - bullae (if large may mimic pneumothorax) - hyperlucent lung fields - elongated cardiac silhouette

Question 26

When do we do ECG and echocardiogram for COPD?

Answer 26

Check for Cor Pulmonale - right atrial and ventricular hypertrophy

Question 27

When do we test alpha-1-antitrypsin levels in COPD?

Answer 27

In young patients who have never smoked

Question 28

What would we see on CT for A1AT deficiency compared to COPD?

Answer 28

- A1AT deficiency - emphysema in lower lobes - COPD - emphysema in upper lobes

Question 29

Why do we do FBC for COPD?

Answer 29

- assess severity of exacerbation - may show: polycythaemia (haematocrit >55%), anaemia and leukocytosis

Question 30

When do we do ABG for COPD?

Answer 30

- if acute exacerbation to check O2 and CO2 levels - COPD causes CO2 retention --> type 2 respiratory failure - PaCO2>50mmHg and/or PaO2<60mmHg = respiratory insufficiency

Question 31

What are some differential diagnoses for COPD?

Answer 31

- asthma - congestive heart failure - orthopnoea, bibasilar inspiratory crackles, BNP - bronchiectasis - recurrent childhood infections, sputum, bronchial dilation - TB - fever, night sweats, weight loss - bronchiolitis - PFTs restrictive/mixed, younger - upper airway dysfunction - chronic sinusitis/postnasal drip - sinus pressure, rhinorrhoea, headache - GORD - ACEi induced chronic cough - lung cancer (do CXR)

Question 32

Describe the GOLD group method for categorising risk of exacerbations of COPD.

Answer 32

- GOLD group A: low risk (0-1 exacerbations per year, not requiring hospitalisation) and fewer symptoms (CAT<10) - GOLD group B: low risk (0-1 exacerbations per year, not requiring hospitalisation) and more symptoms (CAT>=10) - GOLD group E: high risk (>/=2 exacerbations per year or >/=1 requiring hospitalisation) and any level of symptoms

Question 33

What is the first step of management for any patient with COPD?

Answer 33

Smoking cessation - NRT (especially in pregnant women as varenicline and bupropion contraindicated) - varenicline - bupropion (contraindicated in epilepsy patients)

Question 34

What are some non-pharmacological management methods for COPD? (3)

Answer 34

- annual influenza vaccine - one-off pneumococcal vaccine - pulmonary rehabilitation in patients who view themselves as functionally disabled by COPD

Question 35

What is an example of a SABA (COPD)?

Answer 35

Salbutamol sulfate

Question 36

What is an example of a SAMA (COPD)?

Answer 36

Ipratropium bromide

Question 37

What is an example of a LABA (COPD)?

Answer 37

Salmeterol, Olodaterol (ultra long-lasting)

Question 38

What is an example of a LAMA (COPD)?

Answer 38

Tiotropium bromide

Question 39

What are some examples of a ICS (COPD), and when do we use these?

Answer 39

- budesonide, beclomethasone, fluticasone, mometasone - consider if Hx of asthma, or blood eosinophils >300

Question 40

What is the first-line treatment for GOLD group A, B and E COPD?

Answer 40

- GOLD group A: SABA/SAMA/LABA/LAMA - GOLD group B: LABA+LAMA plus SABA/SAMA - GOLD group E: LABA+LAMA or LABA+LAMA+ICS plus SABA/SAMA

Question 41

What is the first-line treatment for GOLD group A/B/E COPD if persistent dyspnoea/exercise limitation after initial therapy?

Answer 41

- LABA+LAMA - plus SABA/SAMA - consider O2 therapy/ventilatory support - consider mucolytic (e.g. acetylcysteine if chronic bronchitis) - consider theophylline - consider bronchoscopic intervention/surgery - supportive care + pulmonary rehabilitation + palliative care

Question 42

What is the first-line treatment for GOLD group A/B/E COPD if persistent exacerbations after initial therapy?

Answer 42

- LABA+LAMA or LABA+LAMA+ICS - plus SABA/SAMA - consider O2 therapy/ventilatory support - consider **roflumilast** (oral phosphodiesterase-4 inhibitor if FEV1<50% and chronic bronchitis) - consider **azithromycin** - consider mucolytic

Question 43

What are the 4 asthmatic features of COPD?

Answer 43

- Hx of asthma or atopy - eosinophilia - FEV1 variability min. 400ml - diurnal variation in peak flow min. 20%

Question 44

Describe the general **first-line** treatment algorithm for COPD.

Answer 44

- 1st line: bronchodilators - SABA or SAMA - 2nd line if no asthmatic features/steroid responsiveness: add LABA+LAMA (if on SAMA, change to SABA) - 2nd line if asthmatic features/steroid responsiveness: add LABA+ICS, have SABA/SAMA as required - 3rd line final step: LABA+LAMA+ICS triple therapy if patients remain breathless/exacerbations (if already taking SAMA, discontinue and switch to SABA)

Question 45

How do we manage an acute exacerbation of COPD?

