COPD Flashcards
Which features suggest an acute exacerbation of COPD
Worsening breathlessness Increased sputum volume and purulence Cough Wheeze Fever URTI in past 5 days Increased RR or HR
Signs that indicate a severe exacerbation of COPD
Marked breathlessness and tachypnoea Pursed-lip breathing and/or use of accessory muscles at rest New-onset cyanosis or peripheral oedema Acute confusion/drowsiness Marked reduction in ADLs
When should hospital admission be considered for acute exacerbation of COPD
Severe SOB Inability to cope at home Rapid onset of symptoms Acute confusion Cyanosis O2 sats less than 90% Worsening peripheral oedema New arrhythmia
Management of acute exacerbation of COPD if hospital admission not required
Increase doses or frequency of SABA
If no contraindications, consider oral corticosteroids for people with significant increase in breathlessness
Consider antibiotics
First choice oral antibiotics for acute exacerbation of COPD
Amoxicillin
Doxycycline
Clarithromycin
What should be done if there is no improvement in symptoms on first choice antibiotic
Send a sputum sample for culture and susceptibility testing
Offer an alternative first choice antibiotic from different class
Which antibiotic can be co-prescribed if the patient is at higher risk of treatment failure(previous or current culture with resistant bacteria)
Co-amoxiclav
When should a sputum sample for culture and sensitivity testing be carried out
Not routinely
If symptoms have not improved following antibiotic treatment
What should be done as follow up for all people who have had an exacerbation of COPD
Consider need for CXR if recurrent infections
Counsel with regard to medications
Consider need for referral to resp specialist and/or pulmonary rehab
Offer short course of oral corticosteroids and antibiotics if needed
When should oral corticosteroids and oral antibiotics be prescribed as follow up for acute exacerbation of COPD
Have had an exacerbation within the last year, and remain at risk of exacerbations
When should a patient with COPD be referred to a respiratory specialist
Diagnostic uncertainty
COPD is very severe or rapidly worsening
Age less than 40 yrs and family history of alpha-1-antitrypsin deficiency
Frequent infections
When should a person with COPD be referred to pulmonary rehabilitation
Functionally disabled(MRC dyspnoea scale grade 3 or above)
Recent hospitalisation for an acute exacerbation
When should COPD patients not be referred to pulmonary rehab
If unable to walk
Have unstable angina, or have had a recent MI
Pharmacological intervention if person with COPD continues to be limited by symptoms or has exacerbations despite use of SABA
LABA plus a long-acting muscarinic antagonist (if no asthmatic features or features suggestive of steroid responsiveness)
LABA plus ICS if steroid responsive
How is bronchodilator therapy administered for most patients
Hand-held inhaler
Spacer where appropriate
Advice for usage of a spacer with a metered-dose inhaler
Administer drug by single actuations of MDI into spacer, inhaling after each actuation
Minimal delay between inhaler actuation and inhalation
Normal tidal breathing can be used
Repeat if a second dose is required
Advice regarding spacer cleaning
Do not clean the spacer more than monthly, because more frequent cleaning affects their performance(because of build-up of static)
Hand wash using warm water and washing-up liquid, and allow the spacer to air dry
Side effects of nebuliser therapy
Dry/irritated throat
Sneezing
Nosebleed
Nausea
When should nebuliser therapy be considered
People with distressing or disabling breathlessness despite maximal therapy using inhalers
When should the dose of theophylline be reduced in COPD patients
Should be reduced in people prescribed macrolide or fluoroquinolone antibiotics for an exacerbation
When should theophylline(slow release) be considered in COPD management
After a short trial of short-acting and long-acting bronchodilators, or people who cannot use inhaled therapy
Use of mucolytic therapy in COPD management
Consider if a person with stable COPD develops a chronic cough productive of sputum
When should prophylactic antibiotic treatment for COPD be initiated in secondary care
For people with COPD who have had more than three exacerbations requiring steroid therapy and at least one exacerbation requiring hospital admission in the previous year
Macrolides should only be started following resp specialist referral
Use of phosphodiesterase-4 inhibitors in COPD management
May be considered for severe disease with persistent symptoms and exacerbations
Must be initiated by a respiratory specialist
What information should self-management plans offer for people with COPD
COPD and its symptoms
Non-pharmacological measures including diet, physical activity, pulmonary rehab, smoking cessation
Vaccinations
Appropriate use of inhaled therapies
Early recognition and management of exacerbations
What is required for confirmation of COPD diagnosis
Spirometry
Post bronchodilator FEV1/FVC less than 0.7 confirms persistent airflow obstruction
MRC dyspnoea scale grade 1
Not troubled by breathlessness except during strenuous exercise
MRC dyspnoea scale grade 2
Short of breath when hurrying or walking up a slight hill
MRC dyspnoea scale grade 3
Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace
MRC dyspnoea scale grade 4
Stops for breath after walking about 100 m or after a few minutes on the level
MRC dyspnoea grade 5
Too breathless to leave the house, or breathless when dressing or undressing
Key indications for NIV
COPD with respiratory acidosis
Type II resp failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
Cardiogenic pulmonary oedema unresponsive to CPAP
Weaning from tracheal intubation
Which medication can be used if unresponsive to NIV in severe cases
Doxapram - respiratory stimulant
What is alpha-1 antitrypsin deficiency
Caused by a lack of a protease inhibitor (Pi) normally produced by the liver. The role of A1AT is to protect cells from enzymes such as neutrophil elastase.
It classically causes emphysema (i.e. chronic obstructive pulmonary disease) in patients who are young and non-smokers.
Inheritance of A1AT
Autosomal recessive
Features of A1AT
lungs: panacinar emphysema, most marked in lower lobes
liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children
IX for A1AT
A1AT concentrations
spirometry: obstructive picture
Mx of A1AT
no smoking
supportive: bronchodilators, physiotherapy
intravenous alpha1-antitrypsin protein concentrates
surgery: lung volume reduction surgery, lung transplantation
Indications for long-term oxygen therapy in COPD
4 Bs
Blue (cyanosis, sp02 <92%)
Breathing (severe airway obstruction, FEV1 <30%)
Blood (secondary polycythaemia)
Ballooning (peripheral oedema, raised JVP, hepatomegaly)
