COPD Flashcards by Tara Emami

what is first line treatment for COPD?

SABA or SAMA PRN
salbutamol/ipratropium

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what is the second line treatment for COPD if there are asthmatic features or features suggestive of steroid responsiveness?

LABA + ICS regularly
SABA or SAMA PRN

salmeterol + beclometasone/fluticasone

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what are asthmatic features or features suggestive of steroid responsiveness?

previous diagnosis of asthma or atopy
raised eisinophil count
substantial variation in FEV1 over time (At least 400ml)
substantial diurnal variation in PEFR (At least 20%)

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what is the second line treatment of COPD if there are no asthmatic features or features suggestive of steroid responsiveness?

LABA + LAMA regularly
SABA PRN

salmeterol + tiotropium

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what else is important as part of COPD management?

smoking cessation
one-off pneumococcal vaccine
annual influenza vaccine
pulmonary rehab if functionally disabled

consider:
long-term oxygen
lung volume reduction surgery in selected pts

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what is third-line management of someone who has daily adverse symptoms with COPD w/o asthmatic features?

consider 3 month trial of LABA + LAMA + ICS

If no improvement, revert to LABA + LAMA

salmeterol + tiotropium + beclamatesone/fluticasone

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what is third-line management of someone who has 1 severe or 2 moderate exacerbations/year with COPD w/o asthmatic features?

LABA + LAMA + ICS

ICS reduces frequency of exacerbations

salmeterol + tiotropium + beclamasone/fluticasone

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what is third-line management of someone who has daily adverse symptoms or 1 severe or 2 moderate exacerbations/year with COPD with asthmatic features?

LABA + LAMA + ICS
salmeterol + tiotropium + beclamasone/fluticasone

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what are features of cor pulmonale?

peripheral oedema
raised JVP
systolic parasternal heave
loud P2

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how do you treat cor pulmonale?

loop diuretic for oedema
long-term oxygen therapy
ACE

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when can you offer PDE-4 inhibitors (phosphodiesterase-4)

roflumilast
reduces the risk of COPD exacerbations if severe COPD + frequent exacerbations

if severe disease- FEV1 after a bronchodilator <50% of predicted normal

and

2 or more exacerbations/year despite triple inhaled therapy with LAMA + LABA + ICS

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when do you consider mucolytics?

chronic productive cough
continue if symptoms improve

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in which patients would you consider oral prophylactic antibiotic therapy for COPD?

they do not smoke
optimised standard treatment
continue to have exacerbations

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what oral prophylactic antibiotic therapy can be used in COPD patients?

azithromycin

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if starting oral prophylactic antibiotic therapy in COPD patients, what do you need to do first?

CT thorax to exclude bronchiectasis
sputum culture to exclude atypical infections + TB
LFTs
ECG to exclude QT prolongation

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when do you consider starting oral theophylline?

after trials of SABA and LABA or to people who cannot use inhaled therapy

reduce dose if macrolide or fluoroquinolone abx are co-prescribed

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what is the definition of COPD?

airway obstruction- FEV1<80%, FEV1:FVC <0.7

chronic bronchitis- productive cough for 3 months of 2 years

emphysema- histological diagnosis of enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls

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what are the causes of COPD?

smoking
pollution
alpha-1 anti-trypsin deficiency

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what are the symptoms of COPD?

productive cough
dyspnoea
wheeze
weight loss

what are the signs of COPD?

tachypnoea
prolonged expiratory phase
hyperinflation (decreased cricosternal distance <3 fingers; loss of cardiac dullness; displaced liver edge)
wheeze
early-inspiratory crackles
cyanosis
signs of steroid use
cor pulmonale- raised JVP, oedema, loud P2

describe pink puffers in emphysema

increased alveolar ventilation- breathless but not cyanosed
near normal paO2
normal or low paCO2
progress to T1RF

describe blue bloaters in chronic bronchitis

decreased alveolar ventilation- cyanosed but not breathless
hypoxic and hypercapnic- rely on hypoxic drive
progress to T2RF

what are the complications of COPD?

acute exacerbations +/- infx
polycythaemia
pneumothorax- ruptured bullae
cor pulmonale
lung ca

what are the CXR findings of COPD?

hyperinflation >6 ribs anteriorly - decreased cricosternal distance, displaced liver edge, loss of cardiac dullness
prominent pulmonary arteries
peripheral oligaemia
bullae

what are the ECG findings in COPD?

p pulmonale- right atrial hypertrophy RVH RAD

what are the spirometry findings for COPD?

FEV1:FVC<0.7 FEV1<80% raised TLCO raised residual volume

what could be seen on ECHO with COPD patients?

pulmonary hypertension

what is important to remember with flying in COPD patients?

FEV1<50% risky

what is the aim with LTOT?

paO2>8 for >15h/day increased survival by 50%

when do you consider LTOT?

clinically stable non-smokers paO2<7.3 (stable on 2 occassions 3 weeks apart) or paO2 7.3-8 with PHT/cor pulmonale/polycythaemia/nocturnal hypoxaemia terminally ill patients

what classification assesses severity in COPD?

Gold classification 1 - mild: FEV1 ≥80% predicted. 2 - moderate: 50%-79% ≤ FEV1 3 - severe: 30%-49% ≤ FEV1 4 - very severe: FEV1 <30% predicted

what are smoking cessation methods?

nicotine replacement therapy (patch + another method) bupropion varenicline

what is the mechanism of action of bupropion?

a norepinephrine and dopamine reuptake inhibitor + nicotinic antagonist should be started 1-2 weeks before the patients target date to stop

when is bupropion contraindicated?

epilepsy pregnancy breast-feeding eating disorder relative CI

what is the mechanism of action of varenicline?

nicotinic receptor partial agonist start 1 week before pt target stop date 12 weeks- monitor regularly to ensure not smoking

when is varenicline contraindicated?

pregnancy breast-feeding caution in depression/self-harm

what is the smoking cessation method used in pregnancy?

CBT, motivational interviewing, structured self-help and support from NHS stop smoking services then can try NRT (Remove patches before going to bed)

what is the treatment of acute exacerbation of COPD in type 2 respiratory failure despite medical therapy?

BiPAP for assistance of ventilation

what are the most common bacterial causes of COPD exacerbations?

haemophilus influenzae streptococcus pneumoniae moraxella catarrhalis

what are the most common viral causes of COPD exacerbations?

human rhinovirus 30% of exacerbations

as per NICE guidelines, recommend admission in COPD patients if any of the following criteria are met:

severe breathlessness acute confusion or impaired consciousness cyanosis O2<90% social - inability to cope at home/living alone significant comorbidity eg cardiac disease or insulin-dependent diabetes

how do you treat COPD exacerbation?

1. increase frequency of bronchodilator use + consider giving via nebuliser 2. prednisolone 30mg for 5 days 3. abx if sputum is purulent or clinical signs of pneumonia- amoxicillin/clarithromycin/doxycycline

what are common infective causes of COPD exacerbations?

bacteria - haemophilus influenzae - streptococcus pneumoniae - moraxella catarrhalis viruses - human rhinovirus 30% exacerbations

when do you recommend admission for exacerbation of COPD?

severe breathlessness acute confusion or impaired consciousness cyanosis O2< 90% social reasons significant comorbidity (eg cardiac disease/ insulin-dependent diabetes)

what initial BiPAP settings are used in COPD?

EPAP: 4-5 IPAP: 10 (RCP), 12-15 (BTS)