Diagnosis and Management of COPD Flashcards
COPD description
a broad, non specific term that describe a group of
pulmonary disorder with symptoms of chronic cough and expectoration, dyspnea, and impaired expiratory air flow.
COPD is brought about by a mixture of obstructive diseases of the airways (e.g. bronchitis or bronchiolitis) and destruction of the lung tissue parenchyma (emphysema).
airflow obstruction in COPD is usually reversible, true or false
false
The airflow obstruction is usually progressive and irreversible, and it may be associated with airway hyperactivity
main cause for COPD
smoking and exposure to
environmental tobacco smoke
risk factors of COPD
smoking
genetics
history of tuberculosis
dusty work environment
pollution and biomass combustion
asthma
ageing and comorbidities
premature birth
pathogenesis of COPD
Pathogenesis refers to the process by which a disease or disorder develops, including the mechanisms that contribute to its onset, progression, and maintenance.
Bronchioles are normally held open by elastin fibres that are attached to the alveolar walls. In COPD the small airways are narrowed by inflammation
and fibrosis of alveolar wall, destruction of elastin attachments and occlusion of lumen by mucus and
inflammatory exudate
how do we diagnose COPD
can be diagnosed with the symptoms that the patient presents with
history of exposure to COPD risk factors..etc
Lung function tests (spirometry)
symptoms of COPD
exertional breathlessness
chronic cough
regular sputum production
frequent winter ‘bronchitis’
Wheeze
according to the guidelines, when are HCPs to suspect a diagnosis of COPD in a patient
when the patient presents with any of the main risk factors or COPD, plus any of these symptoms;
** exertional breathlessness
* chronic cough
* regular sputum production
* frequent winter ‘bronchitis’
* Wheeze
list any additional questions to ask someone that presents with symptoms indicative of COPD with regards to other symptoms they might be experiencing
ask if there is any;
- wieght loss
- ankle swelling
- reduced exercise and tolerance
- fatigue
- waking up a night with breathlessness
- occupational hazard
chest pains and coughing up blood are major symptoms in COPD, true or false
false, as they are uncommon in COPD and could be a different diagnosis
how do we assess someone with suspected COPD
Take history about;
The onset of the disease
Any known exposures to the disease
Impact of symptoms on daily life and occupation:
Previous exacerbations or hospitalization.
Past medical history and comorbidities
Family history
which test is used as a confirmatory test in COPD
Spirometry
name some other tests used to investigate suspected COPD in patients
Chest X-rays to exclude other causes
Full blood count (to identy anaemia or polycythaemia)
FEV1description
forced expiratory volume in one second
FVC = forced vital capacity
a post bronchodilator FEV1/FVC of less than 0.7 confirms what?
persistent airflow obstruction
airway obstruction is irreversible in asthma, true or false
false, it is largely reversible in asthma
what does a FEV1 less than 0.7 indicate
note that the FEV1 number allows the degree of airflow limitation to be quantified
a limitation in airflow
less than 0.5 indicates severe airway obstruction
what does the MRC( Medical Research
Council) dyspnoea scale do?
it grades the effects of breathlessness on daily activity. grades are from 1-5, with 1 being when they are the least affected by breathlessness, and 5 being when they are the most affected(severely) by breathlessness
it is used alongside spirometry values to assess the severity of COPD
the aim of the COPD assessment test (CAT)
to check the impact of COPD on wellbeing and daily life
has a scoring range of 0-40, and consists of 8 questions
note that is is** not a diagnostic tool**
when to refer someone with COPD to a respiratory specialist
when;
Lung cancer is suspected (for example they have haemoptysis or suspicious features on chest X-ray).
- There is diagnostic uncertainty
- COPD is very severe or rapidly worsening.
- Cor pulmonale is suspected.
- The person is less than 40 years of age and/or there is a family history of alpha-1-antitrypsin deficiency. If alpha-1-antitrypsin deficiency is confirmed, screening is indicated for the person’s family.
Cor pulmonale, also known as pulmonary heart disease, is a condition where the right side of the heart fails due to increased blood pressure in the lungs, often caused by lung diseases
note that Referral to a respiratory specialist may also be required to assess the need for:
* Oxygen therapy.
* Long-term non-invasive ventilation.
* Nebulizer therapy or long-term oral corticosteroids.
* Lung surgery
aims of COPD treatment
to reduce symptoms
improve exercise tolerance
improve quality of life
prevent/ reduce exacerbations
individualise care
reduce mortality
prevent disease progression
name some pharamcological treatments used in treating COPD
Short-Acting Muscarinic Antagonists
(Anticholinergics) - SAMAs
Short Acting Beta-2 Agonist (SABA) like salbutamol and terbutaline
Long-Acting Beta2 Agonists (LABAs) like salmeterol(serevent), formoterol, indacaterol and olodaterol
Long Acting Muscarinic Antagonist / Anticholinergics (LAMAs) like tiotropium
describe SAMA’s, their MoA and anything important to know about them
they work by relaxing the bronchial smooth muscles(bronchodilation)
they last up to 6 hours
they are more effective when used with SABAs
they improve the quality of life, breathlessness and mucous secretion
some common side effects are dry mouth, Arrhythmias; constipation; cough; dizziness; dry mouth; headache; nausea
usual dose for SAMAs are 1-2 puffs 3-4 times daily
an example is Ipratropium(atrovent)
should SAMAs be used in pregnancy
yes they can be used in pregnancy as long as benefits outweigh the risks
how do SABAs work
These are selective beta2 agonists which cause
bronchodilation. Used for immediate relief rather than prophylactic use
examples are salbutamol and terbutaline
some side effects of SABAs
arrhythmias, dizziness,
headache, hypokalaemia, palpitations, tremor
LABAs have a similar mode of action to SABAs, true or false
true
how long do LABAs last for
12 hours
LABAs are used in patients using SABAs regularly, true or false
true
exanples of LABAs
salmeterol(serevent), formeterol, indacterol and olodaterol
MoA of LAMAs
similar to that of SAMAs, i.e, LAMAs (e.g., tiotropium, aclidinium, glycopyrronium, umeclidinium) work by blocking muscarinic (M₃) receptors in the airways, leading to bronchodilation.
