2- primary care management of COPD Flashcards
what are 4 key parts of making COPD diagnosis?
- history = main part
- examination
- chest x-ray
- spirometry
what are the common symptoms of COPD?
- breathlessness
- cough
- sputum
- frequent chest infections
- wheeze
how do you measure how breathless someone is?
by using mMRC dyspnoea scale
what are the different grades of mMRC dyspnoea scale?
grade 0 = only breathless when strenuous exercise (Normal healthy people)
grade 1 = short of breath when hurrying on level or walking up slight hills
grade 2 = walk slower than people same age on level due to breathlessness, or have to stop for breath when walking on my own pace at level
grade 3 = stop for breath after walking 100 metres or after a few mins on level
grade 4 = too breathless to leave house or breathless when dressing & undressing
what should be involved in COPD clinical examination?
- vital signs (oxygen saturation & respiratory rate important)
- general exam (look for cyanosis, tar staining etc)
- chest exam (hyperinflated chest, crackles, wheeze, etc )
= may be normal clinical exam
what is COPD differential diagnosis?
- Asthma
- Lung cancer
- Tuberculosis
- Bronchiectasis
- Left heart failure
- Interstitial lung disease
- Cystic Fibrosis
- Idiopathic Cough
what are risk factors for COPD?
- smokers
- older adults
- deprived populations
what are some cross overs that could come up in COPD history that are red flags for lung cancer and should refer?
in history = haemoptysis, unexplained persistent change in cough/dyspnoea/chest or shoulder pain/weight loss, hoarseness, fatigue in smoker over 50
what are some cross overs that could come up in COPD clinical exam that are red flags for lung cancer and should refer?
in clinical exam = chest signs, finger clubbing, cervical and/or persistent supraclavicular lymphadenopathy
what is GOLD spirometry square?
GOLD 1 = mild = FEV1≥ 80% predicted
GOLD 2 = moderate = FEV1 between 50% and 80%
GOLD 3 = severe = FEV1 between 30% and 50%
GOLD 4 = very severe = FEV1 less than 30%
when should you perform spirometry?
if any of these indicators present in person over 40:
- dyspnoea = progressive, worse with exercise, persistent
- chronic cough = intermittent & unproductive, recurrent wheeze
- chronic sputum production
- recurrent lower respiratory tract infections
- history of risk factors = host factors, tobacco smoke, smoke from gas cooking & heating fuels, occupational dust/vapours/gas/chemicals
- family history & childhood factors = low birthweight, childhood respiratory infections
what is A, B, C and D GOLD square measurements?
A = mMRC 0-1 and 0 or 1 exacerbations leading to hospital admissions
B = mMRC ≥ 2 and 0 or 1 exacerbations leading to hospital admissions
C = mMRC 0-1 and 2 or more exacerbations leading to hospital admissions
D = mMRC ≥ 2 and 2 or more exacerbations leading to hospital admissions
what is A,B, C and D gold square explanations?
A = few symptoms & no exacerbations (consider differential diagnosis)
B = breathless people
C = few symptoms and exacerbates a lot (alternative diagnosis?)
D = symptomatic & exacerbating (unwell)
what is non-pharmacological management of COPD?
- quit cigarettes
- vaccinated (reduce serious illness & death)
- active lifestyle & exercise
- self management education - risk factor management, inhaler technique, breathlessness, written action plan
- manage comorbidities (heart failure, obesity, lung disease, ischaemic heart disease, bronchiectasis)
what is the most effective drug to help with smoking cessation?
varenicline (most effective)
- NRT (nicotine replacement therapy)
is pulmonary rehabilitation effective in help for COPD?
yes
- reduces hospitalization
- reduces symptoms
- helps health status
what are the different pharmacological management for COPD?
- bronchodilators
- inhaled steroids
=combination therapies work best
what are the most effective bronchodilators?
LABA and LAMA = best used in combination as increases FEV1 and reduced symptoms best
what is exacerbation reduction vs steroid risk result and what does that mean?
taking steroids, increase risk of pneumonia = effective in some people but causes pneumonia in some so tricky to know who to give it to
more eosinophils = more chance of exacerbating so raised eosinophil suggests you should add in steroids (as reduces exacerbations)
for raised eosinophil & more advanced COPD steroid use does slightly increase pneumonia risk but not as much as it helps reduce exacerbations
what is most effective way to take inhaled steroid for moderate to severe COPD?
triple inhaled therapy of ICS/LABA/LAMA improves lung function and works best
when should you definitely use ICS in treatment of COPD?
- history of hospitalizations
- ≥ 2 moderate exacerbations per year
- blood eosinophils >300 cells/microlitre
- history of asthma
when should you consider use of ICS?
- 1 moderate exacerbation of COPD per year
- blood eosinophils 100-300 cells/microlitre
when should you definetely not use ICS in COPD?
- repeated pneumonia
- blood eosinophils <100 cells/microlitre
- history of microbial infection
what drug should be given for people with COPD who are breathless?
LABA/LAMA
what is COPD exacerbation?
acute worsening of respiratory symptoms resulting in need for more therapy
symptoms are not specific for COPD e.g. fever
exacerbations can be due to several random factors
goal = minimize negative impact of current exacerbation
what is differential diagnosis for exacerbation?
- Pneumonia
- Pneumothorax
- Pleural Effusion
- Pulmonary Embolism
- Pulmonary Oedema
- Cardiac arrhythmia
