COPD Flashcards
COPD is like a combination of which two things?
Airway damage (bronchitis) + parenchymal damage (emphysema)
FEV1:FVC should be what in COPD
<0.7
If their FEV1 is >80% predicted normal can you diagnose COPD?
Only in the presence of resp symptoms
What is the respiratory drive in COPD?
hypoxia (not hypercapnoea)
What could be some causes other than smoking?
Noxious particles/gases- pollution or occupational
Other risk factors?
alpha-1-anti trypsin
Asthma/recurrent resp infections
Women
How do you calculate pack years?
(cigarettes per day /20) x number of years
What is the diagnostic criteria
> 35y
+ risk factor e.g. smoking
+ wheeze/breathlessness/chronic cough/sputum production/winter ‘bronchitis’
How do you confirm the diagnosis
post-bronchodilator spirometry (although this isn’t necessary)
How do you categorise how severe COPD is?
> 80% mild
50-79% mod
30-49% severe
<30% very severe
But also consider clinical- frequency of exacerbation, breathlessness, exercise capacity, BMI, PaO2 on ABG, cor pulmonale
What can you use to predict survival?
BODE index
BMI
(airflow) Obstruction (FEV1% after bronchodilator)
Dyspnoea (use MMRC scale)
Exercise capacity (6min walking distance)
What do you need to consider in treatment other than inhalers?
Smoking cessation (the single most important intervention in patients who are still smoking)
Pneumococcal vaccine (one off) and annual flu vaccine
Pulmonary rehab (support and education from mdt) if indicated- offer to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)
Self-management plan
Optimise Rx for co-morbs
What is the first line inhaled therapy?
SABA or SAMA
If the person is still breathless/has exacerbations despite first line treatment, what do you do?
No asthmatic features/no steroid responsive features: offer LABA and LAMA
Asthmatic/steroid responsive features: consider LABA + ICS
If the person with asthmatic features (step 2) is still breathless?
Offer LAMA+LABA+ICS (triple therapy. Use combined inhalers where poss)
What are ‘asthmatic features’ or ‘features that suggest steroid responsiveness’?
Previous diagnosis or asthma or atopy
Higher blood eosinophil count
Variation in FEV1 over time (at least 400ml)
Diurnal variation in PEFR (at least 20%)
Should oral theophylline be prescribed?
NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy.
The dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed.
What are the features of cor pulmonale
peripheral oedema, raised jugular venous pressure, systolic parasternal heave, loud P2
How do you treat the symptoms of cor pulmonale?
Loop diuretic for oedema
Consider LT O2 therapy
Are ACE-inhibitors, calcium channel blockers and alpha blockers recommended?
No
Which factors improve survival?
smoking cessation
Long term O2 therapy if fit criteria
Lung volume reduction surgery in selected patients
Do you always continue the SABA in COPD?
Yes (?)
Can you use a mucolytic for chronic productive cough?
Yes consider
What advice do you give about exercise?
Work to their own level. Become a bit short of breath but don’t over stretch
If mobile, walk 20-30mins 3-4x per week
If immobile- upper limb
How often should you follow up?
V severe- 6 monthly
Rest annual
What should be included in COPD annual review?
Spirometry
BMI
MMRC dyspnoea scale (up a hill, 100m, can’t leave house etc)
Symptom control
Drug SEs
Complications e.g. cor pulmonale (do they get ankle swelling)
Inhaler technique
Mental health
In very severe- review spO2 - do they need referral for home O2 therapy?
?referral to resp/OT/social services
what can be done to help manage exacerbations at home?
Give rescue meds- steroids and abx
Written action plan
There is evidence of survival benefit if O2 therapy is used for ??? hours daily?
> 15
Chronic hypoxaemia causes?
Slowly progressive pulmonary HTN–>RVH–>cor pulmonale–> secondary polycythaemia –> thrombosis
How do you manage someone with what could be acute exacerbation COPD but no diagnosis in terms of oxygen?
If you suspect (e.g. >50yo smoker) same as you would for diagnosed- get ABGs!!
Long term O2 therapy should be minimum ____/day?
15 hours
Incl overnight- hypoxaemia can worsen sleep
In whom should you consider long term O2 therapy?
Very severe (<30% FEV1)
Cyanosis
Polycythaemia
Peripheral oedema
Raised JVP
SpO2 <92% on room air
How do you asses the need for LTOT?
2 ABGs, >3 weeks apart in people with confirmed, stable COPD who are receiving optimum management
<7.3kPa O2
OR
<8kPa O2 and peripheral oedema/polycythaemia (haematocrit >55%)/pulmonary HTN
What do you need to consider as a danger of LTOT?
If they smoke- fire
If they are hypercapnic or acidotic on LTOT wyd?
refer to specialist for ? LT NIV
When would you use short burst oxygen therapy?
Relief of SOB e.g. after exercise. Don’t need to be hypoxaemic
How do you monitor LTOT?
ABGs (not SpO2)
