3. Chronic Obstructive Pulmonary Disease (COPD)

📄Definition

Progressive, irreversible airflow limitation due to chronic inflammation from smoking or environmental exposure.

Includes:

  • Chronic bronchitis: productive cough ≥3 months for ≥2 consecutive years

  • Emphysema: alveolar wall destruction & airspace enlargement

Mnemonic: COPD
Chronic
Obstructive
Pulmonary
Disease

🔬Pathophysiology

  • Inhaled irritants (e.g. smoke) → inflammation → mucus hypersecretion + alveolar destruction

  • Leads to air trapping, reduced gas exchange, and increased work of breathing

🛡️Risk Factors

Mnemonic: SCARE
Smoking (most important)
Cooking fuel/air pollution (biomass exposure)
Alpha-1 antitrypsin deficiency
Repeated childhood infections
Environmental/occupational exposure (e.g. coal, dust)

📋Clinical Features 

Mnemonic: COUGHED
Chronic productive cough
Overexertion causes dyspnoea
Unusual wheeze
Gradual onset of symptoms
Hyperinflated chest
Exercise limitation
Daily sputum production

📊 Diagnosis

Confirmed by spirometry

  • Post-bronchodilator FEV₁/FVC <0.7 (fixed obstruction)

  • No full reversibility (contrast with asthma)

Other investigations:

  • CXR: rule out malignancy, assess hyperinflation

  • Alpha-1 antitrypsin: if <40 yrs or FHx

  • FBC: polycythaemia (from chronic hypoxia)

  • Sputum culture: if recurrent exacerbations

🩻 CXR Findings

Mnemonic: HEAVES
Hyperinflated lungs
Elongated heart shadow
Attenuated vessels (vascular markings ↓)
Vertical heart
Emphysematous bullae
Small peripheral markings (loss of definition)

Severity 

Based on FEV₁ % predicted:

SeverityFEV₁ %Description
Mild≥80%Often underdiagnosed
Moderate50–79%Symptoms with exertion
Severe30–49%Symptoms at rest
Very Severe<30%Risk of respiratory failure

Also use MRC Dyspnoea Scale (Grade 1–5) to assess breathlessness

Management 

Mnemonic: STOP BREAD
Smoking cessation – most important
Therapy tailored to breathlessness/exacerbations
Oxygen (LTOT) if PaO₂ ≤7.3 kPa
Pulmonary rehab for MRC ≥3
Bronchodilators: SABA/SAMA initially
Regular LABA + LAMA if persistent breathlessness
Exacerbation prevention: ICS if eos ≥2% or frequent flare-ups
Antibiotics if signs of infection
Diet and flu/pneumococcal vaccines

Inhaler choice based on eosinophil count, exacerbation history, and breathlessness

Exacerbation Management

Mnemonic: COPD-X
Corticosteroids: prednisolone 30mg OD × 5 days
Oxygen – target SpO₂ 88–92%
Prompt antibiotics if ↑sputum purulence
Duonebs (salbutamol + ipratropium)
X-ray to exclude pneumonia/pneumothorax

Consider hospital admission if confusion, cyanosis, or worsening hypoxia

Monitoring & Review

  • Annual review (inhaler technique, adherence, symptoms)

  • Monitor MRC dyspnoea scale, exacerbation frequency, BMI

  • Consider home rescue pack (antibiotic + steroid) for frequent exacerbators

❗Complications

Mnemonic: CHAP
Cor pulmonale (right heart failure)
Hypercapnic respiratory failure
Acute exacerbations
Pneumothorax (esp. in bullous disease)

Differential Diagnoses

Mnemonic: ABC LUNG
Asthma
Bronchiectasis
CHF
Lung cancer
Upper airway obstruction
Neuromuscular disease
GORD-associated cough

Last updated in line with NICE NG115 (March 2023)
Reviewed for PassMap: 14 July 2025
This content is NICE-compliant and exam-optimised for the Physician Associate Regulation Assessment (PARA).

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