COPD

Question 1

GOLD spirometric grades

Answer 1

Question 2

single breath diffusing capacity

Answer 2

DL- CO (transfer factor for carbon monoxide)
a measure of gas exchange from the alveoli to erythrocytes in the pulmonary capillaries
used to assess ability of the lungs to transport gas via diffusion across the air blood barrier

Question 3

causes of obstructive lung disease

Answer 3

COPD
bronchial asthma
bronchiectasis
cystic fibrosis

Question 4

causes of restrictive lung disease

Answer 4

sarcoidosis
pneumoconioses
ARDS
idiopathic pulmonary fibrosis
hypersensitivity pneumonitis
granulomatosis with polyangiitis
radiation induced lung injury
drug induced interstitial lung disease

pleural effusion, pneumothorax
deformities of the thorax/mechanical limitation
respiratory muscle weakness

Question 5

specialised testing in obstructive lung disease

Answer 5

bronchial challenge test
bronchodilator responsiveness test (post bronchodilator test)

Question 6

indications for bronchial challenge test

Answer 6

methacholine challenge test
for patients with suspected airway hyper-responsiveness
pulmonary function testing is performed before and after the administration of ethacholine

Question 7

bronchodilator responsiveness testing

Answer 7

post bronchodilator test
if there is increase in FEV1 by > 12%, the obstruction is reversible, which usually indicated asthma
may also be the result of reversible component of airway obstruction in COPD

Question 8

what should be kept on hand during a methacholine challenge test

Answer 8

medications that reverse bronchospasm
eg. epinephrine, atropine
as this may trigger a life threatening asthma attack

Question 9

indications for body plethysmography

Answer 9

gold standard for measuring lung volumes and can also measure TLC and RV unlike spirometry

indicated for:
- patients who cannot actively participate in spirometry
- obstructive lung disease on spirometry, to evaluate for air trapping eg. in emphysema
- to distinguish between extrinsic vs intrinsic causes for restrictive lug disease

Question 10

what result is diagnostic of COPD

Answer 10

FEV1/FVC < 0.7

Question 11

stepwise drug management for COPD

Answer 11

Question 12

multidisciplinary management for COPD

Answer 12

GP
respiratory physician for advanced COPD
nurse for spirometry and inhaler technique
respiratory nurse for domiciliary oxygen treatment
pulmonary rehabilitation clinic
physiotherapist for exercise training
occupational therapist
speech therapist for swallowing training to avoid aspiration
physiologist: anxiety/depression are common comorbidities
pharmacist for medications
dietetic
government supported programs
HITH
palliative care

Question 13

the single most important intervention to prevent lung damage

Answer 13

smoking cessation

Question 14

what does pulmonary rehabilitation involve

Answer 14

exercise training
education
behaviour modification
outcome assessment eg. with 6 minute walk test

Question 15

general management points for lifestyle in stable COPD

Answer 15

smoking cessation
physical activity
pulmonary rehabilitation
vaccinations: ensure up to date with pneumococcal and receive an annual influenza vaccine
nutrition: obesity causes impaired quality of life but reduced mortality ‘obesity paradox’

Question 16

for as-required SABA therapy, use

Answer 16

1. salbutamol 100 to 200 micrograms by inhalation via pMDI with spacer, as required (1-2 inhalations)

OR

1. terbutaline 500 micrograms by inhalation via DPI, as required (1 inhalation)

Question 17

does SABA therapy reduce rate of decline of lung function or improve survival

Answer 17

no.

Short-acting bronchodilator therapy is used as required to provide short-term symptom relief for patients with COPD. There is no evidence that short-acting bronchodilator therapy reduces the rate of decline in lung function or has any effect on survival.

Question 18

do LABA/LAMAs reduce frequency of exacerbations of COPD

Answer 18

Long-acting bronchodilators improve lung function (as measured by forced expiratory volume in 1 second [FEV1]). They also provide symptomatic relief of breathlessness, improve exercise capacity, reduce the frequency and severity of exacerbations, reduce hospitalisations and improve quality of life. Symptomatic and functional benefits should be seen within 6 to 12 weeks, and can occur even in the absence of any change in FEV1.

Question 19

if adding a LAMA / LABA use

Answer 19

LAMA: tiotropium 13 or 18 micrograms [Note 3] by inhalation via DPI, daily (1 inhalation, multiple other LAMA options available)

LABA: indacaterol 150 micrograms by inhalation via DPI, daily [Note 4], increasing to 300 micrograms daily if required (1-2 inhalations)

Question 20

risk/benefit of adding an ICS

Answer 20

Triple therapy improves lung function and quality of life, and reduces exacerbations, compared with other treatments

ICS are associated with an increased risk of pneumonia in patients with COPD. The benefits of adding ICS must be balanced against the increased risk of pneumonia and local adverse effects (dysphonia, upper airway candidiasis).

Question 21

is domiciliary oxygen therapy prescribed for smokers

Answer 21

Domiciliary oxygen therapy is not prescribed in smokers because there is a potential risk of fire

Question 22

what test is required to determine eligibility for for long term oxygen therapy

Answer 22

Arterial blood gas analysis on room air is required to determine eligibility for domiciliary oxygen therapy.

Question 23

LTOT useful for COPD patients who have

Answer 23

Long-term continuous oxygen therapy has been shown to prolong survival in patients with stable chronic obstructive pulmonary disease (COPD) who have:

consistent partial pressure of oxygen (PaO2) of 55 mmHg or less when breathing air at rest and awake
evidence of complications of hypoxaemia (eg polycythaemia, pulmonary hypertension, right-sided heart failure) and a PaO2 of 56 to 59 mmHg.

Question 24

what are some scores you can use to assess COPD severity

Answer 24

CAT score
mMR breathlessness score

Question 25

resources for inhaler technique

Answer 25

national asthma council Australia instructional video

Question 26

MDI inhaler techqnique

Answer 26

show them the inhaler: the cap, the spacer, facemask (if needed), the counter on the inhaler device. check expiry date. 1. shake before use (not all inhalers need to be shaken) 2. reduce mouthpiece cover. Prime it if it's your first time using it or if you haven't used it in a while (usually this means releasing two puffs, check your device) 3. one puff in the spacer at a time, breathe in an out normally for 4 breaths. 4. rinse mouth if you are using an ICS ask the patient to demonstrate

Question 27

DPI inhaler technique

Answer 27

remove cover check dose counter and expiry keep inhaler upright and twist at the base, twist around and then back until a click is heard breathe out gently away from the inhaler form a seal and breathe in deeply breathe out gently repeat steps to complete doses replace cover