2- secondary care management of COPD

Question 1

what is the approach in clinic?

Answer 1

• confirm diagnosis
• determine any additional diagnosis or exacerbating factors
• Optimise therapy
• Consider surgical options – for a very small proportion of patients (unfortunately)
• Discuss anticipatory care, and end of life management as not actually too much to be done sometimes

Question 2

what scans are useful to test for differential diagnosis of COPD in secondary care?

Answer 2

CT scans are useful for differential diagnosis

Echocardiography is useful too as picks of left heart failure etc

sputum culture also helpful

Question 3

what are examples of triple inhalers?

Answer 3

trelegy (dry powder) & trimbow (pMDI)
= trimbow better

Question 4

what eosinophil count suggests ICS?

Answer 4

> 0.3 (300 cells/microlitre)

Question 5

what are surgical options for COPD?

Answer 5

• Bullectomy
• Lung volume reduction surgery
• Endobronchial valves and coils
• Lung transplant

Question 6

what is a bullectomy?

Answer 6

removal of bullae (air in a space with no perfusion - physiological dead space)

bullae has to be more than 50%

Question 7

what is lung volume reduction surgery?

Answer 7

• Effective for more heterogeneous (unevenly distributed) bullous emphysema
• Surgical removal of the upper lobe(s)
• Rarely done these days
• Must have been through pulmonary rehabilitation

= not common

Question 8

what are endobronchial valves/coils?

Answer 8

• One way valves or self collapsing coils inserted via a bronchoscope
• Block ventilation to bullae, and areas of poor V/Q matching

Question 9

when is lung transfer the only option?

Answer 9

for patients with pulmonary hypertension

Question 10

why can surgery for COPD not be that good?

Answer 10

Patients are often too old, or too frail for surgery

Question 11

is long term oxygen therapy given?

Answer 11

yes - you can assess people as can be beneficial in terms of mortality particularly for people with hypertension

• if oxygen saturation <92% and treatment optimised already then could be candidate

Question 12

what is anticipatory care?

Answer 12

helping make a plan for people (like palliative care) as most people with COPD who go to secondary care can’t be helped much - most patients are frail elderly with significant co-morbidities

Question 13

what is treatment for palliation of breathlessness?

Answer 13

• A fan is the most useful intervention
• Anxiolytics = reduce anxiety
• Lorazepam 0.5mg PRN = anxiety/sedative to take as needed
• Oral liquid morphine 1mg PRN = pain & relaxation medication take as needed
• Pulmonary rehabilitation

Question 14

what is an exacerbation of COPD?

Answer 14

an acute worsening of respiratory symptoms that results in additional therapy

• symptoms not specific to COPD= differential diagnosis should be considered

Question 15

what are some differential diagnoses for COPD exacerbation?

Answer 15

• Pneumonia
• Pneumothorax
• Pleural Effusion
• Pulmonary Embolism
• Pulmonary Oedema
• Cardiac arrhythmias

Question 16

what are some good tests to be done for exacerbations of COPD in secondary care?

Answer 16

• CXR (always)
• ECG (always)
• CTPA (sometimes)
• Echo (sometimes)
• A careful history

Question 17

what is treatment for exacerbations of COPD?

Answer 17

• Increased short acting bronchodilators are recommended as initial management
• Systemic steroids can improve lung function, oxygenation and shorten recovery time. Duration of therapy should be not more than 5-7 days
• Antibiotics, when indicated, can shorten recovery time, reduce the risk of early relapse, treatment failure. Duration of therapy should be 5-7 days

Question 18

what is hypercapnic respiratory failure?

Answer 18

• Acute on Chronic Type 2 Respiratory Failure
• Low pO2
• (Very) High pCO2
• High HCO3

= metabolic compensation for a chronic respiratory acidosis

Question 19

what is treatment of hypercapnic respiratory failure?

Answer 19

non-invasive ventilation (NIV) = increases tidal volume, increasing minute volume to blow off CO2

Question 20

what are the 2 levels of pressure of non-invasive ventilation?

Answer 20

1. expiratory positive airways pressure = lowers work of breathing, overcomes intrinsic PEEP, reduces pCO2
2. Inspiratory Positive Airways Pressure, increases tidal volume & minute volume, reduces pCO2

Question 21

what are important considerations for non-invasive ventilation?

Answer 21

• Will the patient tolerate the mask?
• Does the patients have an advanced care planning to avoid NIV?
• What will we do if NIV fails?
• What is the ceiling of therapy?
• If it works reverses the pH/pCO2 is there a reversible trigger to treat?
• If the patient survives, will they need NIV at home, and will they manage with it?

Question 22

how does exacerbation management in hospital differ from at home?

Answer 22

Exacerbation management in hospital is the same as at home, but we have the option of NIV, for some people