COPD X Flashcards
Describe the spirometry and symptology required for diagnosis of COPD.
Spirometry: FEV1 <80% and FEV1/FVC <70% post bronchodilator - confirm presence of persistent airflow limitation Symptoms: SOB, cough, increased sputum production
What are the 8 key aspects of COPD management?
- Vaccination 2. Smoking cessation 3. Nutrition 4. Managing comorbidities 5. Pharmacotherapy 6. Pulmonary rehab 7. Action plan 8. Self management
Risk factors for COPD.
*** SMOKING *** - relationship exists between amount of tobacco smoked and rate of decline in FEV1 Other risk factors: parental smoking, genetic factors, asthma, SES status, nutritional and environmental factors
Pitfalls of spirometry
May under diagnose younger patients and over diagnosed elderly patients
Is it COPD or Asthma?
- asthma is diagnosed by increased FEV1 > 12% and by > 200ml post bronchodilator - if FEV1 improves by > 400ml this would suggest underlying asthma or co-existing asthma and COPD
Which other investigations would you order to r.o other pathologies which are not COPD?
- CXR - haematology/biochemistry - complex lung function tests - EST - ECG - TTE
How is severity of COPD confirmed?
MILD - FEV1 60-80% predicted - few symptoms, SOB with moderate exertion - little or now effect on daily activities MODERATE - FEV1 40-59% predicted - SOB when walking on level ground - increasing limitation of ADLs - recurrent chest infections - exacerbations requiring steroids/antibiotics SEVERE - FEV1 <40% - SOB on minimal exertion - severely limited ADLs - increasing frequency and severity of exacerbations
What are the 5 most prevalent comorbidities in patients with COPD?
- HTN 2. Hyperglycaemia 3. Atherosclerosis 4. Dyslipidaemia 5. Osteoporosis
What does COPD- X stand for?
Case finding/confirm diagnosis Optimise function Prevent deterioration Develop plan of care Manage eXacerbations
What are the physical activity recommendations for patients with COPD?
- aim to walk for at least 150min/week (30min/day x 5 a week) - instruction patients to walk until the feel too breathless to continue, have a rest and then resume walking
Describe the non-pharmacological strategies recommended to optimise COPD.
- smoking cessation - pulmonary rehab, all symptomatic patients should be referred - regular physical activity - self management and support groups
What are the 2 main aims of pharmacological treatment in COPD?
- treat symptoms 2. reduce risk fo severe exacerbations and deterioration
What is the evidence behind the current COPD pharmacological agents?
- SABA/SAMA –> provide short term relief of SOB 2. LAMA/LABA –> may improve lung function, symptoms, quality of life and exacerbation frequency 3. ICS/LABA –> may reduce exacerbation frequency and improve QOL ** Triple therapy results in reduced rate of moderate of severe COPD exacerbations, better lung function and quality of life in comparison to dual therapy.
Does LABA/LAMA combination work better than single LAMA or LABA inhalers?
Yes! Used in combination results are better than monotherapy.
What things would trigger you to consider altering pharmacotherapy in COPD?
- exertional dyspnoea - functional status - history of exacerbations - patient preference
When should you re-assess alteration of pharmacotherapy in COPD?
6 weeks would be reasonable
What is the risk of ICS?
Increased risk of pneumonia
What are some non-pharmacological options for symptomatic management?
- handheld fans - use of breathlessness recovery positions r.e. forward lean
When should you consider adding LAMA/LABA?
In patients who are on SABA who have persistent dysnpea you should consider adding LABA or LAMA or both LAMA/LABA.
When would you consider LAMA/LABA dual therapy?
In patients with a SABA and a either mono LABA or LAMA who have ongoing symptoms of breathlessness.
What is triple therapy and when is it indicated?
- triple therapy = ICS/LAMA/LABA - indicated for patients with repeat exacerbations and more severe COPD symptoms that are not managed on dual LABA/LAMA therapy
Describe the stepwise management of stable COPD.
- Confirm diagnosis and severity 2. Optimise with non-pharmacological interventions 3. Optimise with pharmacological interventions > start with SABA or SAMA for symptom relief > consider adding LABA or LAMA if ongoing sx > from here could consider LABA/LAMA combination > if still symptomatic consider adding ICS ** should always assess adherence and technique prior to changing pharmacotherapy **
When to consider referral to respiratory physician?
At what saturations would you consider referral for home O2?
Stable COPD with SpO2 <92%
What is the greatest risk factor for COPD exacerbation?
A recent history of exacerbation (within the last `12 months).
What is the pneumococcal immunising advice for patients with COPD?
Does vaccination reduce hospitalisation for patients with COPD?
No! Neighter influenza or pneumococcal vaccination reduces hospitalisation but they both reduce risk of exacerbation.
Name 4 mucolytics.
N-acetylcysteine
Erdosteine
Carboxysteine
Ambroxol
What defines an exacerbation of COPD?
- change in baseline dyspnoea, cough and or sputum production
- greatest predictor is recent hx of exacerbation as FEV1 reduces with each exacerbation
- triggers: viral or bacterial infection left heart failre, stress and air pollution
What are the aims of early diagnosis and treatmeant of exacerbations?
- reduce hospitalisation and maintrain baseline FEV1/function
- a delay (>24Hrs) in exacerbation doubles the chance of hospital admission
- hence the aim of a COPD action plan
When should a COPD patient be hospitalised?
- marked increase in symptoms
- in adequate response to community management
- inability to walk between rooms when previously mobile
- inability to eat or sleep due to SOB
- unable to manage at home
- altered mental status suggestive or hypercapnia
- hypoxaemia or cor pulmonale
Describe the use of inhaled bronchodilators in COPD exacerbations.
- effective for initial treatment of exacerbation
- need to increase SABA –> 4-8 puffs every 3-4 hours and titrate to response
** note 4-8 puffs via spacer is equivalent to a 2.5mg neb **
- if SABA needed more than 3 hourly patient needs to seek medical attention
What role do oral corticosteroids play in COPD exacerbations?
- reduce severity and shorten recovery from exacerbation
- 30-50mg daily mane for 5 days, nil tapering required
Indication for antibiotics in COPD exacerbations.
- consider Abx if febrile, increased sputum volume and change in colour of sputum
- amoxicillin 500mg Q8H or 1g Q12H
OR
- doxycycline 100mg daily for 5 days
- if response to Abx not adequate optimise bronchodilators and oral steroid therapy and reassess diagnosis
Indication for NIV in COPD exacerbations
- CPAP or BiPAP may be required
- indication: pH < 7.35, pCO2 > 45 (i.e. type 2 respiratory failure)
