Podcast
Questions and Answers
Which of the following is the MOST common cause of chronic obstructive pulmonary disease (COPD)?
Which of the following is the MOST common cause of chronic obstructive pulmonary disease (COPD)?
- Alpha-1 antitrypsin deficiency
- Genetic predisposition
- Cigarette smoking (correct)
- Exposure to asbestos
Which of the following findings on spirometry is MOST suggestive of COPD?
Which of the following findings on spirometry is MOST suggestive of COPD?
- FEV1/FVC ratio greater than 70%
- Normal FEV1
- Increased FVC
- FEV1/FVC ratio less than 70% (correct)
According to the MRC Dyspnoea Scale, which grade corresponds to breathlessness that stops a person from walking more than 100 metres on the flat?
According to the MRC Dyspnoea Scale, which grade corresponds to breathlessness that stops a person from walking more than 100 metres on the flat?
- Grade 4 (correct)
- Grade 3
- Grade 5
- Grade 2
Which of the following symptoms is NOT typically associated with COPD and should prompt investigation for alternative diagnoses?
Which of the following symptoms is NOT typically associated with COPD and should prompt investigation for alternative diagnoses?
Which of the following statements regarding the use of oxygen therapy in COPD patients at risk of CO2 retention is MOST accurate?
Which of the following statements regarding the use of oxygen therapy in COPD patients at risk of CO2 retention is MOST accurate?
In the management of an acute exacerbation of COPD, which of the following is the MOST appropriate duration of treatment with oral prednisolone?
In the management of an acute exacerbation of COPD, which of the following is the MOST appropriate duration of treatment with oral prednisolone?
A patient with COPD presents with peripheral oedema, raised JVP, and hepatomegaly. Which of the following conditions is MOST likely causing these signs?
A patient with COPD presents with peripheral oedema, raised JVP, and hepatomegaly. Which of the following conditions is MOST likely causing these signs?
A patient with COPD is started on azithromycin. Which of the following monitoring parameters is MOST important to assess before and during treatment?
A patient with COPD is started on azithromycin. Which of the following monitoring parameters is MOST important to assess before and during treatment?
Which of the following best describes the underlying mechanism of oxygen-induced hypercapnia in COPD patients?
Which of the following best describes the underlying mechanism of oxygen-induced hypercapnia in COPD patients?
According to NICE guidelines, which of the following is the initial medical treatment recommended for COPD?
According to NICE guidelines, which of the following is the initial medical treatment recommended for COPD?
Which of the following is NOT a cause of cor pulmonale?
Which of the following is NOT a cause of cor pulmonale?
A patient with COPD has persistent respiratory acidosis (pH < 7.35 and PaCO2 > 6) despite maximal medical treatment. Which of the following is the MOST appropriate next step?
A patient with COPD has persistent respiratory acidosis (pH < 7.35 and PaCO2 > 6) despite maximal medical treatment. Which of the following is the MOST appropriate next step?
Which of the following blood gas abnormalities is MOST indicative of an acute exacerbation of COPD?
Which of the following blood gas abnormalities is MOST indicative of an acute exacerbation of COPD?
Which of the following parameters is used to grade the severity of COPD?
Which of the following parameters is used to grade the severity of COPD?
What is the primary purpose of pulmonary rehabilitation in the long-term management of COPD?
What is the primary purpose of pulmonary rehabilitation in the long-term management of COPD?
A COPD patient on combined LABA/ICS inhaler therapy experiences frequent exacerbations. According to the provided information, what would be the MOST appropriate next step?
A COPD patient on combined LABA/ICS inhaler therapy experiences frequent exacerbations. According to the provided information, what would be the MOST appropriate next step?
What is the functional significance of Transfer Factor for Carbon Monoxide (TLCO) testing in the context of COPD diagnosis and management?
What is the functional significance of Transfer Factor for Carbon Monoxide (TLCO) testing in the context of COPD diagnosis and management?
In the context of NIV, what are typical starting pressures for IPAP, and how frequently should adjustments be made based on ABG results?
In the context of NIV, what are typical starting pressures for IPAP, and how frequently should adjustments be made based on ABG results?
A patient with severe COPD presents with worsening dyspnea, despite adherence to optimal inhaled therapies. Lung volume reduction surgery is being considered. Which of the following is the MOST crucial factor in determining patient suitability for this intervention?
A patient with severe COPD presents with worsening dyspnea, despite adherence to optimal inhaled therapies. Lung volume reduction surgery is being considered. Which of the following is the MOST crucial factor in determining patient suitability for this intervention?
