COPD Flashcards
Diagnosis
no single diagnostic test Use combo of: -history -physical examination -confirmation of airway obstruction using spirometry
define COPD
Airflow obstruction is defined as a reduced FEV1/FVC ratio (where FEV1 is forced expired volume in 1 second and FVC is forced vital capacity), such that FEV1/FVC is less than 0.7.
If FEV1 is ≥ 80% predicted normal a diagnosis of COPD should only be made in the presence of respiratory symptoms, for example breathlessness or cough.
The airflow obstruction is present because of a combination of airway and parenchymal damage. The damage is the result of chronic inflammation that differs from that seen in asthma and which is usually the result of tobacco smoke. Significant airflow obstruction may be present before the person is aware of it.
Symptoms
- exerational breathlessness
- chronic cough
- regular sputum production
- frequent winter “bronchitis”
- wheeze
Compare airway obstruction in COPD to that of asthma
-permanently damaged and narrowed, therefore symptoms are persistent
Compare cough symptoms in COPD to that of asthma
-COPD: chronic cough with sputum
whereas in asthma- irritating cough
Compare night time symptoms in COPD and asthma
COPD: Night time breathlessness and wheeze that keeps patients awake is NOT common, but it is in asthma and is variable
Compare age groups affected in COPD and asthma
COPD: More commonly over 35s
Asthma: more commonly under 35s
Compare likelihood of atopy (genetic) cause in COPD and asthma
COPD: Unlikely to be an atopy (genetic) cause
Asthma: Likely to be an atopy cause
Compare likelihood of patients being smokers in COPD and Asthma
COPD: Nearly all patients are smokers
Asthma: Possible
Patients that may be diagnosed with COPD should also be asked about what factors?
- weight loss
- effort intolerance
- waking at night
- ankle swelling
- fatigue
- occupational hazards
- chest pain
- haemoptysis (blood in mucous from couging)
What tests should patients receive to aid COPD diagnosis
- spirometry
- a chest radiograph to exclude other pathologies
- FBC to identify anaemia or polycythaemia
- BMI calculated
Risk factors for COPD
- smoking
- Age
- male gender
- alpha1 antitrypsin deficiency
- occupation
- existing impaired lung function
Prognosis
COPD severity graded on FEV1%, breathlessness, symptoms etc
What is the BODE index?
B- BMI
O- airflow obstruction
D- dysponea
E - exercise capacity
BODE used to assess prognosis
10 point score that assesses disease outcome
COPD Staging
Mild: FEV1 >80% (or equal to)
Moderate: 50-79%
Severe: 30-49%
Very severe: <30%
Number 1 in management is?
STOP SMOKING
Even with an FEV1<25%, smoking will increase life expectancy
Treatment aims
- stop smoking
- improve symptoms
- prevent acute infective exacerbations
- reduce rate of disease progression
- Maintain nutritional intake, BMI>20
- Increase quality of light (QoL)
Outline the NICE inhaler treatment guideline for a COPD patient with an FEV>50% (or equal to)
-Breathlessness or exercise limitation - SAMA or SABA PRN
↓
-exacerbation or persistent breathlessness
-Add LAMA or LABA
↓
persistent exacerbations or breathlessness
-if LAMA for previous step→LABA+ICS combination inhaler. Consider LAMA and LABA if ICS is declined or not tolerated
-if LABA for previous step→LABA+ICS combination inhaler+LAMA
Outline the NICE inhaler treatment guideline for a COPD patient with an FEV<50%
SAMA or SABA PRN
↓
exacerbations or persistent breathlessness
Either 1 or 2:
1) LABA+ICS combination inhaler and consider LAMA+LAMA if ICS is declined or not tolerated
2) LAMA (offer in preference to regular SAMA QDS.)
Discontinue SAMA
↓
persistent exacerbations or breathlessness
-LABA+ICS in combination inhaler + LAMA
Benefit of LABA/SABA in spirometry terms
Modest increase in FEV1
Symptoms reduced
exercise capacity increases
health status improved
How do antimuscarinics work?