Answer 45

- controlled O2 therapy: 24% Venturi mask - aim for sats 88-92% for hypercapnia, 94-98% if pCO2 normal, PaO2>8kPa - nebulised bronchodilators (salbutamol + ipratropium bromide) - corticosteroids (oral prednisolone for 5 days or IV hydrocortisone if clinically unstable) - IV theophylline - Abx - if evidence of infection e.g. green sputum, signs of pneumonia --> amoxicillin, doxycycline or clarithromycin - NIV (BiPAP) - if respiratory acidosis with high CO2 despite maximum medical treatment, pH 7.25-7.35

Question 46

When is clarithromycin contraindicated?

Answer 46

Prolonged QT interval

Question 47

What oral prophylactic Abx therapy is there for COPD and when do we use this?

Answer 47

Azithromycin, if they meet criteria for recurrent infections: - patient should not smoke - have optimised standard treatments - continue to have exacerbations (3+ requiring steroids, and 1+ requiring hospital in past year) - (CT thorax - exclude bronchiectasis) - (sputum culture - exclude atypical infections and TB)

Question 48

What should you be careful of when giving azithromycin?

Answer 48

Can cause QT interval prolongation --> request ECG

Question 49

What is the most common cause of an acute exacerbation of COPD?

Answer 49

Haemophilus influenzae

Question 50

What do you give to critically ill (including CO2 retaining) COPD patients?

Answer 50

High flow oxygen --> reservoir mask at 15L/min

Question 51

Who do we offer long term oxygen therapy to (LTOT) for COPD?

Answer 51

- assess ABG on two occasions at least 3 weeks apart to show: - pO2 <7.3kPa - OR pO2 7.3-8kPa AND secondary polycythaemia/peripheral oedema/pulmonary hypertension

Question 52

Why can supplemental oxygen be harmful to COPD patients?

Answer 52

- reduces respiratory drive --> hypoventilation --> CO2 retention - patient will often already have chronic respiratory acidosis indicated by raised HCO3-

Question 53

When is oral theophylline recommended for COPD and what should we check first?

Answer 53

- NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy - check U&Es and LFTs before starting - dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed

Question 54

When should mucolytics be considered for COPD?

Answer 54

In patients with a chronic productive cough and continued if symptoms improve

Question 55

When should PDE-4 inhibitors be considered for COPD?

Answer 55

- oral PDE-4 inhibitors such as **roflumilast** reduce the risk of COPD exacerbations in patients with severe COPD and a history of frequent COPD exacerbations - NICE recommend if: - the disease is severe, defined as a forced expiratory volume in 1 second **(FEV1<50%)** after a bronchodilator of less than 50% of predicted normal, and - the person has had **2 or more exacerbations** in the previous 12 months despite triple inhaled therapy with a long-acting muscarinic antagonist, a long-acting beta-2 agonist and an inhaled corticosteroid (LABA+LAMA+ICS)

Question 56

What do we give COPD patients with frequent exacerbations to take home? (2)

Answer 56

- antibiotics - prednisolone

Question 57

What are some complications of COPD?

Answer 57

- Cor Pulmonale (right-sided heart failure) - recurrent pneumonia - depression - lung cancer - pneumothorax (secondary to bullae rupture) - respiratory failure - anaemia - polycythaemia - receiving too much O2 --> acute respiratory acidosis on top of chronic acidosis with compensatory metabolic alkalosis (= elevated HCO3-)

Question 58

How do we manage Cor Pulmonale (right-sided heart failure) due to COPD? (2)

Answer 58

- loop diuretic for oedema - consider long-term oxygen therapy - NOT recommended: ACEi, calcium channel blockers, alpha blockers

Question 59

What is the reported prognosis of COPD based on?

Answer 59

FEV1 - significant correlation between increased FEV1 and lower risk of COPD exacerbation

Question 60

How do we manage a non-severe COPD exacerbation?

Answer 60

- increase the frequency of bronchodilator use and consider giving via a nebuliser - give prednisolone 30 mg daily for 5 days - it is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE do not support this approach. They recommend giving oral antibiotics 'if sputum is purulent or there are clinical signs of pneumonia' - the BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.

Question 61

How do we manage a COPD exacerbation requiring secondary care?

Answer 61

- O2 therapy: 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% - nebulised bronchodilator - steroid therapy - oral prednisolone/IV hydrocortisone - IV theophylline if bronchodilators do not work - if type 2 respiratory failure occurs --> non-invasive ventilation --> BiPAP (EPAP 4-5cm H2O, IPAP 10-15cm H2O)