A patient with a history of severe COPD and chronic hypercapnia is admitted with acute respiratory distress. Initial blood gas analysis reveals a pH of 7.20, PaCO2 of 90 mmHg, PaO2 of 55 mmHg, and HCO3- of 36 mEq/L. Considering the principles of oxygen-induced hypercapnia and the patient's known chronic hypercapnia, which of the following oxygen delivery strategies poses the HIGHEST risk of further exacerbating CO2 retention?
A patient with a history of severe COPD and chronic hypercapnia is admitted with acute respiratory distress. Initial blood gas analysis reveals a pH of 7.20, PaCO2 of 90 mmHg, PaO2 of 55 mmHg, and HCO3- of 36 mEq/L. Considering the principles of oxygen-induced hypercapnia and the patient's known chronic hypercapnia, which of the following oxygen delivery strategies poses the HIGHEST risk of further exacerbating CO2 retention?
Which of the following pathological processes is NOT typically associated with the pathophysiology of COPD?
Which of the following pathological processes is NOT typically associated with the pathophysiology of COPD?
A patient presents with a chronic cough and excessive sputum production for most days of 3 consecutive months in the past 2 years. According to the definition provided, this is MOST consistent with which condition?
A patient presents with a chronic cough and excessive sputum production for most days of 3 consecutive months in the past 2 years. According to the definition provided, this is MOST consistent with which condition?
Unlike asthma, the airway obstruction seen in COPD is:
Unlike asthma, the airway obstruction seen in COPD is:
A patient with a known history of COPD presents to the clinic. Which of the following symptoms should prompt the clinician to consider alternative diagnoses OTHER than COPD alone?
A patient with a known history of COPD presents to the clinic. Which of the following symptoms should prompt the clinician to consider alternative diagnoses OTHER than COPD alone?
According to the MRC Dyspnoea Scale, which grade is assigned to a patient who is only breathless when performing strenuous exercise?
According to the MRC Dyspnoea Scale, which grade is assigned to a patient who is only breathless when performing strenuous exercise?
A patient reports that they have to stop to catch their breath when walking at their own pace on level ground. According to the MRC Dyspnoea Scale, what grade of breathlessness does this represent?
A patient reports that they have to stop to catch their breath when walking at their own pace on level ground. According to the MRC Dyspnoea Scale, what grade of breathlessness does this represent?
Which spirometry finding is MOST indicative of COPD?
Which spirometry finding is MOST indicative of COPD?
What is the MOST important spirometric measurement used to classify the severity of COPD?
What is the MOST important spirometric measurement used to classify the severity of COPD?
A patient's FEV1 is measured at 60% of the predicted value. According to the GOLD classification, what stage of COPD does this represent?
A patient's FEV1 is measured at 60% of the predicted value. According to the GOLD classification, what stage of COPD does this represent?
Which of the following laboratory findings is MOST suggestive of chronic hypoxia in a patient with COPD?
Which of the following laboratory findings is MOST suggestive of chronic hypoxia in a patient with COPD?
Why is a chest X-ray performed as part of the investigation of COPD?
Why is a chest X-ray performed as part of the investigation of COPD?
What additional investigation should be performed in younger patients with COPD, especially those with a family history of early-onset lung disease?
What additional investigation should be performed in younger patients with COPD, especially those with a family history of early-onset lung disease?
What is the MOST important intervention to slow the progression of COPD?
What is the MOST important intervention to slow the progression of COPD?
Which vaccines are routinely recommended for patients with COPD?
Which vaccines are routinely recommended for patients with COPD?
What is the PRIMARY aim of pulmonary rehabilitation in COPD management?
What is the PRIMARY aim of pulmonary rehabilitation in COPD management?
According to the NICE guidelines, what is typically the initial pharmacological treatment for COPD?
According to the NICE guidelines, what is typically the initial pharmacological treatment for COPD?
A patient with COPD continues to have significant symptoms despite using a short-acting beta-2 agonist as needed. They do NOT exhibit asthmatic or steroid-responsive features. What is the MOST appropriate next step in their pharmacological management?
A patient with COPD continues to have significant symptoms despite using a short-acting beta-2 agonist as needed. They do NOT exhibit asthmatic or steroid-responsive features. What is the MOST appropriate next step in their pharmacological management?
A patient with COPD has both persistent symptoms and documented asthmatic features. What is the MOST appropriate second-line therapy as per the NICE guidelines?
