Module 2.2.2 (Management of COPD)

Question 1

What are three most common symptoms in COPD?

Answer 1

• Cough

> often first symptom of COPD

• Sputum production

> COPD patients commonly raise small quantities of tenacious sputum with coughing

> Purulent sputum can reflect ↑ in inflammatory mediators and/or the onset of a bacterial exacerbation but the association is weak

• Exertional dyspnoea (breathlessness)

> Major cause of disability and anxiety associated with the disease

> Described as ↑ effort to breathe, chest heaviness, air hunger or gasping

• Patients may also present with recurrent respiratory tract infections and wheezing
• Episodes of marked deterioration occur periodically = exacerbations = acute exacerbations are more frequent as COPD progresses

Question 2

What are acute exacerbations of COPD characterised by? When is it more frequent and what does it result in?

Answer 2

• Increasing dyspnoea (breathlessness)
• Reduced exercise tolerance
• Tachypnoea (rapid breathing)

More frequent in the winter months and as the severity of COPD worsens –> hospital admission, associated with considerable morbidity and mortality and healthcare costs

Question 3

The risk of COPD increases with the amount smoked and packed years, how to calculate the packed years smoked?

> Smoking history (including pack years smoked) Should be documented for every patient

Answer 3

1 “pack year” = 20 cigarettes smoked/day for one year

• To calculate pack years smoked:

> (no of cigarettes smoked per day x no of years smoked) ÷ 20

Question 4

How is FEV1 effected in smokers per pack-year smoked?

> Strong relationship between number of pack years smoked and the risk, severity and mortality of COPD and risk of lung cancer

Answer 4

Smokers suffer an irreversible loss of FEV1 of 4.4 to 10mL per pack-year smoked

Question 5

What are the risk factors for COPD?

Answer 5

• Genetics - Hereditary deficiency of alpha-1-antitrypsin n
• Lung growth and development – factors that affect development and growth during gestation and childhood linked to ↑ risk of developing COPD
• Aging – may simply represent accumulated exposures throughout life
• Socioeconomics – lower socioeconomic status - ↑ risk n
• Comorbidities – asthma & chronic bronchitis - ↑ risk

see attached image for more

Question 6

For diagnosis of COPD, what symptoms and what age group should COPD be considered in?

Answer 6

COPD should be considered in any patient (> 35 -40 yrs) who has dyspnoea, chronic cough or sputum production and/or a history of exposure to risk factors for the disease

Question 7

What are the key indicators for considering a diagnosis of COPD?

Answer 7

Dyspnea that is

• progressive over time
• characteristically worse with excercise
• persistent

Chronic cough

• may be intermittent and may be unproductive
• recurrent wheeze

Chronic sputum production

• ​Any pattern of chronic sputum production that may indicate COPD

History of risk factors

• genetic factors
• tobacoo smoke
• smoke from home cooking and heating fuels
• occupational dusts, vapours, fumes, gases and other chemicals

Family history of COPD and/or childhood factors

• For example low birth weight, childhood respiratory infections

Physical signs of airflow limitation are usually not present until significant impairment of lung function has occurred​

Question 8

How to diagnose COPD through spirometry?

Answer 8

• Diagnosis of COPD confirmed by the presence of persistent airflow limitation that is not fully reversible

Post bronchodilator

• FEV1/FVC ratio = 0.7
• FEV1 < 80% (declines more rapidly with age)

Question 9

Divide severity of COPD into mild, moderate and severe

Answer 9

MILD

• Few symptoms
• Breathlessness on moderate exertion
• Recurrent chest infections
• Little or no effect on daily activities

FEV1 = 60-80% predicted

MODERATE

• Increasing dyspnoea
• Breathlessness walking on level ground
• Increase the limitation of daily activities
• Cough and sputum production
• Infections requiring steroids

FEV1 = 40-59% predicted

SEVERE

• Dyspnoea on minimal exertion
• Daily activities severely curtailed
• Experiencing regular sputum production
• Chronic cough

FEV1 = < 40% predicted

Question 10

What are the differential diagnoses in COPD

Answer 10

Among patients who present in mid or later life with dyspnoea, cough and sputum production the differential diagnosis is broad

see attached image

Question 11

What is the issue with patients that have an overlap of COPD and asthma?