Name one LABA and one SAMA
- they reduce vagal airway tone and reflex bronchoconstriction
- SAMA - Ipratropium
- LAMA - Tiotropium
ADRs of antimuscarinics
Anticholinergic side effects:
- dry mouth
- blurred vision
- urinary retention
- constipation
- hypotension
List drug classes for COPD treatment
- B2-agonists - SABA, LABA
- Anti-muscarinics - SAMA, LAMA
- corticosteroids
- Methylxanthines
- Mucolytics
- Roflumilast
Important interactions with methylxanthines
Cigarette smoke
some antibioticcs
Name some mucolytic drugs
- Carbocisteine
- Mecysteine
How do mucolytic drugs work
When are they used?
- facilitate expectoration by reducing sputum viscosity
- consider in patients with chronic productive cough
- continue if improvement (stop after 4-week trial if no benefit)
Roflumilast
What does it do?
Licensed for what?
- Anti-inflammatory drug with similar actions to theophylline
- only approved by NICE for CLINICAL TRIAL use only
When is oxygen used for COPD patients?
improves hypoxia and reduces work of breathing
-used for acute exacerbations
and
-long term therapy if FEV<35% and is symptomatic
or
-if patient has polycythaemia or cor pulmonale
or
-if patient’s oxygen saturation is less than 92% on air or is chronically breathless to the point where it affects daily life
LTOT is what?
Describe how it works
Long term oxygen therapy
>15 hours daily
-prolongs life
-Use 24-28% O2 (much lower than asthma, which is 40-60%)
-prevents reduction in respiratory drive
-O2 is a stimulus for for breathing due to chronic retention of CO2 - danger! High O2 concentrations - may cause respiratory depression
NICE Criteria for LTOT
the assessment of patients for LTOT should comprise the measurement of arterial blood gases on two occasions at least 3 weeks apart in patients who have a confident diagnosis of COPD, who are receiving optimum medical management and whose COPD is stable.
Patients receiving LTOT should be reviewed at least once per year by practitioners familiar with LTOT and this review should include pulse oximetry. [2004]
The need for oxygen therapy must be assessed in which COPD patients?
all patients with very severe airflow obstruction (FEV1 < 30% predicted)
patients with cyanosis
patients with polycythaemia
patients with peripheral oedema
patients with a raised jugular venous pressure
patients with oxygen saturations ≤ 92% breathing air.
Assessment should also be considered in patients with severe airflow obstruction (FEV1 30–49% predicted).
To ensure all patients eligible for LTOT are identified, pulse oximetry should be available in all healthcare settings
Mainstay of COPD therapy
-SABA/LABA/LAMA and ICS if indicated
-mucolytics
-oxygen
-oral steroids (prednisolone)
-methylxanthines
are all additional add-on therapies if control is not stable or maintained
is nebulised therapy ok to use at home?
Which COPD patients?
Nebulised therapy at home and spacer devices may be used in patients that remain breathless but are stable, having positive outcomes on day-to day activities i.e. daily tasks. Note home nebs are common in COPD but not asthma.
Maintence oral steroids
Maintenance oral steroids are used at the lowest effective dose in patients that remain symptomatic – think ADRS, counselling and osteoporosis prophylaxis
General one line assessment if need oxygen therapy
Assess need for oxygen (if FEV < 35% and breathless/hypoxic)
General guidance to patients - non-pharmacological management
- Stop smoking
- encourage exercise
- nutrition - BMI>20
- flu and pneumococcal vaccine
Compare treatment of acute exacerbations in COPD to that of asthma
Treat exacerbations very much like that of asthma:
-nebulised salbutamol and ipratropium
-consider theophylline
-oxygen use is different in COPD:
O2 saturation maintained at 88-92% in COPD
Note: Asthma 94-96%, hypercapnia
Types of COPD acute exacerbations
- infective
- non-infective
Why are upper and lower respiratory tract infections common in COPD patients?
- use of steroids
- lung degradation
How are antibiotics chosen for COPD infections?
- use local policy
- lab sensitivity patterns
- previous Rx (resistance)
Common pathogens for lung infection in COPD patients and the treatment (1st choice and 2nd choice)
How long are the treatments?