A patient with COPD has both persistent symptoms and documented asthmatic features. What is the MOST appropriate second-line therapy as per the NICE guidelines?
A patient with severe COPD is already on a LABA/LAMA combination inhaler but continues to experience frequent exacerbations. Which of the following would be the MOST appropriate next step in their treatment?
A patient with severe COPD is already on a LABA/LAMA combination inhaler but continues to experience frequent exacerbations. Which of the following would be the MOST appropriate next step in their treatment?
Which pre-treatment investigations are MOST important to conduct in patients being considered for long-term azithromycin for COPD?
Which pre-treatment investigations are MOST important to conduct in patients being considered for long-term azithromycin for COPD?
A patient with very severe COPD has chronic hypoxemia, polycythaemia and cyanosis. Which of the following long-term treatments is MOST indicated?
A patient with very severe COPD has chronic hypoxemia, polycythaemia and cyanosis. Which of the following long-term treatments is MOST indicated?
Which of the following is an absolute contraindication to long-term oxygen therapy (LTOT) in a patient with COPD?
Which of the following is an absolute contraindication to long-term oxygen therapy (LTOT) in a patient with COPD?
Cor pulmonale is defined as:
Cor pulmonale is defined as:
Which of the following is the MOST common cause of cor pulmonale?
Which of the following is the MOST common cause of cor pulmonale?
A patient with COPD presents with peripheral oedema, raised JVP, and hepatomegaly. Which of the following mechanisms is MOST likely contributing to these clinical signs?
A patient with COPD presents with peripheral oedema, raised JVP, and hepatomegaly. Which of the following mechanisms is MOST likely contributing to these clinical signs?
Which physical examination finding is MOST suggestive of tricuspid regurgitation secondary to cor pulmonale?
Which physical examination finding is MOST suggestive of tricuspid regurgitation secondary to cor pulmonale?
What arterial blood gas (ABG) finding is MOST indicative of an acute exacerbation of COPD?
What arterial blood gas (ABG) finding is MOST indicative of an acute exacerbation of COPD?
During an acute exacerbation of COPD, which of the following blood gas results would indicate the MOST severe respiratory acidosis that may warrant immediate intervention?
During an acute exacerbation of COPD, which of the following blood gas results would indicate the MOST severe respiratory acidosis that may warrant immediate intervention?
Which of the following is the underlying mechanism of oxygen-induced hypercapnia in COPD patients?
Which of the following is the underlying mechanism of oxygen-induced hypercapnia in COPD patients?
What is the recommended target oxygen saturation range for COPD patients at risk of CO2 retention during acute exacerbation?
What is the recommended target oxygen saturation range for COPD patients at risk of CO2 retention during acute exacerbation?
When administering oxygen to a COPD patient with known CO2 retention, which device is BEST for delivering a precise oxygen concentration?
When administering oxygen to a COPD patient with known CO2 retention, which device is BEST for delivering a precise oxygen concentration?
In the initial management of an acute exacerbation of COPD, what is the typical duration of oral prednisolone treatment?
In the initial management of an acute exacerbation of COPD, what is the typical duration of oral prednisolone treatment?
Which of the following additional treatments should be considered in severe cases during acute exacerbations of COPD?
Which of the following additional treatments should be considered in severe cases during acute exacerbations of COPD?
When is non-invasive ventilation (NIV) typically considered in the management of acute exacerbations of COPD?
When is non-invasive ventilation (NIV) typically considered in the management of acute exacerbations of COPD?
Which condition is a contraindication to non-invasive ventilation (NIV)?
Which condition is a contraindication to non-invasive ventilation (NIV)?
What does IPAP refer to in the context of non-invasive ventilation (NIV)?
What does IPAP refer to in the context of non-invasive ventilation (NIV)?
During NIV for COPD, what is the MOST appropriate initial action if the patient's acidosis is not improving?
During NIV for COPD, what is the MOST appropriate initial action if the patient's acidosis is not improving?
A patient with a history of COPD presents with acute respiratory distress. Blood gas analysis reveals a pH of 7.25, PaCO2 of 65 mmHg, PaO2 of 50 mmHg, and HCO3 of 30 mEq/L. The patient is started on BiPAP, and after one hour, a repeat blood gas shows a pH of 7.20, PaCO2 of 70 mmHg, PaO2 of 55 mmHg, and HCO3 of 31 mEq/L. What is the MOST appropriate next step in managing this patient?