Answer 11

Patients with an overlap of COPD and asthma may experience more rapid disease progression than those with either disease alone

Question 12

What is a major complication in COPD patients? What does this result in?

Answer 12

• Development of stable hypercapnia (elevated CO2 in the blood)
• Hypercapnia –> increase in H+ concentration and the development of respiratory acidosis
• pH < 7.35 = acidosis
• pH > 7.45 = alkalosis
• The partial pressure of carbon dioxide (pCO2 or PaCO2) is used to assess the ability of the lungs to excrete carbon dioxide = increased in COPD
• The partial pressure of oxygen (pO2 or PaO2) provides information about the amount of oxygen dissolved in the blood

Question 13

For respiratory acidosis;

A) What does the progression of symptoms and signs depend on

B) What are the symptoms of acute or acutely worsening chronic respiratory acidosis

C) What are the symptoms and signs of slowly developing or stable respiratory acidosis (as in COPD)

Answer 13

A)

• Symptoms and signs depend on the rate and degree of pCO2↑

> CO2 rapidly diffuses across the BBB

> Symptoms and signs are the result of high CO2 concentrations and low pH in the CNS and any accompanying hypoxaemia

B)

• Headache confusion, anxiety, drowsiness and stupor

C)

• May be well tolerated but patients may have memory loss, sleep disturbances, excessive daytime sleepiness and personality changes.
• Signs include gait disturbances, tremor, blunted deep tendon reflexes, myoclonic jerks, asterixis (a movement disorder), and papilloedema (increased pressure in brain –> optic nerve swells)

Question 14

What is the COPD-X Plan –> management of COPD

Answer 14

• C: Confirm diagnosis
• O: Optimise function
• P: Prevent deterioration
• D: Develop support network and self-management plan
• X: Manage eXacerbations

Question 15

What are the main treatment goals in COPD

Answer 15

Main treatment goals are ↓ in symptoms and future risk of exacerbations

• Reduce symptoms
• Improve exercise tolerance
• Improve health related quality of life
• Reduce frequency and severity of exacerbations & consequent decline in lung function
• Slow disease progression

Question 16

Briefly explain the FOUR stages of goals in the care of COPD which is listed below.

1. Active therapy
2. Active therapy with treatment limitations
3. Palliative and supportive care
4. Terminal care

Answer 16

1. Active therapy
   * In the early stages of disease the goal is to provide symptom control, maintain health, delay progress of the disease via aggressive treatment of exacerbations and manage comorbidities
2. Active therapy with treatment limitations

• A point at which there is functional deterioration despite maximal therapy
• Initiation of long term oxygen therapy and functional deterioration are important points to reassess goals of treatment

3. Palliative and supportive care
   * Each exacerbation may be reversible until there is suboptimal or no response to treatment. May then provide palliation with treatment limitations or palliation alone with no active therapy
4. Terminal care

• Patients may elect to avoid active management
• This phase is characterized by

> Profound weakness

> Essentially bedbound

> Drowsy for extended periods

> Disorientated to time with poor attention span

> Disinterested in foods or fluids

> Difficulty swallowing medications

Question 17

What are the management guidelines in COPD?

Answer 17

Guidelines for COPD management recommend a stepwise escalation of therapy based on disease severity, which includes non-drug management of the condition and maintenance drug treatment for stable COPD

1. Stepped treatment based on disease severity
2. Stepped treatment with nonpharmacological interventions
3. Stepped treatment of pharmacological (inhaled medications)

see attached image

Question 18

For managing a COPD exacerbation in primary care;

A) What to do when patient is feeling unwell (finding it harder to breathe than usual and experiencing either more coughing, more phlegm, thicker phlegm than usual)

B) What do when patient is feeling worse

C) What to do if infection (change in color/ volume of phlegm and with/without fever) is present along with part B

D) What do when patient is feeling better

Answer 18

A)

• they start using more short-acting bronchodilator (SABA) e.g. salbutamol 4-8 puffs (400-800 mcg), via MDI and spacer every 3-4 hours, titrated to response

B)

3-4 hourly SABA not relieving symptoms adequately

• Commence oral prednisolone 30-50mg daily for 5 days, then stop

C)

• Commence oral antibiotics (amoxicillin or doxycycline) for 5 days

D)

• Step down short-acting bronchodilator use
• Return to usual daily prescribed medicines
• Write or review and reinforce the use of the COPD Action Plan

Question 19

When to send COPD patient to hospital if exacerbation worsens?

