Chronic Obstructive Pulmonary Disease (Free Trial)

Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓

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Doctor Instruction:

You are a doctor working in the Respiratory Clinic. Your next patient is a 54-year-old gentleman called Richard Harrison - referred for shortness of breath. Please take a history and perform a relevant examination.

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Patient History:

Richard Harrison - a 54-year-old male - customer sales adviser.

You've "always" been short of breath. On further questioning, you think it started around 2 years ago but has worsened. You were originally short of breath when you exerted yourself, but now you must stop after only 100 yards of your walk up the town moor hill in the morning because of how breathless you get. Nothing seems to trigger the breathlessness, but it's particularly worse in the mornings and evenings when you walk to and from work.

You sleep with one pillow, which hasn't changed recently since you're not breathless when lying flat. When asked, you have had a couple of episodes where you wake up at night gasping for breath, but surely that's just stress from a nightmare or something, right?

You cough up clear phlegm each day and have been doing so over the past two years, and the volume seems to spike during winter, but the colour doesn't change. No blood in your mucus. You have no chest pain, palpitations, syncope. No fever or weight loss.

When asked: your wife has noticed that you often make a funny noise when breathing out like you’re whistling.

Ideas, Concerns, Expectations:

• You think it is related to the chimneys and coal mines you worked in when you were young (you knew it would catch up with you someday). You're worried this is something which will not get better and was hoping the doctor would tell you this will go away. It will, won't it?

Past Medical History:

• Hypertension

Drug History:

• Ramipril 2.5mg OD, atorvastatin 20mg ON.

• NKDA

Family History:

• Your father died from a heart attack at 65 years old.

• Your brother has chronic asthma.

Social History:

• You live at home with your wife, with no pets. You value your independence but have found increasing difficulty in going out to shop and you feel knackered when you talk there for 10 minutes.

• You work as a customer sales adviser.

• You have smoked 30 cigarettes a day since you were 24 (=45 pack years).

• You drink a glass of wine at dinner each night.

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Examination Findings:

• Respiratory rate 24

• Laboured breathing with an audible wheeze and the patient lying forward to get a breath when you ask them to get up and take their shirt off.

• Equal chest expansion, but on percussion, you don't hear the usual dullness over the liver and heart. On auscultation, there is widespread wheeze and crackles at the bases.

• Pitting oedema in both ankles.

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Differentials:

1. Chronic obstructive pulmonary disease (with cor pulmonale and associated pulmonary oedema)

2. Congestive heart failure

3. Lung cancer

4. Interstitial lung disease e.g. coal-workers pneumoconiosis

5. Bronchiectasis

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Investigations:

Bedside:

• Sputum sample = culture

• ECG (previous MI, ventricular strain)

Bloods:

• FBC = (infection, anaemia can cause dyspnoea, polycythaemia can be a complication of COPD)

• U&E & LFT = (before meds, screen for concurrent CKD or liver disease)

• Lipids, HbA1c, glucose = (cardiovascular risk factors)

• BNP = (<100 makes the diagnosis of heart failure unlikely as per NICE guidance hence has good -ve predictive value)

• ABG = (respiratory failure, criteria for LTOT)

Imaging & Special Tests:

• CXR = (hyperinflation e.g. >6 anterior ribs, signs of heart failure, screen for suspicious lesions)

• Spirometry = (diagnose and classify COPD according to FEV1)

• Echo = (assess heart failure)

• High resolution CT = (demonstrate emphysema or interstitial lung disease)

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Management (COPD):

Conservative:

• MDT approach

• Smoking cessation

• Vaccinations including pneumococcal, influenza (and COVID)

• Pulmonary rehabilitation

• Personalised self-management plan

• Optimise treatment for co-morbidities

• Ensure good inhaler techniques

Medical:

• STEP 1: Short-acting beta-2 agonists (SABA) PRN e.g. salbutamol or short-acting antimuscarinics (SAMA) PRN e.g. ipratropium

• STEP 2: If no asthmatic or steroid responsive features - long-acting beta-agonist (LABA) + long-acting muscarinic antagonist (LAMA) e.g. Anoro Ellipta

• STEP 2: If asthmatic or steroid responsive features - long-acting beta-agonist (LABA) + inhaled corticosteroid (ICS) e.g. Fostair, Symbicort, Seretide

• STEP 3: Combination of LABA + LAMA + ICS e.g. Trimbo, Trelegy Ellipta

• Additional therapies include prophylactic antibiotics for recurrent exacerbations (e.g. azithromycin).