A patient with a history of COPD presents with acute respiratory distress. Blood gas analysis reveals a pH of 7.25, PaCO2 of 65 mmHg, PaO2 of 50 mmHg, and HCO3 of 30 mEq/L. The patient is started on BiPAP, and after one hour, a repeat blood gas shows a pH of 7.20, PaCO2 of 70 mmHg, PaO2 of 55 mmHg, and HCO3 of 31 mEq/L. What is the MOST appropriate next step in managing this patient?
Why is the Transfer Factor for Carbon Monoxide (TLCO) measured in patients with COPD?
Why is the Transfer Factor for Carbon Monoxide (TLCO) measured in patients with COPD?
A patient with COPD is admitted for an acute exacerbation. The patient is dyspneic, has a respiratory rate of 30 breaths per minute, and is using accessory muscles. Arterial blood gas reveals pH 7.28, PaCO2 60 mmHg, PaO2 52 mmHg, and HCO3 32 mEq/L. The patient is started on appropriate medical therapy, but his condition does not improve. Which of the following interventions should be considered NEXT?
A patient with COPD is admitted for an acute exacerbation. The patient is dyspneic, has a respiratory rate of 30 breaths per minute, and is using accessory muscles. Arterial blood gas reveals pH 7.28, PaCO2 60 mmHg, PaO2 52 mmHg, and HCO3 32 mEq/L. The patient is started on appropriate medical therapy, but his condition does not improve. Which of the following interventions should be considered NEXT?
In a patient with COPD and known bullous emphysema, which of the following findings would INCREASE suspicion for a secondary spontaneous pneumothorax?
In a patient with COPD and known bullous emphysema, which of the following findings would INCREASE suspicion for a secondary spontaneous pneumothorax?
A patient in severe respiratory distress due to a COPD exacerbation is being considered for intubation and mechanical ventilation. After discussing the risks, benefits, and alternatives, the patient explicitly states that they do NOT want to be intubated under any circumstances. What is the MOST ethically and legally sound course of action?
A patient in severe respiratory distress due to a COPD exacerbation is being considered for intubation and mechanical ventilation. After discussing the risks, benefits, and alternatives, the patient explicitly states that they do NOT want to be intubated under any circumstances. What is the MOST ethically and legally sound course of action?
COPD is a reversible condition if detected early.
COPD is a reversible condition if detected early.
Which of the following is a typical symptom of COPD?
Which of the following is a typical symptom of COPD?
What FEV1:FVC ratio is indicative of an obstructive picture on spirometry results for COPD?
What FEV1:FVC ratio is indicative of an obstructive picture on spirometry results for COPD?
In emphysema, damage to the _________ decreases the surface area for gas exchange.
In emphysema, damage to the _________ decreases the surface area for gas exchange.
Match the MRC Dyspnoea Scale grade with the corresponding level of breathlessness:
Match the MRC Dyspnoea Scale grade with the corresponding level of breathlessness:
Which of the following investigations is NOT typically used in the initial assessment of COPD?
Which of the following investigations is NOT typically used in the initial assessment of COPD?
Pulmonary rehabilitation is a single-disciplinary approach focusing solely on physical exercise to improve lung function in COPD patients.
Pulmonary rehabilitation is a single-disciplinary approach focusing solely on physical exercise to improve lung function in COPD patients.
According to NICE guidelines, which of the following is NOT part of the initial medical treatment for COPD?
According to NICE guidelines, which of the following is NOT part of the initial medical treatment for COPD?
What are the two main components of management for cor pulmonale?
What are the two main components of management for cor pulmonale?
In an acute exacerbation of COPD, a low pH and raised pCO2 on arterial blood gas indicates __________.
In an acute exacerbation of COPD, a low pH and raised pCO2 on arterial blood gas indicates __________.
Target oxygen saturations of 94-98% are universally recommended for all COPD patients to ensure adequate oxygenation.
Target oxygen saturations of 94-98% are universally recommended for all COPD patients to ensure adequate oxygenation.
Which of the following is a potential complication of oxygen therapy in COPD patients?
Which of the following is a potential complication of oxygen therapy in COPD patients?
What is the typical prednisolone dosage and duration for treating an acute COPD exacerbation?
What is the typical prednisolone dosage and duration for treating an acute COPD exacerbation?
What is the purpose of EPAP (expiratory positive airway pressure) during NIV?
What is the purpose of EPAP (expiratory positive airway pressure) during NIV?
__________ is a respiratory stimulant that may be used when NIV or intubation is not appropriate during an acute COPD exacerbation.
