COPD Flashcards
Define COPD. (1)
Lung condition which is characterised by chronic respiratory symptoms due to airway/alveoli abnormalities that causes persistent/progressive airway obstruction.
What are the characteristics of COPD? (5)
Chronic
Airflow obstruction
Abnormal inflammatory response
Not fully reversible
Progressive
Define GETomics. (1)
Genetic
Environment
Lifetime factors
What are the s/s of COPD? (7)
Exertional breathlessness
Chronic cough
Regular sputum production
Frequent winter bronchitis
Wheeze
Chest tightness
Fatigue
What are the potential complications of COPD? (5)
Cor pulmonale (abnormal R side of heart enlargement)
Respiratory failure
Sleep apnoea syndrome
Repeated respiratory infection (winter)
OP
When would you consider a COPD diagnosis? (5)
> 35 yrs AND
Smokers/ex-smokers
Have any of the symptoms:
- Exertional breathlessness
- Frequent sputum production
- Chronic cough
- Frequent winter bronchitis
- Wheeze
Without clinical symptoms of asthma:
- Chronic unproductive cough
- Variability in breathlessness
- Night time symptoms
- Diurnal/day to day variability in symptoms.
FEV1/FVC ratio = <0.7 post bronchodilation.
Pre-COPD has respiratory changes/structural changes in lungs = FEV1/FVC ratio = > 0.7
What factors are to be considered in patients who are diagnosed with COPD? (8)
Weight loss
Effort intolerance
Waking at night
Ankle swelling
Fatigue
Occupational hazards
Chest pain
Haemoptysis
State the main differences between COPD/Asthma. (6)
COPD:
Smokers/ex-smokers = Nearly all
Symptoms < 35 yrs = Rare
Chronic unproductive cough = Common
Breathlessness = Persistent + progressive
Night time waking with breathlessness/wheeze = Uncommon
Significant diurnal/day to day variability of symptoms = Uncommon
Asthma:
Smokers/ex-smokers = Possible
Symptoms < 35 yrs = Often
Chronic unproductive cough = Uncommon
Breathlessness = Variable
Night time waking with breathlessness/wheeze = Common
Significant diurnal/day to day variability of symptoms = Common
When would spirometry be used for COPD diagnosis? (3)
At diagnosis
Reconsidering the diagnosis
Monitor disease progression.
(Post-brochodilator spirometry = COPD diagnosis)
What are the main features of restrictive effect in spirometry? (5)
E.g. lung fibrosis:
- FVC = reduced
- FEV1/FVC ratio = >80%
- Lung volume = reduced
- FEV1/FVC = reduced proportionally
What are the main features of obstructive effect in spirometry? (3)
E.g. asthma/COPD:
- FEV1 = reduced > FVC
- FEV1/FVC = <80%
- FVC near predicted.
What additional investigations is considered for COPD diagnosis? (3)
Chest radiography
FBC (Anaemia/Polycythaemia)
BMI
What are the classes of Dyspnoea scale? (5)
- Not troubled by breathlessness except on strenuous exercise.
- SOB when hurrying or walking up slight hill.
- Walks slower on level ground due to breathlessness or has to stop to breath when walking at own pace.
- Stops for breath after walking 100m or after a few minutes on level ground.
- Too breathless to leave home / breathless when dressing or undressing.
What is the GOLD classification of COPD? (4)
Mild = FEV1 >= 80% predicted
Moderate = 50% <=FEV1 < 80% predicted
Severe = 30% <=FEV1 < 50% predicted
Very Severe = FEV1 < 30% predicted
What are the fundamentals of COPD care? (6)
No cure
Aims:
- Prevent symptoms + recurrence
- Slow disease progression
- Preserves optimal lung function
- Enhance quality of life
All patients should have a self-management plan including lifestyle issues:
- Stop smoking
- Medication compliance
- Regular exercise/pulmonary rehabilitation.
- Influenza (regular), Pneumoccocal (once-only) vaccines.
Outline the pharmacological management of COPD. (3)
Bronchodilators (B2-agonist, antimuscarinics, theophylline)
CS
O2
Outline the NICE guidelines of COPD management.
Start inhaled therapies only if:
- Fundamental COPD care has been offered. And
- Inhaled therapies are needed to relieve breathlessness and exercise limitation AND
- People have been trained to use inhalers can demonstrate satisfactory techniques.
- Offer SABA + SAMA to use as needed.
If person is limited by symptoms or has exacerbations despite treatment:
- No asthmatic features or features suggesting steroid responsiveness:
- Offer LAMA + LABA:
- Person has day to day symptoms that adversely impact QofL.
- Consider 3 month trial of LABA + LAMA + ICS.
- If no improvement, revert to LABA + LAMA.
- Explore further tx options if still limited by breathlessness.
- Person has 1 severe or 2 moderate exaberations within a year.
- Consider LABA + LAMA + ICS
- Explore further tx options if still limited by breathlessness.
- Asthmatic features or features suggesting steroid responsiveness:
- Consider LABA + ICS
- Person has day to day symptoms that adversely impact QofL or has 1 severe or 2 moderate exacerbations within a year.
- Offer LABA + LAMA + ICS.
- Explore tx options if still limited by breathlessness.
What factors do you need to consider when adding ICS to long acting brochodilators? (3)
Strongly favours use:
- Hx of hospitalisation(s) for exacerbations of COPD.
- >= 2 moderate exacerbations of COPD/year.
- Blood eosinophils >= 300 cells/ul
- Hx of concomitant asthma.
Favours use:
- 1 moderate exacerbations of COPD/year.
