COPD Flashcards
What is the association with blood eosinophils and COPD?
Lower blood and sputum eosinophils are associated with a greater presence of proteobacteria, notably hemophilus, increased bacterial infection and pneumonia
What are the benefits of Phosphodiesterase 4 inhibitors in severe to very severe COPD and history of exacerbation?
- PDE4 inibitor improves lung function and reduces moderate and severe exacerbations
- PDE4 inhibitor improves lung function and decreases exacerbation in patients who are on a fixed dose LABA-ICS combinations
Are long term glucocorticoids useful in COPD ?
No. No evidence of benefits and numerous side effects
Independent of ICS use at what blood eosinophil count is there an increased risk of pneumonia ?
Blood Eosinophil count <2%
Who is at increased risk of pneumonia on ICS ?
Current smoker
>55 years
History of prev pneumonia or exacerbation
BMI<25
Poor MRC grade
Severe airflow obstruction
Independent of ICS use , eosinophils <2% assoc w pneumonia
As per GOLD criteria what factors STRONGLY favour adding ICS to LABA?
- Hx of hospitalization for exacerbations of COPD
- > / 2 moderate exacerbations per year
- Blood eosinophils >300 cells /ul
- Hx of concomitant asthma
As per GOLD criteria what factors favour adding ICS to LABA?
1 moderate exacerbation of COPD per year (despite appropriate LABA maintenance therapy)
Blood eos 100-300 cells /ul
As per GOLD criteria what factors are AGAINST adding ICS to LABA?
- Repeated pneumonia events
- Blood eos <100 cells /ul
- History of mycobacterium infection
Implications of acute glucocorticoids ?
Reduced rate of treatment failure
Reduced rate of relapse
Improve lung function
Improve breathlessness
Hoe do PDE4 inhibitors work?
Reduce inflammation by inhibiting the breakdown of intracellula cyclic AMP
What is Roflumilast?
Roflumilast is a phosphodiesterase 4 inhibitor. It is an oral medication take. Once a day with no direct bronchodilator activity.
It reduces moderate and severe exacerbations requiring treatment with systemic corticosteroids in patients with :
- chronic bronchitis
- severe to very severe COPD
- hx of exacerbations
Its effects on lung functions are seen when added to LABA or LABA-ICS
The beneficial effects of Roflumilast increase in patients with prior history of hospitalisations
** NB no study directly comparing Roflumilast with ICS
What are the side effects of Roflumilast?
Diarrhoea
Nausea
Weight loss (around 2kg in trial)
Abdo pain
Sleep disturbance
Headache
Adverse effects seem to occur early in treatment and reduce over time with continued treatment
Who should you avoid Roflumilast in?
- Underweight patients
- Depressed patients (caution)
What are the prophylactic abx used in COPD?
Azithromycin 250mg / day OR Azithromycin 500mg three times a week
OR
Erythromycin 250mg BD
Over one year in patients prone to exacerbations , the above have been shown to reduce risk of exacerbations compared with usual care (no data beyond one year)
What are the therapeutic interventions proven to reduce COPD mortality ?
LABA + LAMA + ICS
Smoking Cessation
Pulmonary Rehabilitation
LTOT
NIV
LVRS (Upper lobe predominant emphysema with low exercise capacity) / Lung transplantation
What are the benefits of PR?
Pulmonary Rehabilitation improves :
- Dyspnoea
- Health Status
- Exercise tolerance
In stable patients
PR reduces hospitalisation among patients who have had a recent exacerbations (<4 weeks from prior hospitatlisation)
PR leads to a reduction in symptoms of anxiety and depression
Is educations and self management helpful in COPD?
- Education alone has not been shown to be effective
- Self management intervention with communication with a health care professional improves health status and decreases hospitalisation and emergency department visits
Is integrated care programs useful in COPD?
Integrative care and telehealth have no demonstrated benefits at this time
What is pulmonary rehabilitation ?
Pulmonary rehabilitation is defined as “a comprehensive intervention based on thorough patient assessment followed by patient-tailored therapies that include, but are not limited to, exercise training, education, self-management intervention aiming at behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long-term adherence to health-enhancing behaviors
What is the aim of PR?
Offer to COPD patients with view to improving exercise capacity by clinically important amount as well as dyspnoea. Resistance can affect quadriceps strength. PR should improve psychological wellbeing
What are the caveats to PR referral?
If AAA >5.5cm need to review, if not fit for surgery can still attend PR and undertake moderate intensity aerobic exercise but must not include resistance
If severe locomotor dysfunction ie with PVD should not be referred
If significant cognitive impairment should not be referred
What are the MRC cut offs for PR referral ?
MRC 3-5
Or
Can be MRC 2 if functionally limited by breathlessness
(MRC 5 and housebound can be difficult as can’t routinely offer home PR)
How is PR set up?
Twice weekly sessions for 6-12 weeks, patients should attend minimum of 12 recommended
Cohort or rolling is fine
Undertake aerobic training and muscle resistance . Generic exercises which are individualised
When should patients be offered PR following discharge with exacerbation?