__________ is a respiratory stimulant that may be used when NIV or intubation is not appropriate during an acute COPD exacerbation.
The severity of COPD is graded using the forced inspiratory volume in 1 second (FIV1).
The severity of COPD is graded using the forced inspiratory volume in 1 second (FIV1).
Which of the following is a contraindication for long-term oxygen therapy (LTOT) in COPD patients?
Which of the following is a contraindication for long-term oxygen therapy (LTOT) in COPD patients?
Associate each combination inhaler with its appropriate component medications:
Associate each combination inhaler with its appropriate component medications:
A COPD patient presents with an FEV1 of 40% of predicted. According to COPD severity grading, how would this be classified?
A COPD patient presents with an FEV1 of 40% of predicted. According to COPD severity grading, how would this be classified?
What blood test should be monitored before and during azithromycin treatment and why?
What blood test should be monitored before and during azithromycin treatment and why?
__________ is a condition of right-sided heart failure caused by respiratory disease, most commonly COPD, which leads to increased pressure in the pulmonary arteries.
__________ is a condition of right-sided heart failure caused by respiratory disease, most commonly COPD, which leads to increased pressure in the pulmonary arteries.
During an acute exacerbation, a raised bicarbonate level on an ABG indicates that the patient is acutely retaining CO2.
During an acute exacerbation, a raised bicarbonate level on an ABG indicates that the patient is acutely retaining CO2.
Which Venturi mask color delivers approximately 35% oxygen?
Which Venturi mask color delivers approximately 35% oxygen?
Match the investigation with the clinical indication in COPD assessment:
Match the investigation with the clinical indication in COPD assessment:
List three symptoms that should prompt investigation for a cause other than COPD.
List three symptoms that should prompt investigation for a cause other than COPD.
Ventilation-perfusion mismatch and decreased haemoglobin affinity for __________ (resulting from oxygen binding) are likely mechanisms for oxygen-induced hypercapnia.
Ventilation-perfusion mismatch and decreased haemoglobin affinity for __________ (resulting from oxygen binding) are likely mechanisms for oxygen-induced hypercapnia.
A variation in FEV1 of more than 200 mL is considered an asthmatic or steroid-responsive feature in COPD management.
A variation in FEV1 of more than 200 mL is considered an asthmatic or steroid-responsive feature in COPD management.
Which of the following conditions is LEAST likely to cause cor pulmonale?
Which of the following conditions is LEAST likely to cause cor pulmonale?
What is the initial IPAP range in cm H2O that could be set on NIV for an average patient?
What is the initial IPAP range in cm H2O that could be set on NIV for an average patient?
Name two inclusion criteria for NIV, besides the potential to recover and being acceptable to the patient.
Name two inclusion criteria for NIV, besides the potential to recover and being acceptable to the patient.
Unlike asthma, airway obstruction in COPD is minimally reversible with __________ such as salbutamol.
Unlike asthma, airway obstruction in COPD is minimally reversible with __________ such as salbutamol.
An absence of wheezing definitively rules out COPD.
An absence of wheezing definitively rules out COPD.
Which of the following arterial blood gas (ABG) findings would be most consistent with a COPD patient in acute respiratory failure?
Which of the following arterial blood gas (ABG) findings would be most consistent with a COPD patient in acute respiratory failure?
Aside from infection, name one common trigger for acute exacerbations of COPD?
Aside from infection, name one common trigger for acute exacerbations of COPD?
Which of the following statements regarding the use of oral corticosteroids in COPD management is most accurate?
Which of the following statements regarding the use of oral corticosteroids in COPD management is most accurate?
Weight loss is common in __________ COPD, so body mass index should be assessed at baseline.
Weight loss is common in __________ COPD, so body mass index should be assessed at baseline.
A patient with COPD has the following ABG results while on room air: pH 7.32, PaCO2 68 mmHg, PaO2 52 mmHg, HCO3- 34 mEq/L. How would you interpret these results?
A patient with COPD has the following ABG results while on room air: pH 7.32, PaCO2 68 mmHg, PaO2 52 mmHg, HCO3- 34 mEq/L. How would you interpret these results?
A patient with an acute exacerbation of COPD is being considered for NIV. What chest x-ray finding would be an absolute contraindication to initiating NIV?
A patient with an acute exacerbation of COPD is being considered for NIV. What chest x-ray finding would be an absolute contraindication to initiating NIV?
Which of the following statements best describes the mechanism by which long-term oxygen therapy (LTOT) improves survival in patients with severe COPD?