- Blood eosinophils 100 to < 300cells/ul
Against use:
- Repeated pneumonia events
- Blood eosinophils < 100 cells/ul
- Hx of mycobacterial infection
Explain the use of nebulisers for COPD. (3)
For distressing or disabling breathlessness despite max therapy using inhalers.
Not Rx without an assessment of person’s ability to use it.
Not continued without assessing and confirming 1 or more:
- Reduction in symptoms
- Increase in ability to undertake activities of daily living.
- Increase in exercise capacity
- Lung function improvement.
Explain the use of oral CS in COPD. (2)
For Advanced COPD. Dose is kept at minimum. LT CS not recommended.
Monitor people who are having LT oral CS for OP and give them appropriate prophylaxis. Start prophylaxis without monitoring for people > 65 yrs.
Explain the use of theophylline in COPD. (3)
Only used after a trial of short-acting bronchodilators and long-acting brochodilators or for people who are unable to use inhaled therapy as plasma levels and interactions need to be monitored.
Caution in older people (pharmacokinetics and high risk of comorbidities)
Reduce dose who are having an exacerbation if they’re prescribed macrolide or fluoroquinolone.
Explain the use of oral mucolytics in COPD. (3)
For people with chronic cough productive of sputum.
Only continued if there’s symptomatic improvement e.g. reduction in cough/sputum frequency.
Not routinely used to prevent exacerbations in people with stable COPD.
Explain the use of oral prophylactic ABx. (6)
Azithromycin 250mg TDS a week if they:
- Don’t smoke AND
- Have optimised non-pharmacological management and inhaled therapies, relevant vaccinations and if appropriate have been referred for pulmonary rehabilitation AND
- Continue to have 1 or more of the following, particularly if they’re have significant daily sputum production:
- Frequent (typical 4 or more/year) exacerbations with sputum production.
- Prolonged sputum production exacerbation.
- Exacerbations resulting in hospitalisation.
Explain the use of Roflumilast for COPD. (2)
Add-on to bronchodilator therapy:
- Disease (severe) defined as FEV1, after bronchodilator < 50% of predicted normal and
- Person has had 2 or more exacerbations in prev. 12 months despite triple inhaled therapy with LAMA, LABA and ICS.
Explain the use of O2 saturations for COPD diagnosis. (4)
Monitor patients progress and during exacerbations.
Normal 94-98%
COPD 88-92%
Refer to specialist if < 92% on 1 or more occassion.
When would it be appropriate to give O2 for COPD? (2)
Caution:
- Px may have reduced alveolar ventilation with a low PaO2 and high PaCO2.
- May be cyanosed but not breathlessness.
- Their respiratory centres are relatively CO2 insensitivity and rely on hypoxic drive to maintain respiration.
Define exacerbations. (1)
Sustained worsening of the patient’s symptoms from their usual stable state that is beyond normal day to day variation and acute in onset.
What are the symptoms of exacerbations? (4)
Worsening breathlessness/dyspnoea
Cough
Increased sputum production/sputum volume.
Change in sputum colour.
Explain the self-management of exacerbations. (2)
Patient’s at risk of exacerbations, a course of ABx and CS to keep at home.
Encourage people at risk of having an exacerbation respond quickly to symptoms of an exacerbation:
- Starting oral CS therapy (unless c/i) if increased breathlessness interferes with activities of daily living.
- Starting ABx therapy if there’s sputum purulent.
- Adjusting brochodilators therapy to control symptoms.
State the NICE guidelines of exacerbation management. (3)
When no ABx given, advise:
- ABx isn’t currently needed.
- Seeking medical help without delay if symptoms worsen rapidly or significantly, don’t improve in an agreed time or the person is systemically very unwell.
If sputum sample sent for testing when results available:
- Review ABx choice
- Only change ABx if bacteria resistant and symptoms not improving.
When an ABx is given, advise:
- Possible ADR of ABx, particularly diarrhoea.
- Symptoms not fully resolved by ABx course completion.
- Seeking medical help if symptoms worsen rapidly or significantly or don’t improve within 2-3 days (or other agreed time) or the person becomes systemically very unwell.
Reassessment at any time if symptoms worsen rapidly or significantly, taking account of:
- Other possible diagnosis e.g. pneumonia.
- Symptoms or signs of more serious e.g. cardiorespiratory failure/sepsis.
- Previous ABx use which may have led to resistant bacteria.
Send sputum sample for testing if symptoms have not improved after ABx.
Explain the ABx choice for COPD tx. (4)
1st line:
- Amoxicillin (500mg TDS for 5 days)
- Doxycycline (200mg first day, 100mg OD for 5 days)
- Clarithromycin (500mg BD for 5 days)
2nd line: Use alternative first choice from different class as above.
3rd line:
- Co-amoxiclav (500/125mg TDS for 5 days),
- Co-trimoxazole (960mg BD for 5 days),
- Levofloxacin (500mg OD for 5 days)
1st line IV ABx (if unable to take oral ABx or severely unwell):
- Amoxicillin (500mg TDS)
- Co-amoxiclav (1.2g TDS)
- Clarithromycin (500mg BD)
- Co-trimoxazole (960mg BD)
- Piperacillin with tazaobactam (4.5g TDS)
Define pulmonary rehabilitation. (1)
Multidisciplinary programme of care for px with chronic respiratory impairment that is tailored and designed to optimise each px’s physical and social performance and autonomy.
What does pulmonary rehabilitation consist of? (4)
Multidisciplinary interventions
Physical training
Disease education
Nutritional, psychological and behavioural interventions.
