Management of COPD Flashcards
Who should you consider a diagnosis of COPD in?
Patients over 35 years of age who are smokers/ex-smokers and have symptoms like exertional SoB, chronic cough or regular sputum production
What investigations are recommended in patients with suspected COPD?
Post-bronchodilator spirometry to demonstrate AFO (FEV1/FVC ratio <70%)
CXR
FBC
BMI
What might you see on CXR in COPD patients?
Hyperinflation, bullae, flat hemidiaphragm
Essential to rule out lung cancer
Why should an FBC be done in all COPD patients?
Exclude secondary polycythaemia
How is the severity of COPD categorised?
Based on FEV1
What is considered mild COPD (stage 1)?
FEV1 >80%
What is considered moderate COPD (stage 2)?
FEV 50-79%
What is considered severe COPD (stage 3)?
FEV1 30-49%
What is considered very severe COPD (stage 4)?
<30%
What are features of COPD?
Cough (often productive)
SoB
Wheeze
In severe cases R sided heart failure may develop –> peripheral oedema
What are signs of COPD?
Reduced chest expansion
Prolonged expiration/wheeze
Hyperinflated (barrel) chest
Respiratory failure - tachypnoea, cyanosis, use of accessory muscles, pursed up breathing, peripheral oedema
What is involved in the general management of COPD?
Smoking cessation advice
Annual flu jab
One off pneumococcal vaccination
Pulmonary rehab to those who are functionally disabled by COPD
What is the first line treatment for COPD?
SABA or SAMA first line
For those with COPD who still have breathlessness/exacerbations despite short acting bronchodilators, what is the next step determined by?
Asthmatic features/features suggestive steroid responsiveness
What criteria may be used to help determine if a patient has asthmatic/steroid responsive features?
Any prev diagnosis of asthma/atopy
Higher blood eosinophil count
Substantial variation in FEV1 over time (at least 400ml)
Substantial diurnal variation in peak expiratory flow (at least 20%)
How should those with no asthmatic features be managed if short acting bronchodilators do not control their symptoms?
Add LABA or LAMA
If already taking SAMA, discontinue and switch to SABA
How should those with asthmatic features be managed if short acting bronchodilators do not control their symptoms?
LABA + ICS
If patients remain breathless or have exacerbations, triple therapy (LAMA, LABA and ICS) may be used
Use combined inhalers where possible
Who might be offered oral theophylline for their COPD?
After trials of short and long acting bronchodilators or to those cannot use inhaled therapy
The dose of theophylline must be reduced if what two drugs are being co-prescribed?
Macrolides/fluoroquinolone
What antibiotic is recommended for oral prophylactic antibiotic therapy in COPD?
Azithromycin
What are prerequisites to having prophylactic antibiotic therapy in COPD?
Not smoking
Optimised medical treatments
Continuing to have exacerbations
CT thorax to rule out bronchiectasis
Sputum culture to rule out atypical infections and TB
LFTs and ECG to rule out QT prolongation (as azithromycin can prolong the QT interval)
For what COPD patients should mucolytics be considered?
Those with a chronic productive cough and continued if symptoms improve
What are features of cor pulmonale?
Peripheral oedema, raised JVP, systolic parasternal heave, loud P2
How is cor pulmonale managed?
Loop diuretic for oedema
Consider long term oxygen therapy
Which factors may improve survival in patients with stable COPD?
Smoking cessation (most important intervention!!) Long term oxygen therapy Lung volume reduction surgery in selected patients
Patients who receive LTOT should breathe supplementary oxygen for how many hours a day?
At least 15
What patients should be assessed to see if they are eligible for LTOT?
Very severe airflow (FEV1 <30%), consider for severe airflow (FEV1 30-49%) Cyanosis Polycythaemia Peripheral oedema Raised JVP O2 sats <=92% on air
How is eligibility for LTOT assessed?
ABG on 2 occasions at least 3 weeks apart in those with stable COPD on optimal management
Who should be offered LTOT?
Patients with a pO2 <7.3kPa or those with a pO2 of 7.3-8kPa with one of the following:
- Secondary polycythaemia
- Peripheral oedema
- Pulmonary HTN
Can LTOT be offered to those who continue to smoke?
No
NICE suggest a structured risk assessment involving what is carried out before prescribing LTOT?
Risk of falls from tripping over equipment
Risk of burns and fires and increased risk for those who live in homes where someone smokes
What are features of AECOPD?
Increase in SoB, cough, wheeze
Increase in sputum suggests an infective cause
May be hypoxic and confused
What are the most common causes of infective exacerbations of COPD?
H. influenzae (most common)
Strep pneumoniae
Moraxella catarrhalis
Human rhinovirus most common viral cause
What is the management of AECOPD?
Increase bronchilator use, consider nebulising
Prednisolone 30mg for 7-14 ddays
Oral antibiotics if sputum is purulent/signs of pneumonia
When antibiotic is given (when appropriate) in AECOPD?
Amoxicillin or clarithromycin/doxycycline
