Stable COPD

Question 1

Define COPD

Answer 1

• Airflow obstruction
• Not fully reversible
• Usually progressive deterioration
• Predominantly caused by smoking (90%)

Question 2

How would COPD present on spirometry?

Answer 2

• Obstructive pattern
  
  • FEV1 reduced
  • FVC reduced (>0.8)
  • FEV1/FVC <0.7
• Limited bronchodilator reversibility
• Progressive deterioration in subsequent spirometry

Question 3

Outline the NICE classification of airflow obstruction severity

Answer 3

FEV1/FVC must be <0.7 for obstructive disease

Post-bronchodilator FEV1% predicted:

• Mild: 50-79%
• Moderate: 30-49%
• Severe: <30%

Question 4

Suggest three risk factors for COPD

Answer 4

• Smoking
• Occupational exposure: dust; fumes; chemicals
• Air pollution
• Alpha-1-antitrypsin deficiency

Question 5

When should alpha-1-antitrypsin deficiency be considered in COPD?

Answer 5

• Early onset
• Minimal smoking history
• FHx of alpha-1-antitrypsin deficiency

Question 6

List four symptoms of COPD

Answer 6

Suspect COPD in >35 with any risk factor and 1+ symptoms:

• Exertional breathlessness
• Chronic/recurrent cough
• Regular sputum production
• Frequent LRTIs
• Wheeze
• Weight loss; anorexia; fatigue
• PND; ankle odema: suggestive of cor pulmonale
• Reduced exercise tolerance

Question 7

Give four signs of COPD

Answer 7

May be normal

• Cyanosis
• Raised JVP and/or peripheral oedema
• Cachexia
• Hyperinflated chest
• Use of accessory muscles and/or pursed lip breathing
• Wheeze and/or crepitations
• Hypercapnia: Bounding pulse, CO₂ retention flap, confusion

Question 8

Differentiate between the clinical features of COPD and asthma

Answer 8

Question 9

Outline the MRC dyspnoea scale

Answer 9

1. Only on strenuous exercise
2. Hurrying or walking up a slight hill
3. Either:
   
   • Walks slower than peers on level ground
   • Stops for breath when walking at own pace
4. Either:
   
   • Stops for breath after walking about 100m
   • Stops after a few minutes on level ground
5. Unable to leave house; SOB when dressing or undressing

Question 10

Request three investigations for suspected COPD

Answer 10

• Spirometry
  
  • Post-bronchodilator spiratory to confirm COPD
• CXR: exclude other pathology
• FBC: anaemia or polycythaemia (chronic hypoxia)
• BMI
• Sputum culture
• Serial peak flow: exclude asthma
• ECG; BNP; Echo: suspected cor pulmonale
• Serum alpha-1-trypsin

Question 11

Suggest four lifestyle modifications for COPD

Answer 11

• Smoking cessation
• Dietary advice: BMI is a prognostic factor
• Pulmonary rehabilitation: offer to MRC score 3+
• Vaccinations:
  
  • One-time pneumococal
  • Annual influenza

Question 12

Suggest three non-pharmacological management of COPD

Answer 12

• Chest physio
• Management of anxiety and depression
• Dietitian
• Occupational therapy
• Palliative: end-stage COPD
• LTOT or lung volume reduction if appropriate

Question 13

Outline the medical management of stable COPD

Answer 13

COPD care bundle

• Consider
  
  • Mucolytics: if chronic productive cough of sputum
  • Prophylactic antibiotics ^eg. azithromycin
  • Oral theophylline if either:
    
    • Uncontrolled by short- and long-acting bronchodilators
    • Unable to use inhaled therapy

Question 14

What is meant by ‘asthmatic feautres or features suggesting steroid responsiveness’ in regards to COPD?

Answer 14

• Any previous diagnosis of asthma or atopy
• Elevated serum eosinophils
• Substantial variation in FEV1 over time (at least 400ml)
• Substantial diurnal variation in PEFR (at least 20%)

Question 15

Provide three indications for long-term oxygen therapy in COPD

Answer 15

ABG on two occasions at least 3/52 apart in stable COPD on optimal management, either:

• PaO₂ <7.3 kPa when stable
• PaO₂ >7.3kPa and <8kPa, plus one of:
  
  • Secondary polycythaemia
  • Peripheral oedema
  • Pulmonary HTN

Question 16

What are the criteria for long term oxygen therapy?

Answer 16

• Willing to use at least 16hr/day
  
  • Improves life expectancy
  • Greater benefit when used 20hr/day
• Must be a non-smoker
• Must not retain high PaCO₂

Question 17

Describe Cor pulmonale and its link with COPD

Answer 17

Can occur in advanced COPD

• Either:
  
  • Secondary RV hypertrophy due to pulmonary HTN
  • Peripheral oedema due to salt & water retention
• Causes chronic alveolar hypoxia and hypercapnia
  
  • Due to vasoconstriction of the pulmonary arterioles

Question 18

Outline the treatment of cor pulmonale

Answer 18

• Optimal COPD treatment, including smoking cessation help
• Diuretics: symptom relief