Chronic Obstructive Pulmonary Disease (COPD)

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Key points ⚡
Succinct notes to superpower your revision
Chronic obstructive pulmonary disease\: lung disease with persistent respiratory symptoms and air
of emphysema, chronic bronchitis, and small airway ≥3 months in 2
consecutive years.
Prevalence\: ~3 million in the UK; mortality rate ~30,000/year; 1.4 million GP appointments annually; 2nd largest cause of
emergency admissions in the UK.
Risk factors\: tobacco smoking (80% of cases), indoor air pollution, alpha-1 antitrypsin de
autosomal dominant).
Symptoms\: progressive dyspnoea, chronic productive cough, recurrent LRTIs, fatigue, headache (CO 2
retention).
Examination
pulmonale, CO retention
2
Di
LRTIs), congestive heart failure (orthopnoea, paroxysmal nocturnal dyspnoea), lung cancer (weight loss, haemoptysis),
tuberculosis (night sweats, weight loss).
Investigations\: spirometry (FEV1/FVC \<70%), pulse oximetry, sputum culture, ECG (cor pulmonale), baseline blood tests
(FBC, U&Es, LFTs, CRP), ABG, chest X-ray (hyperin
Management\: smoking cessation, pulmonary rehabilitation, vaccinations (annual in
vaccine), personalised self-management plan; inhalers (step-up process), long-term oxygen therapy, surgical options (lung
volume-reduction, lung transplantation).
Complications\: hypercapnic respiratory failure, secondary polycythaemia, cor pulmonale, bronchiectasis, anxiety,
depression, osteoporosis, sleep disturbance.
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A comprehensive topic overview

Introduction

Chronic obstructive pulmonary disease (COPD) is a lung disease characterised by persistent respiratory symptoms and
air
as a productive cough for at least 3 months in 2 consecutive years. 1
In the UK, the prevalence of COPD is approximately 3
million, and the mortality rate is 30,000 per year. 2
Furthermore, COPD accounts for 1.4 million GP appointments annually
and is the second-largest cause of emergency admissions in the UK. 3
COPD is a very common and important topic, which
doctors in all medical disciplines must be familiar with.

Risk factors

Tobacco smoking\: associated with 80% of COPD cases
4Indoor air pollution\: this usually occurs in the developing world, where biomass is burnt inside homes for cooking and
heating
Alpha-1 antitrypsin de
Alpha-1 antitrypsin is a protease inhibitor with one of its actions being to prevent neutrophil elastase from breaking down
alveolar structures. Therefore, a de5
Some cases of alpha-1 antitrypsin de
antitrypsin by the liver, resulting in accumulation of it in the liver, and therefore cirrhosis.

Clinical features

History
Presenting complaint
COPD patients present with progressive dyspnoea and chronic productive cough.
History of presenting complaint
Dyspnoea\: initially exertional, but can progress to resting dyspnoea over the course of the condition (months to years).
Dyspnoea is graded using the Medical Research Council (MRC) dyspnoea scale (Table 1)
Chronic productive cough\: usually colourless sputum, which m a y become green during lower respiratory tract infections
(LRTIs)
Recurrent LRTIs
Fatigue
Headache (due to CO retention)
2
Table 1. MRC Dyspnoea Scale. Used with the permission of the MRC
6
Grade Level of Activity
1 Breathless during strenuous exercise only
2 Breathless when hurrying or walking up a slight incline
3
Walks slower than people of the same age due to dyspnoea, or needs to pause
for breath when walking at own pace
It is also important to assess the impact of the patient’s COPD on their wellbeing and daily life, using the COPD Assessment
Test (CAT) (Table 2).
Table 2. The CAT. Scores range from 0-40; higher scores indicate a greater impact of COPD on the patient’s daily life
7
SCORE
I never cough I have no phlegm in my
chest at all
My chest does not feel
tight at all
When I walk up a hill or

of breath
1 2 3 4 5 I cough all the time
1 2 3 4 5 My chest is full of phlegm
1 2 3 4 5 My chest feels very tight
1 2 3 4 5
I am not limited to doing
any activities at home
1 2 3 4 5
I am con
home despite my lung 1 2 3 4 5
When I walk up a hill or

completely out of breath
I am completely limited to
doing any activities at
home
I am not con
my home at all despite
Past medical history
Previous exacerbations or hospitalisations
Medical comorbidities, including lung disease (such as asthma)
Psychiatric comorbidities, including depression and anxiety
Previous operations
Medication/allergiesRegular medications (and any recent changes) *ACE-inhibitors can cause a dry cough
Over-the-counter medications
Allergies
Family history
Lung disease
Liver disease (may suggest alpha-1 antitrypsin de
Social history
Smoking history\: quantify in pack-years (1 pack-year = smoking 20 cigarettes a day for a year)
Alcohol history
Recreational drug use
Occupation\: may be exposed to indoor air pollution
Examination
A full respiratory examination should be performed in suspected cases of COPD. See the Geeky Medics guide here.
Most common
Tachypnoea\: due to an increased neural respiratory drive to breathe
Wheeze on auscultation\: due to in
Pursed lips breathing\: to increase airway resistance and therefore reduce expiratory
Less common
Barrel chest (Figure 1)\: due to gas trapping
Peripheral cyanosis (Figure 2)
Cor pulmonale (signs of right heart failure, such as peripheral oedema and hepatomegaly)\: due to pulmonary
hypertension, which results from chronic hypoxic pulmonary vasoconstriction
CO 2
retention
diencephalon (which acts as a relay centre for sensory and motor impulses)
8
Figure 1. Patient with a barrel chest 12[/caption]13
Figure 2. Peripheral cyanosis [/caption]