- Haemophilus influenzae
- Streptococcus pneumoniae
1st choice - Amoxicillin 500mg TDS
or
Tetracycline (doxycycline 200mg stat and then 100mg OD)
2nd choice - broad spectrum macrolide or cephalosporin
Home: 7days
Hospital: 7-14 days
What do you monitor a COPD patient has an acute exacerbation?
• Pulse oximetry/ABGs (arterial blood gases) o blood pH ~7.4 to prevent acidosis o O2 – 7 kPa o CO2 – hypercapnia o Detect cyanosis o Detect hypoxia • HR/RR (tachy-cardia/ponea) • CRP • WCC if infection suspected • theophylline levels (if continued >24h) • serum K+ (nebulised SABA)/glucose • hydration • Blood pH ~ 7.4 (risk of acidosis) • C&S – infection (RTI) • Sputum purulence • ECG and ECHO – cor pulmonale • JVP – cor pulmonale (jugular venous pressure) • RCC – polycythaemia
When are antibiotics given?
Given if 2 or more of increased -breathlessness -sputum volume -sputum purulence Give prednisolone 30mg for 7-10 days to reduce inflammation and give symptom relief Increase bronchodilator - nebulised
What is hypercapnia?
How does if affect treatment?
- COPD patients will have a change in respiratory drive
- a COPD patient is used to high CO2 levels so adopt to take a breath when oxygen is low (instead of what happens in healthy individuals- they take a breath when CO2 levels are high)
- this is hypercapnia
- many COPD patients are chronically hypoxic
- this hypoxia affects oxygen administration in patients, - a high O2 concentration removes patient’s drive to take a breath (when O2 is low)
- Therefore O2 can be fatal to COPD patients
Hypoxia drives what 3 complications of COPD?
-hypercapnia
-cor pulmonale
-polycythaemia
This affects cardiac function
When can hypercapnia be extremely fatal?
If oxygen is administered and is not adjusted to hypercapnic patient
Long term corticosteroid use can lead to what?
Is there any kind of treatment for this?
- leads to osteoporosis
- offer patient prophylactic treatments
What is Cor pulmonale?
- Right heart failure - 90% due to COPD
- due to pulmonary hypertension and thus blood flow resistance in the damaged vasculature
- hypoxia (secondary to hypercapnia)
- requiring an increased oxygen demand and polycythaemia
Symptoms of Cor pulmonale
- peripheral oedema
- hepatomegaly
- raised JVP (jugular venous pressure)
Rx for cor pulmonale
- diuretics to reduce oedema
- O2 to reduce hypoxia
What is polycythaemia?
Increased number of RBCs in response to chronic hypoxia
↓O2→↑RBC→↑haematocrit→↑blood viscosity
Treatment for polycythaemia
- prescribe O2 to reduce hypoxia
- Venesection - remove blood
Review time for COPD patients
minimum annually
Care under wider MDT-
doctor, nurse, physio, dietician, pharmacy, social work, occupational therapists etc.
BMI for COPD patients
BMI must be maintained between 20-25 (weight kg/height meter2); a low BMI has demonstrated a higher mortality.
what is pulmonary rehabilitation?
when is it offered?
- offered to all patients who consider themselves functionally disabled by COPD
- Incorporates a programme of physical training (physiotherapy), disease education, nutritional (maintain BMI>20), psychological and behavioural intervention
All COPD must recieve…
All patients must receive annual vaccinations:
• Influenza
• Pneumococcal
Along with annual FEV1, dyspnoea score, BODE index, BMI
Outline self-care in COPD
Patients should be encouraged to respond promptly to the symptoms of exacerbation at home by:
- starting their oral corticosteroid therapy if their increased breathlessness interferes with activities of daily living
- starting antibiotic therapy if their sputum is purulent
- adjusting their bronchodilator therapy to control their symptoms
Patients at risk of having exacerbation of COPD should be given a course of antibiotic and corticosteroid tablets to keep at home for use as a “self-management” strategy or “rescue-therapy”
Patients given self-management should be advised to contact a healthcare professional if they do not improve