Answer 19

• Marked increased intensity of symptoms
• New or worsening peripheral oedema
• Worsening of hypoxaemia from usual (if known)

> SpO2 <92% if not on home oxygen

• Shortness of breath that is worsening and/or at rest
• High fever
• Altered mental state (confusion, slurred speech, drowsiness)
• Chest pain
• Worsening of co-morbidities (e.g. heart failure, ischaemic heart disease, diabetes)
• Inability to perform daily activities
• Increased anxiety (feeling scared/afraid)

Question 20

For non-pharmacological therapy in COPD

A) What is done for risk reduction

B) What is done to optimise function

Answer 20

A)

• Smoking cessation
• Immunisation

B)

• Physical activity
• Pulmonary Rehabilitation
• Nutrition

Question 21

Smoking cessation in COPD? Why so important?

Answer 21

NEEDS to be a PRIORITY to prevent or limit lung damage and improve prognosis

• More urgent for patients with respiratory diseases to quit smoking
• Therapies should include pharmacological therapies and behavioural support

Brief 5-A strategy to help willing patients quit

> Ask + Advise + Assess + Assist + Arrange

Question 22

For immunisations in COPD;

A) Why are influenza vaccinations given

B) Who are pneumococcal vaccine recommended for

C) What is the maximum amount of the 23vPPV vaccine recommended in a persons adult life

Answer 22

A)

Influenza vaccination can ↓ hospitalisations and death in COPD patients

• Give vaccination every year before the influenza season

B)

• 2 types of vaccines: Pneumococcal polysaccharide vaccine (23vPPV) & Conjugated pneumococcal vaccine (13vPCV)
• Opinion divided about current use of 23vPPV in those aged over 65 years

C)

No more than 3 doses of 23vPPV are recommended in a person’s adult life

• Doses should be spaced at least 5 years apart
• Standard aged related dosing is 65 years (or 50yrs for ATSI)

Question 23

Why is physical activity so important in COPD?

Answer 23

↓ in physical activity commences early in COPD and declines substantially across all severity stages of COPD

• Decline →deterioration in lung function and health status
• Levels of physical activity ↓ further during exacerbations
• Patients may avoid exercise because of a fear of breathlessness

> There is strong evidence of benefit of regular exercise in COPD patients

Question 24

What do pulmonary rehabilitation programs involve? What are the benefits?

Answer 24

Pulmonary rehabilitation programs involve

• Patient assessment
• Supervised exercise training
• Patient education
• Behavior change
• Nutritional intervention
• Psychosocial support

Benefits include

• ↓ dyspnoea, fatigue, anxiety and depression
• ↑ in health related QOL
• ↑ peripheral muscle function
• ↑ exercise capacity
• ↑ sense of control of condition
• ↑ emotional function
• ↓ hospitalization for exacerbation
• Cost-effective

Question 25

What are three tests used for assessment of exercise capacity

Answer 25

• The 6-minute walk test
• The incremental shuttle walk test
• The endurance shuttle walk test

Question 26

What can malnutrition lead to, what does low body weight and/or low fat-free mass (loss of lean tissue) leads to?

Answer 26

• ↓respiratory function
• ↓ability to expectorate
• ↑fatigability
• ↓exercise tolerance and ability to work

Question 27

What effects does obesity in COPD patients have on health-related quality of life? Why is there a reduced mortality risk?

