COPD Flashcards
What is Chronic Obstructive Pulmonary Disease (COPD)?
COPD is a common progressive disorder
characterised by irreversible airway obstruction (FEV1 <80% ; FEV1/FVC < 0.7).
Both emphysema and chronic bronchitis eventually leads to: => airflow limitation, => destruction of lung parenchyma => resultant hyperinflation of lungs, => ventilation/perfusion mis-match, => increased work of breathing => breathlessness
What is emphysema and bronchitis?
- Emphysema is permanent loss of parenchymal lung tissue
=> loss of alveoli decreases capacity for gas transfer
=> loss of lung elastic recoil results in an increased total lung volume
=> expiratory airflow limitation and air trapping
- Chronic Bronchitis clinically defined as cough and sputum production on most days for 3 months of 2 successive years.
What are the causes for COPD?
- Smoking cigarettes = 90% of COPD in developed countries
* 10-20% smokers develop COPD - suggests there is an underlying susceptibility.
=> risk of COPD also increases with pipe, water pipe and marijuana smoking
=> risk also increases with passive smoking
- Occupational exposure to
=> Dust i.e. coal, grains and silica
=> Certain fumes or chemicals i.e. welding fume, isocyanates, and polycyclic aromatic hydrocarbons
- around 20-30% of COPD due to occupational exposure
3. Air pollution - exposure to high levels of indoor air pollutants from burning wood and biomass materials i.e coal
4. Alpha1 anti-trypsin deficiency
5. Maternal smoking, pre-term birth, childhood passive smoking
6. Asthma ?
What are the symptoms of COPD?
Breathlessness - typically persistent, progressive over time, and worse on exertion.
Chronic/recurrent cough.
Regular sputum production.
Frequent lower respiratory tract infections.
Wheeze.
Other symptoms:
Weight loss, anorexia and fatigue — common in severe COPD but other causes must be considered.
Waking at night with breathlessness.
Ankle swelling – consider cor pulmonale.
Reduced exercise tolerance.
*severe cases = right sided heart failure may develop
What are the signs of COPD?
Cyanosis.
Raised jugular venous pressure
Peripheral oedema (may indicate cor pulmonale).
Cachexia.
Hyperinflation of the chest.
Use of accessory muscles and/or pursed lip breathing.
Wheeze and/or crackles on auscultation of the chest.
How is COPD diagnosed?
- Spirometry is required for confirmation of diagnosis:
=> A post bronchodilator FEV1/FVC less than 0.7 confirms persistent airflow obstruction
- Chest x-ray
=> hyperinflation
=> bullae: if large, may sometimes mimic a pneumothorax
=> flat hemidiaphragm
- also important to exclude lung cancer, TB, bronchiectasis, heart failure
3. Full blood count: exclude secondary polycythaemia or anaemia
4. BMI
Additional tests depending on clinical situation:
=> Sputum culture – if sputum is purulent and persistent
=> Serial home peak flow measurements – to exclude asthma if diagnosis is in doubt.
=> ECG and serum natriuretic peptides – if cardiac disease or pulmonary hypertension are suspected.
Echocardiogram may also be indicated.
=> CT thorax – if symptoms seem disproportionate to spirometry measurements; another diagnosis (such as fibrosis or bronchiectasis) is suspected, or an abnormality on chest x-ray.
=> Serum alpha-1-antitrypsin.
Consider alpha-1-antitrypsin deficiency in people with early onset of symptoms, minimal smoking history or a positive family history.
*Referral to a specialist for management and screening of family members is required if alpha-1-antitrypsin deficiency is identified.
How is COPD categorised / staged?
Severity of COPD is categorised using FEV1
Stage 1: Mild COPD**
=> Post bronchodilator FEV1/FVC <0.7
=> FEV1 (of predicted) >80%
**symptoms should be present to diagnose mild copd
Stage 2: Moderate COPD
=> Post bronchodilator FEV1/FVC <0.7
=> FEV1 (of predicted) 50 - 79%
Stage 3: Severe COPD
=> Post bronchodilator FEV1/FVC <0.7
=> FEV1 (of predicted) 30-49%
Stage 4: Very severe COPD
=> Post bronchodilator FEV1/FVC <0.7
=> FEV1 (of predicted) <30%
How can COPD be prevented / lifestyle managements?
- Smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
=> end passive smoking (occupation therapist / social services help with setting) - Moderate exercise regularly
- Eat a healthy diet
- Vaccinations:
=> Annual influenza vaccination
=> One-off pneumococcal vaccination
*helps prevent exacerbation of COPD - Avoid close contact with people who have respiratory infections
- Avoid excessive heat, cold or high altitudes
- Avoid exposure to environmental irritants
- Learn breathing techniques and relaxation techniques
Withdrawal symptoms (irritability, aggression, depression, restlessness, poor concentration, increased appetite, light headedness, disturbed sleep, nicotine cravings) experienced within 48 hours to 4 weeks of stopping smoking.
What is smoking cessation and how does this help?
Patients should be offered:
- Nicotine replacement therapy (NRT) OR
- Varenicline OR
- Bupropion
TARGET STOP DATE => NRT, varenicline or bupropion should normally be prescribed as part of a commitment to stop smoking on or before a particular date
Prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after the target stop date.