Which of the following statements best describes the mechanism by which long-term oxygen therapy (LTOT) improves survival in patients with severe COPD?
Flashcards
COPD
COPD
A long-term, progressive condition involving airway obstruction, chronic bronchitis, and emphysema, primarily caused by smoking.
Chronic Bronchitis
Chronic Bronchitis
Long-term cough and sputum production due to inflammation in the bronchi.
Emphysema
Emphysema
Damage and dilatation of the alveolar sacs and alveoli, decreasing the surface area for gas exchange.
COPD Exacerbations
COPD Exacerbations
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MRC Dyspnoea Scale
MRC Dyspnoea Scale
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COPD Spirometry Results
COPD Spirometry Results
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COPD Severity Grading
COPD Severity Grading
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Cor Pulmonale
Cor Pulmonale
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ABG in COPD Exacerbation
ABG in COPD Exacerbation
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CO2 retention with O2
CO2 retention with O2
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Treating COPD Exacerbation
Treating COPD Exacerbation
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Non-Invasive Ventilation (NIV)
Non-Invasive Ventilation (NIV)
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IPAP
IPAP
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EPAP
EPAP
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NIV Inclusion Criteria
NIV Inclusion Criteria
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NIV Contraindications
NIV Contraindications
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What is COPD?
What is COPD?
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COPD Presentation
COPD Presentation
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COPD: Symptoms to Investigate
COPD: Symptoms to Investigate
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TLCO Test
TLCO Test
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COPD: Long-term management
COPD: Long-term management
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COPD: Initial Medical Treatment
COPD: Initial Medical Treatment
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COPD: Treatment without asthmatic features
COPD: Treatment without asthmatic features
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COPD: Treatment with responsive features
COPD: Treatment with responsive features
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COPD: Severe cases treatment
COPD: Severe cases treatment
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Azithromycin Monitoring
Azithromycin Monitoring
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Long-Term Oxygen Therapy Indications
Long-Term Oxygen Therapy Indications
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COPD Exacerbation: Role of Physio
COPD Exacerbation: Role of Physio
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COPD: Oxygen Saturation
COPD: Oxygen Saturation
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Venturi Masks
Venturi Masks
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NIV Method
NIV Method
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Doxapram Use
Doxapram Use
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What is Chronic Bronchitis?
What is Chronic Bronchitis?
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What is Emphysema?
What is Emphysema?
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What is COPD Dyspnoea?
What is COPD Dyspnoea?
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What will improve prognosis?
What will improve prognosis?
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Why Perform a Chest X-Ray?
Why Perform a Chest X-Ray?
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What is Polycythaemia?
What is Polycythaemia?
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Why do an ECG/Echo?
Why do an ECG/Echo?
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What is Reversibility Testing?
What is Reversibility Testing?
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What is Anoro Ellipta?
What is Anoro Ellipta?
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What is Cor Pulmonale?
What is Cor Pulmonale?
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Cor Pulmonale Signs?
Cor Pulmonale Signs?
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How to Manage Cor Pulmonale?
How to Manage Cor Pulmonale?
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Common Triggers of COPD Exacerbations
Common Triggers of COPD Exacerbations
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Why Get a Chest X-Ray?
Why Get a Chest X-Ray?
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Why Do a Full Blood Count?
Why Do a Full Blood Count?
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Study Notes
- Chronic obstructive pulmonary disease (COPD) includes airway obstruction, chronic bronchitis, and emphysema, and is a progressive condition.
- COPD is typically a result of smoking and is largely preventable, but is not reversible, although it is treatable.
- Lung tissue damage obstructs airflow.
- Chronic bronchitis involves long-term cough and sputum production from bronchial inflammation.
- Emphysema involves alveolar sac and alveoli damage and dilatation, decreasing gas exchange surface area.
- Airway obstruction in COPD is minimally reversible with bronchodilators like salbutamol, unlike asthma.
- COPD patients are susceptible to exacerbations where lung function worsens and exacerbations triggered by infection are termed infective exacerbations of COPD.
Presentation
- COPD typically presents in long-term smokers with persistent symptoms of shortness of breath, cough, sputum production, wheeze, and recurrent respiratory infections (especially in winter).
- COPD does not cause clubbing, haemoptysis or chest pain, which warrant investigation for other causes like lung cancer, pulmonary fibrosis, or heart failure.
