COPD Flashcards
Background
Chronic obstructive pulmonary disease.
lung disease characterised by AIRFLOW OBSTRUCTION which is:
- Progressive, - not fully reversible, - Don’t change significantly over several months.
Caused by:
COMBO of airway and parenchymal (part of lung involved in gas exchange) damage. Damage happens from CHRONIC inflammation.
COPD preventable and treatable but not curable.
DEFINED AS:
Airflow obstruction defined as reduced FEV1/FVC ratio = <0.7
IF FEV1 is ≥ 80% predicted normal a diagnosis of COPD should only be made in the presence of respiratory symptoms.
Diagnosis
Suspect in PPL >35 who have a risk factor and 1 or + of the following symptoms:
- exertional breathlessness
- chronic cough
- regular sputum production
- frequent winter ‘bronchitis’
- wheeze
OR CAN BE other symptoms
ON examination may be:
· Spirometry/ Post bronchodilator spirometry
· chest radiograph to exclude other pathologies
· FBC to identify anaemia or polycythaemia
· BMI calculated
. Sputum culture
. Serial home peak flow measurements - exclude asthma
. ECG and serum natriuretic peptides - checks cardiac status
. Echocardiogram - Checks cardiac status
. etc check nice
ASTHMA VS COPD?
diagnostic uncertainty remains, or both COPD and asthma are present, use the following findings to help identify asthma:
- large (>400 ml) response to bronchodilators
- large (>400 ml) response to 30 mg oral prednisolone daily for 2 weeks
- serial peak flow measurements showing ≥20% diurnal or day-to-day variability.
Signs & Symptoms
MAIN symptoms:
- Exertional breathlessness
- Chronic cough
- Regular sputum production
- Frequent winter ‘bronchitis’
- wheeze
Other:
- Weight loss
- Reduced exercise tolerance
- Waking at night with breathlessness
- Ankle swelling
- Fatigue
- Occupational hazards
- Chest pain
- Haemoptysis (Blood cough)
Breathlessness scale
1 Only by hard exercise
2 short breath when hurrying/ hill walking
3 Slower walker BC of breathlessness/ has to stop to breath when at own walking pace
4 stops for breath walking 100 M or a few mins on level ground
5 too breathless to leave house/breathless when changing clothes
Grading severity
Stage 1 mild
stage 2 moderate
stage 3 severe
stage 4 very severe
Treatment (NON pharmacological)
- Smoking cessation = NRT (Gum, Lozenges, Patches, Microtab, Inhalator, Nasal spray), Bupropion (SNRi - aids cessation with motivational support), Varenicline (selective nicotine receptor partial agonist - helps cessation)
- Vaccines - pneumococcal, influenza
- Pulmonary rehabilitation
- Co develop self management plan
-Optimise treatment for co morbidities. (All taken from diagram)
Treatment (Pharmacological) STABLE COPD
STABLE COPD MANAGMENT 1.2:
Diagram - NG 115 (in Y3 pack too)
EXTRAS:
* Nebulisers for ppl with distressing or disabling breathlessness despite max inhaled therapy. DONT give without assessing ability to use it. DONT continue unless 1 or more of:
- reduction in symptoms,
- increase in ability to do daily activities, exercise capacity.
- improvement in lung function.
Give choice of facemask or mouthpiece, provide ongoing support if nebuliser continued.
Oral therapy:
Corticosteroids:
Don’t start in primary care for maintenance treatment. Can be used long term in advanced COPD- lowest dose possible. Monitor for osteoporosis if needed give prophylaxis. >65 DONT monitor just prophylaxis. Mainly for exacerbation
Theophylline:
Only be used after a trial of SABA and LABA, or for people who are unable to use inhaled therapy,
- plasma levels and interactions need to be monitored,
- Reduce dose if having exacerbation and on macrolide or fluoroquinolone. Elders caution required.
Oral Mucolytic:
For chronic cough + productive sputum. Only continue if there is symptomatic improvement. DONT use to prevent exacerbations in stable COPD.
Prophylactic antibiotic:
AZITHROMYCIN (500mg 3/7 minimum 6-12 months) USE IF:
- Don’t smoke, done non Pharmacological, 1 or + Frequent exacerbations resulting in hospital or >3 exacerbations needing steroid.
B4 starting prophylactic optimise treatments, take culture, train patient in airway clearance technique, CT scan of thorax = rule out bronchiectasis etc.
Do ECG and baseline LFT.
Counsel on AE eg GI upset, hearing and balance issues, cardiac effects, drug resistance.
Review first 3 months then every 6 months. LFT 1 month after then every 6 months. ECG 1 month after if QT prolongation stop treatment.
