COPD & alpha-1 antitrypsin flashcards
25 high-yield MRCP Part 1 cards from the Intellect Medicos Respiratory Medicine course. Try to answer each question before you open it — then study them properly with spaced repetition, which brings each card back just before you would forget it.
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What spirometry finding confirms COPD?
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Post-bronchodilator FEV1/FVC < 0.7.
Why? Persistent (not fully reversible) airflow obstruction after a bronchodilator is the defining feature of COPD.
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In stable COPD WITHOUT asthmatic features, what inhaler is added if the patient is still limited despite a short-acting bronchodilator (NICE NG115)?
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A LAMA + LABA combination.
Why? Dual long-acting bronchodilation improves symptoms and exacerbations. If there ARE asthmatic/steroid-responsive features, LABA + ICS is used instead.
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What is the mechanism of action of tiotropium?
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Long-acting muscarinic (M3) receptor antagonist (LAMA).
Why? Blocking acetylcholine at airway M3 receptors relaxes bronchial smooth muscle.
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Which infection risk is increased by inhaled corticosteroids in COPD?
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Pneumonia.
Why? ICS should be used when there are asthmatic features or frequent exacerbations, and patients should be warned about pneumonia risk.
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Which two tests should be done before starting long-term azithromycin prophylaxis in COPD (course notes)?
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An ECG (to exclude QT prolongation) and liver function tests.
Why? Macrolides prolong the QT interval and can be hepatotoxic.
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What is the mechanism of action of roflumilast?
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Phosphodiesterase-4 (PDE-4) inhibitor.
Why? It raises cAMP in inflammatory cells, reducing airway inflammation and exacerbations.
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When is roflumilast used in COPD (course notes / NICE)?
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Severe COPD with chronic bronchitis (post-bronchodilator FEV1 < 50% predicted) AND 2 or more exacerbations in the last 12 months despite triple inhaled therapy; started by a specialist.
Why? It is an oral add-on for severe COPD with frequent exacerbations.
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What oral steroid regimen is used for an acute exacerbation of COPD?
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Prednisolone 30 mg once daily for 5 days.
Why? A short course speeds recovery and reduces treatment failure. Use IV hydrocortisone if the patient cannot take oral medicine.
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In an acute COPD exacerbation, what oxygen target is used BEFORE the ABG is available?
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SpO2 88–92% (e.g. 28% Venturi mask at 4 L/min).
Why? Many COPD patients retain CO2, and high-flow oxygen can worsen hypercapnia and acidosis.
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What is the most common bacterial cause of an infective COPD exacerbation?
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Haemophilus influenzae.
Why? Other common organisms are Streptococcus pneumoniae and Moraxella catarrhalis.
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What are the first-choice oral antibiotics for an infective exacerbation of COPD (NICE NG114)?
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Amoxicillin, doxycycline or clarithromycin.
Why? Antibiotics are given when sputum is purulent or there are signs of pneumonia; choice depends on allergy and previous cultures.
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Why does co-prescribing clarithromycin or ciprofloxacin with theophylline need caution?
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They inhibit the hepatic cytochrome P450 metabolism of theophylline, raising levels and the risk of toxicity.
Why? Theophylline has a narrow therapeutic index; levels should be monitored and the dose adjusted.
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Name three features of theophylline toxicity.
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Any three of: nausea and vomiting, tachyarrhythmias, seizures, hypokalaemia, agitation.
Why? Theophylline is a phosphodiesterase inhibitor and adenosine antagonist with a narrow therapeutic index.
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What ABG criteria indicate NIV in an acute exacerbation of COPD (BTS)?
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Respiratory acidosis (pH < 7.35 with PaCO2 > 6.5 kPa) persisting despite optimal medical therapy.
Why? NIV (bilevel) supports ventilation and clears CO2; BTS quality standards aim to start it within 60 minutes of the blood gas that prompted the decision.
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What PaO2 criteria make a COPD patient eligible for long-term oxygen therapy (LTOT)?
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PaO2 < 7.3 kPa when stable, or 7.3–8 kPa with secondary polycythaemia, peripheral oedema or pulmonary hypertension.
Why? LTOT for at least 15 hours a day improves survival in chronic hypoxaemia.
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Which COPD patients should NOT be offered LTOT?
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Those who continue to smoke.
Why? Smoking near oxygen is a serious fire and burns risk.
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LTOT in COPD should be used for at least ______ hours a day.
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15
Why? Survival benefit in the trials was seen only with prolonged daily use.
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Which pattern of emphysema favours lung volume reduction surgery?
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Upper-lobe predominant emphysema.
Why? Removing the worst, hyperinflated upper lobes lets the healthier lung expand. NICE refers for lung volume reduction assessment if FEV1 < 50%, non-smoker, 6-minute walk ≥ 140 m, with hyperinflation and emphysema on CT.
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Alpha-1 antitrypsin deficiency is caused by mutations in the ______ gene on chromosome 14.
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SERPINA1
Why? A1AT is a serine protease inhibitor made by the liver that protects the alveoli from neutrophil elastase.
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Alpha-1 antitrypsin deficiency is caused by mutations in the SERPINA1 gene on chromosome ______.
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14
Why? A1AT is a serine protease inhibitor made by the liver that protects the alveoli from neutrophil elastase.
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What is the inheritance pattern of alpha-1 antitrypsin deficiency?
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Autosomal co-dominant.
Why? Both alleles are expressed, so heterozygotes (e.g. PiMZ) have intermediate levels.
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Which A1AT genotype is usually responsible for clinical disease?
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PiZZ (about 10–15% of normal A1AT levels).
Why? PiMM is normal; PiMZ and PiSS give about 60%, PiSZ about 40%.
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What type of emphysema does alpha-1 antitrypsin deficiency cause?
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Early-onset panacinar emphysema, mainly in the lower lobes.
Why? Smoking-related emphysema is typically centriacinar and upper-lobe predominant.
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Does NICE recommend IV alpha-1 antitrypsin replacement therapy for A1AT deficiency?
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No — NICE advises not to offer A1AT replacement therapy.
Why? Management is smoking cessation, standard COPD treatment, vaccination, screening relatives and, for end-stage disease, transplantation.
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Which biologic did NICE recommend in 2026 as an add-on for uncontrolled COPD with a blood eosinophil count of at least 0.3 × 10⁹/L, and what is its target?
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Dupilumab: a monoclonal antibody against the IL-4 receptor alpha subunit (blocks IL-4 and IL-13 signalling).
Why? NICE TA1142 (March 2026): add-on to triple therapy (or LAMA + LABA if ICS unsuitable) when there has been ≥ 1 severe or ≥ 2 moderate exacerbations in 12 months. Response is reviewed at 12 months.