PR should commence within 1 month of discharge
What other resp conditions can PR be utilised for ?
Non CF Bronchiectasis
ILD
NB Asthma not routinely recommended
When can you repeat PR?
Can repeat PR if done >1 year previously but note if didn’t get benefit last time unlikely they will this time
Who should get Roflumilast?
- FEV1 <50% predicted
- 2 or more exacerbations in the last 12 months despite triple therapy
What does evidence show is the effect of Roflumilast?
Reduced rate of moderate or severe exacerbation compared with placebo
What is the most common complication following LVRS?
Persistent air leak
What is the aim of endobronchial valve insertion?
To reduce the lung volume in emphysema to achieve atelectasis of selected lung segments
It is done by delivering a catheter passed along a bronchoscope, a synthetic valve is placed in the target location and fixed to the bronchial wall. Valve is designed to prevent airflow in inspiration but allow air and mucus out during expiration
Several valves may be needed (1 or more for each segment to be treated)
Duckbill and umbrella valves ; duckbill in circulation
In the right patients what is the effect of LVRS/EBV?
- Reduction in gas trapping - improving lung function and reducing sensation of breathlessness
- Improving exercise capacity
- Improving QOL
- Prolonging survival by delaying development of resp failure and need for frequent hospitalization
What is the only intervention that modifiers the natural history of COPD?
Stopping smoking
What is the benefit for LVRS via VATS?
Improves QOL
Improves exercise capacity
Improves lung function
Of those with severe emphysema in the short term
NB hospital stay with VATs is shorter than open
What is the benefit of LVR by EBV?
Improves QOL
Improves exercise capacity
Improves lung function
*Greatest for those with heterogenous emphysema without collateral ventilation and those where lobar occlusion is complete
What is the benefit of LVR via open surgery?
Improves QOL
Improves exercise capacity
Improves lung function
Sustained improvement with QOL and exercise capacity demonstrated
Those with UL emphysema and reduced exercise capacity will benefit most
What are the criteria for LVR MDT discussion?
- Evidence of symptomatic hyperinflation due to emphysema with impaired QOL. MRC > 3
- PR within 12 months or ongoing participation
- Non smoker for at least 4 months
- 6MWT >140m or ISWT >80m
- FEV1 <50%
- RV >150%
- RV /TLC > 55%
- DLCO >20%
- PCO2 < 7
- BMI > 18
NB not suitable if severe co-morbidities , severe progressive disease, severe PH
What are the main reasons LVR found not to be appropriate following MDT discussion?
Lack of suitable target area
XS risk (BMI/DLCO)
Significant co-morbidities
What are the criteria for LVRS following MDT discussion?
1.Upper lobe heterogenous emphysema
2. RV/TLC >60 , TLCO >20 , BMI>18
3. Collateral ventilation and low exercise capacity
4. Predominantly apical disease with collateral ventilation and reduced exercise capacity
5. Lower lobe heterogenous disease with collateral ventilation
What are the criteria for EBV following MDT discussion?
- Upper lobe or lower lobe heterogenous emphysema without collateral ventilation
- RV >180% , TLCO > 20 , BMI > 18
- Previous thoracic surgery
What is included in the DECAF score ?
Dyspnoea (0: can leave house , 1: can’t leave house but can wash dress , 2: can’t wash /dress/ leave house
Eosinophilia (<0.5)
Consolidation (Yes)
Acidaemia (pH <7.3)
aF (Yes)
What does DECAF score predict?
In hospital mortality in acute COPD exacerbation
If patient has DECAF score of 1 what is their hospital mortality ?
1.5%
Score of 0-1 , low risk 0-1.5%
If patient has DECAF score of 2 what is their hospital mortality ?
5.4%
If patient has DECAF score of 3-6 what is their hospital mortality ?
15.3-50%
HIGH risk
What is the BODE score and what does it consist of ?
Predicts 4 year survival in COPD patients
BMI (<21)
Obstructive Spirometry (FEV1)
Dyspnoea
Exercise (6MWT)
What is the associated 4 year survival with BODE 0-2?
80%
What is the associated 4 year survival with BODE 3-4?
67%
What is the associated 4 year survival with BODE 5-6?
57%
What is the associated 4 year survival with BODE 7-10?
18%
What is the CAT tool ?
COPD Assessment tool, identifies overall impact of COPD on patients healthy
What does the CAT tool include ?
Cough, Phlegm, Chest tightness , Breathlessness, Activities , Confidence , Sleep , Energy
What does a CAT score of 0-10 indicate ?
Low health impact
What does a CAT score of 11-20 indicate ?
Medium health impact
What does a CAT score of 21-30 indicate ?
High health impact
What does a CAT score of 31-40 indicate ?
V. High health impact
Outline MRC 1 (mMRC 0)
Not troubled by breathlessness except with strenuous exercise
Outline MRC 2 (mMRC 1)
SOB when hurrying or walking up a slight hill
Outline MRC 3 (mMRC 2)
Walks slower than contemporaries on level ground bc of breathlessness or has to stop for breath when walking at own pace
Outline MRC 4 (mMRC 3)
Stops for breath after walking around 100m after a few minutes on level ground
Outline MRC5 (mMRC 4)
Too breathless to leave the house or breathless when washing /dressing
What is independent risk factor for cancer on CT?