AFTER starting IF GI UPSET - reduce dose to 250 mg 3/7.
Roflumilast phosphodiesterase-4 inhibitor.
ADD ON to bronchodilators for severe COPD + chronic bronchitis. used IF:
- Severe = FEV1<50% of predicted normal. AND
- 2 or + exacerbations with triple inhaled therapy.
OXYGEN
Long term oxygen therapy = LTOT
- Can cause respiratory depression (slow/shallow breathing = too much CO2 [hypercapnia]).,
Asses need in ppl with:
- Very severe airflow obstruction (FEV1 <30% predicted),
- cyanosis (blue tint to skin),
- polycythaemia,
- peripheral oedema (swelling),
- raised JVP,
- oxygen SATS of 92%> breathing air.
Consider for ppl with severe airflow obstruction (FEV1 30–49% predicted).
Measure ABGs on 2 occasions in at least 3 weeks apart in ppl with COPD.
CONSIDER LTOT in non smoker and:
PaO2 in arterial blood <7.3 kPa when stable OR PaO2>7.3 - 8 kPa when stable, and have 1 or + of:
Secondary polycythaemia, peripheral oedema, pulmonary HTN.
DONT GIVE LTOT to people who smoke and reject advise.
Ambulatory OXYGEN:
For PPL on LTOT who want to continue outside home or have exercise issues and show improvement in exercise capacity with oxygen.
NOT OFFERED FOR BREATHLESSNESS IN COPD.
Treatment (Pharmacological) EXACERBATION COPD
Asses whether hospital admission needed usually only if severe.
Consider Hospital IF: Severe breathlessness, Cant be at home alone, Poor general condition, Rapid onset symptoms, acute confusion/ impaired consciousness, cyanosis, O2 <90% (give O2 whilst waiting admission OR O2 via venturi mask [target 88-92%]), worsening peripheral oedema, new arrhythmia, failure to respond to initial treatment, on LTOT, changes in chest X-ray.
USE hospital at home when can.
NO ADMISSION TREATMENT ACUTE EXACERBATION:
Increase dose/frequency of SABA/SAMA - keep on same delivery system. If they become fatigued may need nebuliser.
ORAL corticosteroid if have increase breathlessness ruining daily activities - 30mg prednisolone 5 days. (frequent use - osteoporosis prophylaxis 3-4 courses/year)
Antibiotic: consider severity of symptoms, risk of complications, previous sputum culture, risk of antimicrobial resistance. CHOICES:
1st - Amoxicillin 500mg TDS 5 days.
ALT - Doxycycline 200mg on first day, then 100mg OD for 5-day total.
Clarithromycin 500mg BD 5 days.
* no improvement for 2-3 days then send sputum sample find susceptible ALT drug.
High risk treatment failure - co-amoxiclav 500/125 mg TDS 5 days.
For antibiotic, give advice on:
Potential AEs, inc. diarrhoea.
Seek medical help if: Symptoms worsen rapidly or significantly or don’t improve within 2–3 days (or agreed time) or become systemically very unwell.
NO antibiotic given, seek medical help immediately if:
Symptoms (EG sputum colour changes, increase volume or thickness) worsen rapidly or significantly or don’t start to improve within agreed time or become systemically very unwell.
STABLE COPD FOLLOW UP
FREQUENCY:
- review at least once a year.
- if very severe review twice a year.
- Regular review to long term non invasive ventilation user.
WHAT TO REVIEW:
- Symptom control and impact of COPD on life.
- meds (techniques)
- smoking status and BMI
- Vaccine status
- Complications
- Spirometry
VERY severe COPD - O2 sats with pulse oximetry
- if treatment needs adjusting
EXACERBATION COPD FOLLOW UP
Reassess if no improvement look for other issues eg different condition, resistance etc.
send sputum sample for tests.
IF STABLE: asses any changed symptoms, optimise treatment, check adherence, consider referral for pulmonary rehabilitation, offer short course steroid/antibiotic for home if they had exacerbation within last year and know how to use it and its risk, review self management plan.
END STAGE COPD
Focus on palliative care - relieve symptoms and improve quality of life. Make advanced care plan if they want. coordinate care with nurses. optimise treatment for symptoms. consider hospice administration if best for patient or they prefer.
Drug treatment for breathlessness :
- Opioids- when unresponsive to other therapy.
- Benzodiazepines, TCA, major tranquilisers or oxygen.
Advance care planning:
discuss future care and support needs (what treatments, who to look after them, support etc), should have copies of this plan at home or hospital.
Advance decisions — allow a person to state in advance how they wish to be treated if they lose capacity.
- they can have advance refusal of some meds. or ask for certain meds