Answer 27

metabolic consequences and adverse consequences in terms of impaired HrQOL:

• ↑fatigue
• ↑dyspnoea
• ↑use of inhaled medications
• ↓weight bearing exercise capacity

paradoxically a reduced mortality risk possibly due to ↓ static lung volumes or ↑free fat mass

Question 28

What should the choice of pharmacotherapy be based on for COPD?

> Decrease symptoms and risk and severity of exacerbations

> Improve health status and exercise tolerance

Answer 28

• Potential benefits
• Side-effects
• Cost of treatment
• Patient preference

Question 29

How is pharmacotherapy introduced for COPD? What is the goal?

Answer 29

Pharmacotherapy is introduced in a stepped approach until adequate control of breathlessness, functional capacity and exacerbation frequency is achieved

Question 30

What are the FOUR steps used in the pharmacotherapy of COPD?

Answer 30

1. Use a short-acting bronchodilator for short term relief of breathlessness (either a SABA or a SAMA)
2. For patients receiving a short-acting bronchodilator (SABA or SAMA) with persistent dyspnoea add a LABA# or LAMA* (or both if monotherapy is inadequate)

= Do not use LABA monotherapy if patients have an asthma-COPD overlap

* = If adding a LAMA the SAMA should be discontinued

3. For patients with an FEV1 <50% predicted and ≥ 2 exacerbations in 12 months:

> Consider initiating an ICS + LABA/LAMA fixed dose combination

> For moderate to severe COPD with frequent exacerbations who are not receiving a LAMA consider adding a LAMA to ICS/LABA

> Balance risk of corticosteroids and risk of pneumonia

4. For severe COPD (FEV1 <40% predicted), consider adding lowdose theophylline (100mg twice daily):

> Avoid long-term (>2 weeks) use of systemic corticosteroids

Question 31

There is no fixed time frame for assessment following pharmacotherapy alterations –> what is a reasonable time to assess dyspnoea improvement?

Answer 31

6 weeks may be reasonable to assess dyspnoea improvement but longer time periods would be required to assess quality of life and frequency of exacerbations

Question 32

What inhaler devices deliver medication used in the treatment of both asthma and COPD?

Answer 32

• Standard pressurised metered dose inhaler (pMDI)
• Breath-activated pMDI (BA pMDI)
• Nebulisers
• Soft mist inhalers
• Dry-powder inhaler (DPI) (capsule)
• Dry-powder inhaler (DPI) (breath-activated)

> Consider patient factors when choosing the optimal device

Question 33

What factors affect drug deposition and effectiveness for inhaler devices

Answer 33

Patient characteristics

• Anatomy
• Lung function
• Inhaler technique

Drug delivery

• Particle size distribution
• Nasal inhalation vs oral

Device and formulation characteristics

• Spray force (plume velocity)
• Spray duration
• Plume characteristics

Question 34

Choosing an appropriate inhaler device

> Adherence and technique are also crucial when it comes to inhalers and quality use of medicines

Answer 34

Not all devices are suitable for all patients

• pMDIs (pressure metered-dose inhaler) - should use a spacer at all times
• Try to avoid multiple inhaler types
• Non-English speaking – communication resources
• Inadequate inspiratory flow rate

> Avoid DPIs and BA-pMDIs – use pMDIs alone or with a spacer

• Inability to coordinate actuation and inhalation

> Avoid pMDI without spacer – use BA-pMDI or DPI

• Consider cognitive function

Question 35

Summary

Answer 35

COPD

• Characteristic symptoms are cough, sputum, and dyspnoea
• Progressive with acute exacerbations
• Persistent (not fully reversible: post-bronchodilator spirometry FEV1/FVC < 0.7) airflow limitations and gas-exchange abnormalities

> Smoking is the major risk factor and quitting smoking can have a major impact on disease progression

> Comorbidities can increase the complexity of managing COPD

> Pulmonary rehabilitation programs improve outcomes

> Pharmacotherapy is used in a stepped approach according to disease severity

> SAMAs and LAMAs should not be used concurrently

> The small benefits of ICS need to be balanced against the risks of pneumonia

> You need to consider patient characteristics when considering the most appropriate inhaler device