COPD Flashcards
How do COPD patients present?
Chronic cough +/- sputum production
SOB
Recurrent lower respiratory tract infections
Symptoms being triggered by viral infections
Smoking history or air pollution exposure
>40 years of age
Is spirometry diagnostic of COPD?
No!
Need clinical findings
Spirometry is only confirmatory testing
Vice versa, a patient can have “preserved” lung function on spirometry but be diagnosed with COPD based on history and clinical features/exacerbations
List 3 things that reduce mortality in COPD
1) Supplemental oxygen in select populations
- Those with severe resting hypoxemia on RA (ABG PaO2 ≤55mmHg or SpO2 <88%; PaO2 ≤60% if pulmonary HTN/RHF )
- Must be worn continuously for at least 16-18 hours/day
2) Stop smoking
3) ?NIV
- Recommended if pCO2 >=52 when stable + nighttime hypoxemia SpO2 =<88%
- However evidence is mixed
Can you rely on pulse oximetry readings in smokers?
No
Smokers can still be hypoxic despite normal resting O2 saturation because pulse oximeter cannot tell the difference between oxy and carboxyhaemoglobin
Need to check ABG
Do inhalers improve mortality in COPD?
No
Only symptoms and exacerbations
Patients without symptoms/exacerbations can get away with ventolin PRN
Can long-term azithromycin reduce exacerbation of COPD?
Yes
Consider in moderate/severe COPD (despite inhaler use)
Which monotherapy inhaler should you NOT use in COPD?
Monotherapy ICS
Which monotherapy inhaler should you NOT use in asthma?
Monotherapy beta-agonist
What does a significant pre- and post-bronchodilatory spirometry suggest in COPD?
Shows how much room for improvement there is with the addition of inhaler therapies
Once COPD is well controlled, a significant post-bronchodilatory may be absent
COPD patients can have bronchodilatory response
When should you suspect asthma COPD overlap?
Childhood asthma
Peripheral eosinophilia
Allergic triggers
When to test for alpha-1-antitriypsin deficiency?
Can consider testing in emphysema which may be useful particularly for counselling family members
What is considered a bronchodilatory response on spirometry?
200ml or 12% increase in FEV1 or FVC
How to interpret spirometry in COPD?
5 steps
1) Look at the curve
- FEV1/FVC <70% should look curvilinear
2) FEV1/FVC ratio <70% = obstruction
3) Degree of obstruction is based on FEV1% predicted (predicted values are based on age, sex, and height)
4) Look at FVC
- If normal and all above suggests obstruction, you are done. Confirmed obstructive.
- If low, consider mixed obstructive restrictive picture but this needs full RFTs. A low FVC may also mean that the patient has so much air trapping that they couldn’t exhale long enough
5) Bronchodilator response (12% or 200ml increase in FEV1 or FVC)
- Gives you an idea of what optimal lung function could be with treatment
COPD GOLD staging is based on…
FEV1% predicted
Exacerbation frequency and whether it leads to hospitalisation
Severity of dyspnoea symptoms (mMRC or CAT)
What’s the BODE index?
Predicts mortality, hospitalisation post lung volume reduction surgery B - BMI O - obstruction; FEV1% predicted D - dyspnoea; mMRC dyspnoea scale E - exercise; 6MWT
Discuss the stepwise management for COPD management
1st line
- If the patient only has symptoms from a trigger (e.g. URTI), start with SABA or SAMA
2nd line
- For chronic symptoms, start with either a LAMA or LABA
- LAMAs outperform LABAs
- LABA/LAMA combination is associated with reduced rate of COPD exacerbations annually as compared to LABA/ICS
- Don’t use LAMA and SAMA together
3rd line
- Consider adding ICS for moderate/severe COPD however this should never be used as monotherapy (this is the opposite of asthma treatment in which LABAs should never be used as monotherapy and ICS are the cornerstone of therapy)
- ICS may increase the risk of pneumonia so not add unless exacerbations are frequent
Systemic steroids should not be used long-term
Pulmonary rehab can help with symptoms and functional improvement/ET and can reduce hospitalisation if patients have had an exacerbation within the last month
Long-term azithromycin (either low dose daily or 3 times/week) can reduce exacerbations but has the risk of adverse cardiac events due to QT prolongation or ototoxicity.
Rx for COPD exacerbation
Prednisolone for 5/7
SABA with spacer or nebuliser
+/- abx for infective exacerbation
+/- BIPAP or intubation if T2RF
Potential underlying aetiologies to consider in COPD exacerbation
PE
Viral infection
Environmental exposures
When would you use abx in COPD exacerbation?
Fever
Raised inflammatory markers
Very unwell
Change in amount, colour, purulence of sputum
Consolidation on CXR (complicated by pneumonia)
What abx to use and for how long in COPD exacerbation?
Mild: amoxycillin 500mg TDS or doxycycline 100mg BD
Severe: Ceftriaxone 1g + azithromycin 500mg
5-7 days
Risk factors for COPD
Smoking
alpha-1 anti-trypsin deficiency
Dust and fume exposure, smoke from cooking
Bronchial hyperresponsiveness
Respiratory infections/mucous hypersecretion
How do classify mild, moderate, severe COPD?
Mild: FEV 1 60-80% predicted
Moderate: FEV1 40-60% predicted
Severe: FEV1 <40% predicted
IE COPD. List causative pathogens
1) Bacterial
2) viral
1) Haemophilus influenzae, strep pneumoniae, mycoplasma, moraxella, klebsiella, chlamydia, pseudomonas, staph
2) influenza, rhinovirus, RSV, metapneumovirus
List non-infective causes of NIE COPD
PE LVF PTX Anxiety Sedation Environmental pollution
Acute rx exacerbation of COPD
- Oxygen, aim SpO2 88-92%
- Consider NIV +/- intubation in T2RF (pH <7.35, paCO2 >45)
- Steroids for 5 days
- Bronchodilators/burst therapy with salbutamol + ipratropium
- Abx
Dose equivalent of 1mg dexamethasone
1) Methylprednisolone
2) Prednisolone
3) Hydrocortisone
4) Cortisone
1) 4mg
2) 5mg
2) 20mg
4) 25mg
What’s a typical setting for biPAP for COPD exac?
10 (insp)/5 (exp)
5 exp keeps the alveoli opened, allows lung to get rid of CO2
Is theophylline recommended in COPD management?
Oral bronchodilator
No
What is the evidence behind the use of bronchodilators in COPD management?
Improves lung function and symptoms, and decreases exacerbations
?Maybe some mortality benefit
LAMAs are better than LABAs
What is the evidence behind the use of ICS in COPD management?
Reduces exacerbations and symptoms, but not rate of decline in lung function or mortality
Indicated only in severe disease (FEV <50%) and a history of frequent exacerbations
Increase risk of pneumonia
Any benefit with long-term oxygen therapy for nocturnal desaturation (not OSA)?
No
Improves quality of sleep and reduces ventricular premature contractions, but does not reduce mortality