Normally, this will be after 2 weeks of NRT therapy, and 3-4 weeks for Varenicline and Bupropion.
Further prescriptions should be given only to people who have demonstrated that their quit attempt is continuing
if unsuccessful using NRT, varenicline or bupropion, do not offer a repeat prescription within 6 months
- Nicotine Replacement Therapy
=> Adverse effects: nausea & vomiting, headaches, flu-like symptoms
=> NICE recommend offering a combination of nicotine patches and another form of NRT (such as gum, inhalator, lozenge or nasal spray) to people who show a high level of dependence on nicotine or who have found single forms of NRT inadequate in the past
- Bupropion
=> Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
should be started 1 to 2 weeks before the patients target date to stop
small risk of seizures
=> Contraindicated in epilepsy, pregnancy and breast feeding
- Varenicline
=> Nicotinic receptor partial agonist
=> Should be started 1 week before the patients target date to stop
=> The recommended course of treatment is 12 weeks (but patients should be monitored regularly and treatment only continued if not smoking)
=> Adverse effect: Nausea (most common), headache, insomnia, abnormal dreams
=> Varenicline should be used with caution in patients with a history of depression or self-harm.
=> Contraindicated in pregnancy and breast feeding
NICE recommended that all pregnant women should be tested for smoking using carbon monoxide detectors.
=> All women who smoke, or have stopped smoking within the last 2 weeks, or those with a CO reading of 7 ppm or above should be referred to NHS Stop Smoking Services.
Interventions:
=> First-line interventions in pregnancy is CBT, motivational interviewing or structured self-help and support from NHS Stop Smoking Services
=> NRT is used if the above measures fail - little evidence for use in pregnancy.
=> Varenicline and Bupropion are contraindicated
What is pulmonary rehabilitation?
Pulmonary rehab is a exercise & education programme that helps patients with COPD stay active; made up of two components:
=> a physical exercise programme
=> information on looking after your body and your lungs, and advice on managing your condition and your symptoms, including feeling short of breath
PR helps to:
=> improve your muscle strength so you can use O2 more efficiently and become less breathless
=> cope better with feeling of breathlessness
=> improve your fitness so you feel confident with everyday tasks
=> feel better mentally
=> understand your condition and how to manage it better
EVIDENCE: helps people walk further, helps them feel less tired and breathless when carrying out day-to-day activities => higher activity & exercise levels
*won’t improve your lung function / breathing tests / disease
Anyone who needs it (functionally disabled by COPD) can be referred by GP
Team of different HCP including physiotherapists, nurses, occupational therapists to help you exercise safely and at the right level for you. Most enjoy the course and it helps build confidence. It’s a great fun meeting others in a similar situation.
Pulmonary rehab course lasts 6-8 weeks, with 2 sessions about 2 hours each week. Group of 8-16 people.
=> First hour = exercise
=> Second hour = discussion
- why exercise is so important for people with lung conditions
- ways to be more positive about exercise
- how to use breathing techniques during physical activity or when you feel anxious
- how to manage anxiety and low mood
- how to use your inhalers and other medicines
- how to eat healthily
- how to stop smoking
- what to do when you’re unwell
What is the management for stable COPD
- First line: SABA or SAMA (short acting muscurinic antagonist) as required
- Second step is dependent on presence of asthmatic features / features suggesting steroid responsiveness. The criteria is:
=> previous diagnosis of asthma or atopy
=> higher blood eosinophil count (FBC during investigation)
=> substantial variation in FEV1 over time (at least 400ml)
=> substantial diurnal variation in peak expiratory flow (at least 20%)
2b. No asthmatic features/ features suggesting steroid responsiveness
=> Add a LABA + LAMA *if already on SAMA, stop & switch to SABA as required
2c. Asthmatic features/ features suggesting steroid responsiveness
=> LABA + ICS + SABA or SAMA as required
=> Triple therapy i.e. LAMA, LABA, ICS if patient remains breathless or has exacerbations *if on SAMA, stop and switch to SABA as required
- NICE recommends combined inhalers where possible
3. Oral theoplylline - after trials of short and long acting bronchodilators or people who can’t use inhaled therapy.
- Oral prophylactic antibiotics therapy:
=> Azithromycin prophylaxis is recommended in select patients
=> Patients should not smoke, have optimised standard treatments and continue to have exacerbations
=> CT thorax (to exclude bronchiectasis) and sputum culture (to exclude atypical infections and tuberculosis)
=> LFTs and ECG to exclude QT prolongation (azithromycin can prolong the QT interval) - Mucolytics - considered in patients with chronic productive cough + continued if symptoms improve.
Examples of SAMA: Ipratropium, Oxytropium
Examples of LAMA: Tiotropium, Glycopyrrolate, Umeclidium
Examples of SABA: Abuterol, Salbutamol, Terbutaline, Bitolterol, Levabuterol
Examples of LABA: Salmeterol, Formoterol, Olodaterol
Examples of ICS: Fluticasone, Budesonide, Mometasone, Beclomethasone, Ciclesonide, Flunisolide
How is Cor Pulmonale as a complication of COPD managed?
- Features: Peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2
- Loop diuretic for oedema, consider long term O2 therapy
- ACE-i, CCB, alpha blockers not recommended