• Advanced: nebulisers e.g. salbutamol/ ipratropium, oral theophylline, oral mucolytic e.g. carbocisteine, non-invasive ventilation (NIV). Long-term oxygen therapy (LTOT)

Surgical:

• Lung volume reduction surgery or lung transplant.

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Viva Questions:

What is COPD?

COPD, or Chronic Obstructive Pulmonary Disease, is a progressive lung condition involving chronic bronchitis and emphysema. It causes airflow obstruction, leading to symptoms like shortness of breath and chronic cough. Smoking is a primary cause, and while there's no cure, treatments can manage symptoms and improve quality of life.

Is COPD an obstructive or restrictive disease?

COPD is an obstructive lung disease, characterised by difficulty exhaling air. Obstructive diseases, including COPD, show reduced airflow, while restrictive lung diseases e.g. pulmonary fibrosis involve difficulty fully expanding the lungs with reduced lung volumes.

What is an exacerbation of COPD?

An exacerbation of COPD refers to a sudden worsening of symptoms in individuals with Chronic Obstructive Pulmonary Disease. During an exacerbation, there is a notable increase in breathlessness, coughing, and sputum production. Exacerbations may be triggered by infections, air pollution, or other factors.

How do you manage an acute exacerbation of COPD?

• Bronchodilators: Quick-relief medications to open airways.

• Corticosteroids: Reduce airway inflammation.

• Oxygen Therapy: Ensure sufficient oxygen levels.

• Antibiotics: If bacterial infection is present.

• Non-Invasive Ventilation: For respiratory support.

• Lifestyle Changes: Smoking cessation, avoiding pollutants.

• Monitoring: Regular assessment of vital signs and response to treatment.

• Pulmonary Rehabilitation: Programs to enhance lung function and exercise tolerance.

• Fluid Management: Maintain hydration cautiously.

• Hospitalisation: For severe cases or respiratory failure.

Why are ABGs often performed when a patient presents with an acute exacerbation of COPD?

ABGs are often performed during acute COPD exacerbations to assess oxygen and carbon dioxide levels, aiding in the diagnosis of respiratory failure. Elevated carbon dioxide levels (hypercapnia) in ABGs indicate type 2 respiratory failure, a common feature of respiratory failure in COPD exacerbations. This information guides treatment decisions, such as the need for oxygen therapy and ventilatory support, and helps monitor the effectiveness of interventions.

What does pulmonary rehabilitation involve?

Pulmonary rehabilitation involves supervised exercises (aerobic and strength training), education on condition management, breathing retraining, nutritional counseling, psychosocial support, behavioral assistance (e.g., smoking cessation), symptom management strategies, and empowerment for self-care. It is personalised to enhance exercise capacity and overall well-being in individuals with chronic respiratory diseases like COPD.

What is the difference between CPAP and BiPAP?

CPAP (Continuous Positive Airway Pressure):

• Pressure Delivery: CPAP delivers a continuous, constant positive pressure throughout the entire breathing cycle—both during inhalation and exhalation.

• Purpose: Primarily used to treat obstructive sleep apnea by preventing the collapse of the upper airway during sleep.

BiPAP (Bi-level Positive Airway Pressure):

• Pressure Delivery: BiPAP delivers two distinct pressure levels: a higher pressure during inhalation (IPAP - Inspiratory Positive Airway Pressure) and a lower pressure during exhalation (EPAP - Expiratory Positive Airway Pressure).

• Purpose: BiPAP is used in various clinical settings to assist with breathing in conditions such as acute respiratory failure, COPD exacerbations, and neuromuscular disorders. The dual pressure settings make it more comfortable for patients and can assist in overcoming the resistance of the airways during exhalation.