COPD Flashcards
When should azithromycin be considered for COPD?
Don’t smoke AND
Optimised non-pharm management including PR AND
ONE OF:
4+exacerbations/year OR
Prolonged exacerbations with sputum OR
exacerbations requiring hospital
Need to have sputum culture inc TB, airways clearance training, and CT to rule out bronchiectasis.
Need to have ECG for QT and LFTs (and advise on risk of hearing loss & tinnitus)
Review at 3 months then every 6
Don’t need to stop during exacerbation
When should Azithromycin be monitored?
Don’t smoke AND
Optimised non-pharm management including PR AND
ONE OF:
4+exacerbations/year OR
Prolonged exacerbations with sputum OR
exacerbations requiring hospital
Need to have sputum culture inc TB, airways clearance training, and CT to rule out bronchiectasis.
Need to have ECG for QT and LFTs
Review at 3 months then every 6
Don’t need to stop during exacerbation
What are the most common SEs with Roflumilast (selective phosphodiesterase 4 inhibitor)?
Most common SEs: diarrhoea, wt loss, nausea, abdo pain, headache
Indications:
COPD
FEV<50%
2+ exacerbations/year despite triple therapy
Dose is 500micrograms
What are the criteria for Roflumilast (selective phosphodiesterase 4 inhibitor)?
COPD
FEV<50%
2+ exacerbations/year despite triple therapy
Most common SEs: diarrhoea, wt loss, nausea, abdo pain, headache
Dose is 500micrograms
What are criteria for lung volume reduction Surgery or endobronchial valves?
Offer review:
FEV1<50% + 6MWT >140m
Breathlessness (mMRC ≥2 or CAT≥10) that affects QOL despite optimal treatment and PR
Don’t smoke
+ <2 exacerbations per year for valves
Hyperinflation: RV≥175% or TLC>120%
Gas transfer ≥20%
Homogenous/heterogenous emphysema (not paraseptal)
Optimised co-morbidities (nb. RSVP>50 may need RH cath)
What are indications for consideration of bullectomy?
Need CT thorax showing Bullae occupying at least 1/3 hemithorax
What are indications for lung transplant referral for COPD?
FEV1<50%
SOB affects QOL despite optimal medical treatment and PR
Don’t smoke
Don’t have contraindications
Okay if have had lung volume reduction
What are the evidence-based improvements for the use of LAMAs in COPD?
Reduced exacerbations, SOB and FEV1.
FEV1 decline over time NOT slowed
Pt with COPD has FEV1 of 54%. What is his classification by GOLD and NICE criteria?
Gold 2
NICE Moderate
1/mild ≥80%
2/mod 50-79
3/sev 30-49
4/v.sev <30 (or <50% with respiratory failure)
Exacerbation hx:
≥2 (or 1 hospital) = C/D
0-1 = A/B
Symptoms:
MRC 0-1/CAT<10 = A/C
MRC ≥2/CAT≥10 = B/D
What are the GOLD criteria for COPD?
1/mild ≥80%
2/mod 50-79
3/sev 30-49
4/v.sev <30 (or <50% with respiratory failure)
Exacerbation hx:
≥2 (or 1 hospital) = C/D
0-1 = A/B
Symptoms: (based on mMRC)
MRC 0-1/CAT<10 = A/C
MRC ≥2/CAT≥10 = B/D
What is the MRC dyspnoea scale?
1 = strenuous exercise only
2 = SOB hurrying or walking up incline
3 = walks slower than contemporaries on level ground or has to stop for breath when walking at own pace
4 = stops after 100m or a few mins on level ground
5 = can’t leave house, or SOB on dressing/undressing
mMRC is same but 0-4
What is ECOG score?
0 = no limitations
1 = can’t do strenuous, but able to carry out light housework/office work
2 = ambulatory and can carry out self care but not work. Up >50% day
3 = limited self care only and spends >50% day in bed/chair
4 = confined to bed/chair
5 = dead
When should you perform spirometry in pt with COPD?
At diagnosis
To reconsider diagnosis if show exceptionally good response to treatment
Monitor disease progression
Nb. should perform post-bronchodilator spirometry to confirm diagnosis (not same as assessing bronchodilator response)
Should you perform post-bronchodilator spirometry in COPD?
Measurements should be taken post-bronchodilator to confirm diagnosis however reversibility testing not required
Can a pt still have COPD if FEV1/FVC ratio >0.7?
Yes - think especially if young person with typical symptoms
Is emphysema on CT scan an independent risk for lung cancer?
Yes
What investigations should pt have when diagnosed with COPD?
CXR
FBC
BMI
+/- sputum, serial PEFR, ECG + BNP, Echo, CT chest, alpha1at, TLCO
In addition to a large bronchodilator response (>400ml), what other non-symptom factors may suggest asthma?
> 400ml response to 30mg prednisolone given over 2 weeks
PEFR variability >20%
What features of COPD are associated with worse prognosis?
FEV1
Smoking status
SOB (MRC score)
Chronic hypoxia/cor pulmonale
Low BMI
Sev/freq of exacerbations
Hospital admission
Symptom burden (CAT score)
Exercise capacity (6MWT)
TLCO
LTOT/NIV
Multimorbidity
Frailty
Pt with COPD has done fundamentals and still has symptoms?