they are used to replace SAMA therapy
they last 12 hours
some effects of LAMAs
Improves FEV1, quality of life, reduce exacerbation and dyspnoea
what therapy is used for a person with stable COPD who develops a chronic producutive cough(produces sputum)
Oral mucolytic therapy, with Carbocisteine
list the fundamental (non inhaled therapies) treatments for confirmed COPD according to the guidelines
Offer treatment and support to stop smoking
* Offer pneumococcal and influenza vaccinations
* Offer pulmonary rehabilitation if indicated
* Co-develop a personalised self-management plan
* Optimise treatment for comorbidities
these treatment plans should be revisted in every review
when do we start inhaled therapies in COPD
only if;
first line non-inhaled interventions have been offered and inhaled therapies are needed to relieve breathlessness and exercise limitation, and
people have been trained to use inhalers and can
demonstrate satisfactory technique
Review medication and assess inhaler technique and adherence
regularly for all inhaled therapies
first line inhaled therapy for COPD
Offer SABA or SAMA to use as needed
if first line inhaled therapies do not work, and person has exacerbations, what do we do
if the person shows no asthmatic features or features suggesting steroid responsiveness, then offer LABA+LAMA
however if the person has asthmatic features or features suggesting steroid responsiveness, then consider, LABA + ICS
i.e we opt for long term treatments
“Steroid responsiveness” in a medical context means a condition or disease that shows a positive response to treatment with corticosteroids, or “steroids,” characterized by improvements in symptoms, lung function, or other relevant measures
what do we offer the patient if their day-day symptoms adversely affect their quality of life
what do we do if what we offer them does not work still
Consider 3-month trial of
LABA + LAMA + ICS
if no improvement, then revert back to LABA + LAMA
if the person has 1 severe or 2 moderate exacerbations of their COPD within a year, what do we do
Consider
LABA + LAMA + ICS
if a patient with asthmatic features or features suggesting steroid responsiveness has day-day symptoms that adversely impact their quality of life, or has 1 severe or 2 moderate exacerbations within a year, then what do we do
Offer LABA + LAMA + ICS
describe acute exacerbation of COPD
s a sustained worsening of the person’s symptoms
from their usual stable state, which is beyond normal day-to-day variations, and is acute in onset.
Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour
in severe COPD exacerbations, what is recommended
hospitalisation of the patient
if patient has moderate exacerbations, where there is a sustained worsening of respiratory symptoms in COPD, what is recommended
note that at this stage most/all inhaled therapies would have been exhausted
treatment with systemic corticosteroids and/or antibiotics
Many exacerbations in COPD (including some severe exacerbations) are caused by bacterial infections so will respond to antibiotics, true or false
false
Many exacerbations (including
some severe exacerbations)
are not caused by bacterial
infections so will not respond to
antibiotics
first choice oral antibiotic treatments for COPD
Amoxicillin 500 mg three times a day for 5 days
or
Doxycycline 200 mg on first day, then 100 mg once a day for 5-day course in total
or
Clarithromycin 500 mg twice a day for 5 days
this is guided by the most recent sputum cultures. review antibiotic choice after every sputum sample test
second choice oral antibiotics if first choice has shown no improvement in symptoms after 2-3 days
can offer an alternate first choice antibiotic that has not been previously used, or
Co-amoxiclav 500/125mg 3 times a day for 5 days
or
Co-trimoxazole 960mg twice a day for 5 days
or
Levofloxacin 500mg once a day for 5 days (only if other
alternative choice antibiotics are unsuitable;
with specialist advice)
which systemic corticosteroid is offered for COPD patients in exacerbation managements, and what counselling points are offered
Offer 30 mg oral prednisolone daily for 5 days
counsel on;
common side effects like osteoporosis, menstrual irregularities, Cushing’s syndrome, electrolyte imbalance, GI discomfort…etc(refer to BNF for more )
not stopping corticosteroids abruptly
interactions if taking any other meds
why, when and how to stop corticosteroid treatment
etc
Revise counselling points on corticosteroids
what is a nebuliser
a medical device that transforms liquid medication into a fine mist or aerosol, allowing it to be inhaled directly into the lungs for faster and more effective absorption, particularly for respiratory conditions
apart from systemic corticosteroids and antibiotics, what other alternative is offered for exacerbation management in COPD
Nebulised bronchodilators driven by air;
- Ipratropium 250-500mcg QDS
or
- Salbutamol 2.5-5mg QDS/PRN
how to follow up a person who has had an exacerbation of COPD
Consider:
Other possible diagnoses, such as pneumonia.
Symptoms or signs suggestive of a more serious illness or condition, such as cardiorespiratory failure or sepsis.
Previous antibiotic use which may have led to resistant bacteria.
The need for admission.