Emphysema
As per NICE what ix should all COPD patients have?
Spirometry, FBC, CXR , BMI
(Can also consider Sputum, serial peak flow , ECG, Echo, CT scan)
What are the classifications for COPD as per NICE/BTS?
All with FEV1/FVC <0.7
MILD FEV1 ≥ 80%
MODERATE 50-80%
SEVERE 30-50%
VERY SEVERE <30% (or severe with respiratory failure)
What are the fundamentals of COPD care ?
- Support to stop smoking
- Offer pneumococcal , COVID and flu vaccines
- Offer PR if indicated
- Co develop personalised Mx plan
- Optimise treatment
Inhaled therapies only if the above optimised
What are the treatment algorithms inhaler wise as per NICE?
SABA or SAMA as first line
If limited by symptoms / exacerbation despite tx
-IF no asthmatic features suggesting steroid responsiveness : LABA/LAMA BUT if continued to have day to day sx affecting life LABA-LAMA-ICS or if 1 severe or 2 moderate exacerbations LABA-LAMA-ICS
- IF asthmatic features (ie prev asthma , atopy, high eosinophil count , variation in FEV1 , diurnal variation) : LABA/ICS BUT if still day to day symptoms or 1 significant or 2 moderate exacerbations then LABA-LAMA-ICS
Who should have steroid in COPD?
Long term corticosteroids not recommended , if unavoidable aim to reduce as much as possible
If over 65 years then should have prophylaxis
Who should have theophylline ?
Only after trial of SABA/ LABA etc or in people who are unable to tolerate inhaled therapy. Difficult pharmacokinetics in the elderly
Reduce dose of theophylline for people who having exacerbation if prescribed macrolide (clari) or fluoroquinolone (Ciprofloxacin)
What are the criteria for prophylactic Azithromycin?
Patients need to :
- non smoker
- optimised non pharmacological and inhaled therapies , relevant vaccinations and continue to have one or more of following :
—- frequent (typical ≥ 4 or more per year) exacerbations with sputum production
—- prolonged exacerbations with sputum production
—- exacerbations resulting in hospitalization
BEFORE offering, ensure:
- Sputum culture and sensitivity and TB done - to identify a specific cases of persistent infection or recurrent infection that may need tx (NTM , Pseud)
- Training in sputum clearance
- CT throrax to rule out bronchiectasis
Also:
ECG (to review QTc)
LFTs
Warn we small risk of hearing loss and tinnitus
Review @ 3/12 and then 6/12
** NOT necessary to stop prophylactic Azithro in exacerbation **
How do we assess for LTOT?
2 ABGs on 3 occasions at least 3 weeks apart
What are the criteria for LTOT?
PaO2 <7.3
Or PaO2 7.3 - 8 with:
- peripheral oedema
- pulmonary HTN
- secondary polycythemia
Who is not allowed LTOT?
Smokers (need to have quit for 6 months)
Who gets referred for Bullectomy?
Breathless and CT scan shows bullae occupying at least 1/3
In what gene is the mutation that leads to alpha 1 antitrypsin deficiency ?
SERPINA 1 gene
What is PRISM?
Preserved Ratio Spirometry
Some patients can have respiratory sx and /or emphysema on CT or physiological abnormalities (including low or normal FEV1, gas trapping, hyperinflation, reduced lung diffusion capacity and /or rapid FEV1 decline) without airflow obstruction
At risk of developing airflow obstruction but not all do
Why do COPD patients sometimes collapse after coughing ?
Syncope during coughing in patients with severe COPD can occur due to rapid increase in the intrathoracic pressure during prolonged coughing attacks (NB can also cause rib #)
What is GOLD A?
0-1 moderate exacerbations (not req hospitalization)
mMRC 0-1
CAT <10
What is GOLD B?
0-1 moderate exacerbations (not req hospitalization)
mMRC ≥ 2
CAT ≥ 10
What is GOLD E?
2 moderate exacerbations or ≥ 1 leading to hospitalization
What proportion of patients continue to smoke despite having COPD dx as per GOLD estimation?
40%
What are the effects of bronchodilator therapy ?
LABA and LAMAs improve:
- lung function
- dyspnoea
- health status
- reduce exacerbation rates
LAMAs have a greater reduction of exacerbation compared with LABAs and decrease hospitalisations
Combined LABA/LAMA therapy improves FEV1 and reduces symptoms compared with mono therapy
Treatment for Group A GOLD pts ?
SABA/SAMA
Treatment for Group B GOLD pts ?
LABA and LAMA
Treatment for Group E GOLD pts ?
LABA and LAMA (and ICS if eos ≥ 0.3)
How long does it take to recover from COPD exacerbation?
4-6 weeks ; some never recover to baseline
Who should get annual LDCT scans ?
Ppl w COPD due to smoking
How do you calculate pack years
No. Of cigarettes per day/20 * Years