If no asthmatic features: LABA + LAMA
If asthmatic features: ICS + LABA
Nb. ‘ol’ inhalers are SABA/LABA
Nb2. ‘ium, glycoporrolate’ are LAMA
Pt diagnosed with COPD. What treatment should they recieve?
If no exacerbations and not limited by symptoms:
- Smoking cessation, pneum + inf. vaccines, PR if indicated, self-management plan, treat co-morbidities
- SABA or SAMA
If exacerbations/limited by treatment:
- Above +
LABA + LAMA if no asthmatic features
LABA + ICS if asthmatic features
Pt with COPD already takes LABA/LAMA. Still has symptoms affecting QOL. What treatment should you give?
3month trial LABA + LAMA + ICS –> if no improvement, back to LABA + LAMA
Nb. if 1 severe or 2 mod exacerbations within a year, then LABA + LAMA + ICS w/o 3 month limit
Which type of inhalers increase risk of Pneumonia?
ICS
Pt with COPD already takes LABA + ICS. Still has symptoms affecting QOL. What treatment should you give?
Triple therapy
Nb. also the case if 1 severe or 2 mod exacerbations within a year
When should nebuliser be considered in chronic COPD?
Exacerbation
At home - distressing/disabling SOB despite maximal therapy
Need to confirm that leads to one of: reduction in symptoms, increase in ability to undertake ADLs, increased exercise capacity or improved lung function
When should pt with COPD on long term steroids be given prophylaxis for osteoporosis?
Monitor unless >65 when just give
When should theophylline be used in COPD?
After SABA and LABA already tried. Need to see one of: reduction in symptoms, increase in ability to undertake ADLs, increased exercise capacity or improved lung function
When should mucolytics be considered in COPD?
Chronic cough with sputum - need to see reduction in frequency of cough and sputum production in response
When should you assess a COPD patient for LTOT?
Gold 4/very severe (+consider in severe)
Cyanosis, peripheral oedema, raised JVP
Polycythaemia
SATS ≤92
Nb need 2xABG at least 3 weeks apart
Nb2. don’t given LTOT for isolated nocturnal hypoxaemia
Which patients with COPD should be offered PR?
Recent hospitalisation for acute exacerbation
MRC≥3 (or person considers themselves functionally disabled)
Nb. not suitable if can’t walk, unstable angina or recent MI
Who should be reviewed for lung volume reduction surgery in COPD?
Severe or very severe COPD
SOB that affects QOL (mMRC≥2/CAT ≥10) despite optimal therapy
Non-smoker
6MWT >140m
Hyperinflation (assessed by lung function of plethysmography) AND emphysema on CT
Gas transfer ≥20%
Nb. if RVSP>50 then need RH cath
When can bullectomy be considered for COPD?
Bulla occupying at least 1/3 thorax
How often should pt with COPD be followed up in primary care?
1/year if mild-sev
2/year if very sev
Pt with COPD has exacerbation. Go to see GP. Can be safely managed in community. What tests should be sent?
None (sputum culture not recommended)
When should ABG done on pt with COPD?
Pts with exacerbation presenting to hospital
What CT features may make a COPD compatible/incompatible for lung volume reduction?
Compatible:
- Emphysema
Non-compatible:
- Significant bronchiectasis
- Lots of mucus
- Paraseptal emphysema
- Fibrosis
- Suspicious nodule
Ng. >95% fissure integrity = can use valves, <80% surgery (or coils but worse outcomes)
What is the most common complication after lung volume reduction surgery?
Pneumothorax (valves > surgery)
Exacerbation of COPD
+ LRTI in surgery
Incidence of pnx 18-30% after valves (usually a good sign). Therefore observe for 3 nights in hospital. More likely in those with high RV and more emphysema in untreated ipsilateral lobe
When should NIV be considered in acute exacerbation of COPD?
pH <7.35 + pCO2 >6.5 + RR>23 after medical management
nb. pH<7.25 consider IMV
nb. same criteria for obesity
What are contraindications for NIV?
Absolute: facial deformity or burns, fixed upper airway obstruction
Relative: pH<7.15 (or 7.25 + GCS<8), confusion/agitation, cognitive impairment
When should acute NIV be considered in neuromuscular disease?
RR >20 if FVC<1 even if normal pCO2
OR pH<7.35 + pCO2 >6.5
What initial settings should be used when starting pt with acute exacerbation of COPD on NIV?
EPAP 3 (can be higher if OSA suspected)
IPAP 15 (20 if pH<7.25) –> uptitrate to 20-30 over 10-30mins
I:E 1.2-1.3 (1.1 in OHS/NMD)
Insp time 0.8-1.2 (longer in OHS/NMD)
BUR 16-20
nb. IPAP 10 for NMD
Nb.2 EPAP shouldn’t go above 8
How long should NIV be used for in acute setting?
As much as poss over 24hours then taper as able
What positive outcomes have been attributed to lung volume reduction surgery?
Increased QOL
Increased FEV1
Increased 6MWT
Increased survival
What is 5yr survival of pt with COPD + pulmonary hypertension with mPAP >40mmHg?
15%