MRC Dyspnoea Scale
- The Medical Research Council (MRC) Dyspnoea Scale assesses breathlessness with these grades:
- Grade 1: Breathless on strenuous exercise.
- Grade 2: Breathless when walking uphill.
- Grade 3: Breathlessness slows walking on the flat.
- Grade 4: Breathlessness stops them from walking more than 100 meters on the flat.
- Grade 5: Unable to leave the house due to breathlessness.
Diagnosis
- Diagnosis relies on clinical presentation and spirometry results.
- Spirometry shows an obstructive pattern with a FEV1:FVC ratio below 70%.
- There is little or no response to reversibility testing with beta-2 agonists like salbutamol, a reversible obstruction is more suggestive of asthma.
Severity
- Severity is graded using the forced expiratory volume in 1 second (FEV1):
- Stage 1 (mild): FEV1 more than 80% of predicted.
- Stage 2 (moderate): FEV1 50-79% of predicted.
- Stage 3 (severe): FEV1 30-49% of predicted.
- Stage 4 (very severe): FEV1 less than 30% of predicted.
Other Investigations
- Other investigations for COPD include:
- Body mass index at baseline, weight loss occurs in severe disease.
- Chest x-ray to exclude other pathology like lung cancer.
- Full blood count for polycythaemia, anaemia, and infection. Polycythaemia is raised haemoglobin due to chronic hypoxia.
- Sputum culture to assess for chronic infections like pseudomonas.
- ECG and echocardiogram to assess for heart failure and cor pulmonale.
- CT thorax for alternative diagnoses like fibrosis, cancer, or bronchiectasis.
- Serum alpha-1 antitrypsin to check for alpha-1 antitrypsin deficiency.
- Transfer factor for carbon monoxide (TLCO) tests diffusion of inhaled gas into the blood, TLCO is reduced in COPD.
Long-Term Management
- Smoking cessation is crucial to prevent worsening of lung function and prognosis.
- Pneumococcal and annual flu vaccines are recommended.
- Pulmonary rehabilitation improves function and quality of life through physical training and education.
- Initial medical treatment involves short-acting beta-2 agonists and short-acting muscarinic antagonists.
- NICE guidelines (updated 2019) recommend short-acting beta-2 agonists (e.g., salbutamol) and short-acting muscarinic antagonists (e.g., ipratropium bromide) for initial medical treatment.
- The second step, when symptoms or exacerbations persist, depends on asthmatic or steroid-responsive features, measured by previous asthma diagnosis/atopy, FEV1 variation over 400ml, peak flow diurnal variability exceeding 20%, and elevated blood eosinophil count.
- Absence of asthmatic features means treatment is a combination of a long-acting beta agonist (LABA) and a long-acting muscarinic antagonist (LAMA).
- Anoro Ellipta, Ultibro Breezhaler, and DuaKlir Genuair are LABA/LAMA combination inhalers.
- Presence of asthmatic features means treatment is a combination of a long-acting beta agonist (LABA) and an inhaled corticosteroid (ICS).
- Fostair, Symbicort, and Seretide are LABA/ICS combination inhalers.
- The final inhaler step combines a LABA, LAMA, and ICS.
- Trimbow, Trelegy Ellipta, and Trixeo Aerosphere are LABA/LAMA/ICS combination inhalers.
- In severe cases, additional options are:
- Nebulisers e.g salbutamol or ipratropium.
- Oral theophylline.
- Oral mucolytic therapy e.g. carbocisteine.
- Prophylactic antibiotics (e.g., azithromycin).
- Oral corticosteroids (e.g., prednisolone).
- Oral phosphodiesterase-4 inhibitors (e.g., roflumilast).
- Long-term oxygen therapy at home.
- Lung volume reduction surgery, removes damaged tissue to improve the function of the healthier tissue.
- Palliative care, opiates and other drugs may be used to help breathlessness.
- Patients on azithromycin require ECG and liver function monitoring before and during treatment.
- Long-term oxygen therapy (LTOT) is for severe COPD with chronic hypoxia, polycythaemia, cyanosis, or cor pulmonale, smoking is a contraindication due to the fire risk.
- Long-term oxygen therapy (LTOT) is used for severe COPD with chronic hypoxia (sats < 92%), polycythaemia, cyanosis, or cor pulmonale.
Cor Pulmonale
- Cor pulmonale is right-sided heart failure caused by respiratory disease.
- Increased pressure and resistance in pulmonary arteries (pulmonary hypertension) limits right ventricle function.
- This increased pressure causes back-pressure into the right atrium, vena cava, and systemic venous system.