Di

Dyspnoea and productive cough have important di
the features which di
Table 3. Di
DiAsthma
Bronchiectasis
Features di
Diurnal variation in symptoms and peak
History of atopy
Eosinophilia (blood and sputum)
Lung function tests\: bronchodilator reversibility
*Note that COPD and asthma can co-exist
Expectorate larger volumes of sputum
More frequent lower respiratory tract infections,
often starting in childhood
High-resolution chest CT\: bronchial dilation
Congestive cardiac
failure
Orthopnoea
Paroxysmal nocturnal dyspnoea
History of cardiovascular disease
Fine basal inspiratory crepitations
Bloods\: elevated BNP
Echocardiogram\: reduced ejection fraction
Lung cancer
Weight loss
Haemoptysis
Chest X-ray and bronchoscopy\: the presence of
tumour
Tuberculosis
Drenching night sweats
Weight loss
Positive sputum culture and microscopyInvestigations
Bedside investigations
Spirometry
Typical
FEV1 is also used to classify the severity of COPD (Table 4)
9
See the Geeky Medics spirometry interpretation guide for further information
Table 4. Severity grading of COPD
Severity of
COPD
FEV1
Mild >80%
Moderate 50-80%
Severe 30-50%
Pulse oximetry
Aim for SpO of 88-92%
2
Avoid administering excessive amounts of O \:
2
O displaces CO in haemoglobin, which increases CO in the blood
2 2 2
Increased CO 2
in the blood cannot be removed due to failure of alveolar ventilation in emphysema, leading to
hypercapnic respiratory failure
Other investigations
Sputum culture\: enables targeted antibiotic therapy during exacerbations of COPD
ECG\: cor pulmonale (peaked p waves and right axis deviation) (Figure 3)
Figure 3. Peaked p wave (“p pulmonale”), indicating right atrial hypertrophy in cor pulmonale
14
Laboratory investigations
Baseline blood tests\: FBC, U&E, LFTs, CRP
Arterial blood gas (ABG)
During stable disease\: PaCO 2 2>6.0 and bicarbonate >30 indicates that the patient is a “CO -retainer”During exacerbations\: check for respiratory acidosis (PaCO 2
>6.0 and pH \<7.35)
Imaging
Chest X-ray\: hyperin
10
>6 anterior ribs or >10 posterior ribs visible in the mid-clavicular line
Flattened diaphragm
Hyperlucent lungs
Figure 4. Hyperin
15

Management (long-term)

*For further information on the management of acute exacerbations of COPD, see here.
Conservative management
Smoking cessation\: see the Geeky Medics guide on smoking cessation for useful tips
Pulmonary rehabilitation
Annual in
Personalised self-management plan
Medical management
Inhalers
Medical management of COPD is largely administered through inhalers, with a step-up process as needed (Figure 4).Figure 5.Medical management of COPD (adapted from NICE guidelines 11
). Asthmatic features include\: previous diagnosis of
asthma/atopy, increased blood eosinophils, diurnal variation of peak
acting beta-2 agonist; SAMA= short-acting muscarinic antagonist; LABA= long-acting beta-2 agonist; LAMA= long-acting muscarinic
antagonist; ICS= inhaled corticosteroid.
*Note that some clinicians prefer to use the international GOLD guidelines for the management of COPD, so please ensure
that you know which guidelines your medical school will use for your examinations.
9
Long-term oxygen therapy
Indications (one of the following)\:
SpO \<88%
2
PaO \<7.3kPa
2
Contraindicated in current smokers due to the risk of explosion and/or burns
Surgical management
Lung volume-reduction surgery\: for very severe COPD, which does not respond to optimal medical management
Lung transplantation\: if not suitable for other surgical options

Complications

Hypercapnic respiratory failure (PaO 2 2
\< 8.0 and PaCO > 6.0)
Secondary polycythaemia (raised haemoglobin)\: due to chronic hypoxaemia
Cor pulmonale\: right heart failure, caused by pulmonary hypertension as a result of chronic hypoxic pulmonary
vasoconstriction
Bronchiectasis\: due to chronic and repeated infections
Anxiety and depression
Osteoporosis\: due to chronic steroid use, smoking, lack of bone-strength exercise and vitamin D de
Sleep disturbance

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allows authors to improve their articles, leading to even better content on Geeky Medics!References
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Related notes

National Institute for Health and Care Excellence. C h r o n i c O b s t r u c t i v e P u l m o n a r y D i s e a s e i n O v e r 1 6 s \: D i a g n o s i s a n d
M a n a g e m e n t . Published in 2018. Available from\: [LINK]
Asthma
Cabot R. B a r r e l c h e s t . CC BY-SA. Available from\: [LINK]
Bronchiectasis
Fletcher W. P e r i p h e r a l c y a n o s i s . CC BY-SA. Available from\: [LINK]
Croup
Heilman J. P p u l m o n a l e . CC BY-SA. Available from\: [LINK]
Cystic Fibrosis
James Heilman, MD. COPD chest x-ray. Published August 2010. Licence\: CC BY-SA. Available from\: [LINK]
Interstitial Lung Disease

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Reviewer

Contents

Dr Neeraj Shah
Respiratory Medicine Registrar
Introduction
Risk factors
Clinical features
Di
Investigations
Management (long-term)
Complications
Source\: geekymedics.com