- Causes includes COPD, pulmonary embolism, interstitial lung disease, cystic fibrosis, and primary pulmonary hypertension, with COPD being the most common cause.
- Early cor pulmonale may be asymptomatic.
- Symptoms are shortness of breath, peripheral oedema, breathlessness on exertion, syncope, and chest pain.
- Signs on examination include hypoxia, cyanosis, raised JVP, peripheral oedema, parasternal heave, loud S2, murmurs, and hepatomegaly. JVP is raised due to a back-log of blood in the jugular veins. Hepatomegaly is due to back pressure in the hepatic vein, which is pulsatile in tricuspid regurgitation. Murmurs include pan-systolic murmurs in tricuspid regurgitation.
- Management involves treating symptoms and the underlying cause, e.g diuretics for oedema, long-term oxygen therapy is often used.
- Prognosis is poor unless there is a reversible underlying cause.
Acute Exacerbation
- Acute COPD exacerbations involve rapidly worsening symptoms like cough, shortness of breath, sputum production, and wheezing.
- Viral or bacterial infection often triggers them.
Arterial Blood Gas
- An acute exacerbation leads to respiratory acidosis:
- Low pH indicates acidosis.
- Low pO2 indicates hypoxia and respiratory failure.
- Raised pCO2 indicates CO2 retention (hypercapnia).
- Raised bicarbonate indicates chronic retention of CO2.
- CO2 makes blood acidotic by becoming carbonic acid (H2CO3).
- Low pH with raised pCO2 suggests acute CO2 retention, indicating respiratory acidosis.
- Raised bicarbonate indicates chronic CO2 retention, with the kidneys producing more bicarbonate to balance the acidic CO2. During an acute exacerbation, the kidneys cannot keep up and the blood becomes acidic despite raised bicarbonate.
Other Investigations
- Other investigations during an acute exacerbation are:
- Chest x-ray, for pneumonia or other pathology.
- ECG, to look for arrhythmias or evidence of heart strain.
- Full blood count.
- U&E.
- Sputum culture.
- Blood cultures in patients with signs of sepsis. Full blood count looks for infection (raised white blood cells).
Oxygen Therapy
- Many COPD patients retain CO2 when treated with oxygen, known as oxygen-induced hypercapnia and target saturations of 88-92% are used. The mechanism involves ventilation-perfusion mismatch and haemoglobin binding less well to CO2 when also bound to oxygen.
- Target saturations of 88-92% are used for patients with COPD at risk of retaining CO2, and these may be adjusted to 94-98% when confident they do not retain CO2.
- Venturi masks deliver a specific oxygen concentration; they deliver 24% (blue), 28% (white), 31% (orange), 35% (yellow), 40% (red) or 60% (green) oxygen. They allow some of the oxygen to leak out the side of the mask and normal air to be inhaled along with oxygen. Environmental air contains 21% oxygen.
Management of an Acute Exacerbation
- First-line medical treatment of an acute exacerbation involves regular inhalers or nebulisers, steroids, and antibiotics (if there is evidence of infection). Steroids are e.g. prednisolone 30mg once daily for 5 days.
- Respiratory physiotherapy is used to help clear sputum.
- Additional options in severe cases include IV aminophylline, non-invasive ventilation (NIV), and intubation with ventilation.
- Doxapram may be used as a respiratory stimulant where NIV or intubation is not appropriate.
Non-Invasive Ventilation
- Non-invasive ventilation (NIV) uses a full face mask, hood, or tight-fitting nasal mask to forcefully ventilate the lungs.
- NIV involves inspiratory positive airway pressure (IPAP) during inspiration and expiratory positive airway pressure (EPAP) during expiration.
- NIV is considered when there is persistent respiratory acidosis despite maximal medical treatment, potential to recover, and patient acceptance. Persistent respiratory acidosis is pH < 7.35 and PaCO2 > 6 after maximal treatment.
- Decision to initiate NIV should be made by a registrar or above.
- Main contraindications are untreated pneumothorax or any abnormality affecting the face, airway, or GI tract. The decision to initiate is made by a registrar or above, and patients should also have a chest x-ray before NIV to exclude pneumothorax.
- Potential pressures: IPAP 16-20cm H2O, EPAP 4-6cm H2O
- ABGs are monitored closely whilst on NIV, and The IPAP is increased by 2-5 cm increments until the acidosis resolves. IPAP usually starts at 12 and increases every 2-5 minutes untilthe target pressure is reached.
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