W5 COPD and Cystic Fibrosis (AG)

Question 1

Why do we need to do spirometry?

Answer 1

To assess lung function
Look at airway limitation using GOLD guidelines

Question 2

Main difference between Asthma and COPD?

Answer 2

Asthma- Reversible, Eosinophilic disease
COPD- Progressive and Non-reversible

Question 3

Treatment Guidelines GOLD:
What is the layout of GOLD like?

Answer 3

ABCD cube

• Spirometrically confirmed diagnosis
• Assessment of airflow limitation
• Assessment of symptoms/risk of exacerbation (whether they have led to hosp admissions)
• Post-bronchodilator measure FEV1/FVC ratio= should be >70% to be classed as good.

Question 4

GOLD- pharmacological treatment- what is given to the groups?

Answer 4

Group A= Bronchodilator
Group B= LABA or LAMA
Group C= LAMA
Group D= LAMA OR LAMA + LABA OR ICS + LABA (COPD with asthmatic features- as ICS as LABA only works in the presence of ICS in asthma patients will work with good levels eosinophil levels)

Question 5

What is CAT Score?
What is mMRC?

Answer 5

COPD Assessment Test
- Higher scores denote a more severe impact of COPD on a patient’s life

Modified Medical Research Council Dyspnoea scale
- Assesses the degree of dyspnoea in patients.

Question 6

GOLD Treatment guidelines for COPD:
Dyspnea:

Answer 6

1. LABA or LAMA
2. LABA + LAMA OR LABA + ICS then LABA +LAMA + ICS
3. Consider switching inhaler device or molecules
   Investigate and treat other causes of dyspnea

Question 7

GOLD Treatment guidelines for COPD:
Exacerbations:

Answer 7

1. LABA or LAMA
2. LABA + LAMA
   IF eos <100= Roflumilast, FEV1 <50% & chronic bronchitis OR Azithromycin in fromer smokers
   IF eos >100= LABA + LAMA + ICS

Question 8

What are the 5 Fundamentals of COPD care?

Answer 8

After confirmed diagnosis of COPD:

Offer Pulmonary Rehabilitation if indicated
Offer pneumococcal and influenza vaccinations
Offer smoking cessation
Co-develop a personalised self-management plan
Optimise treatment for co-morbidities

These treatments and plans should be revisited at every review

Question 9

NICE Guidlines COPD:
On what conditions should inhaled therapies be started? (3)
Which Inhaled therapies?

Answer 9

Only if:
- All the 5 fundamentals have been offered (if appropriate) and
- inhaled therapies are needed to relieve breathlessness and exercise limitation and
- people have been trained to use inhalers and can demonstrate satisfactory technique

Offer SABA or SAMA To use as needed

Review medication and assess inhaler technique and adherence regularly for all inhaled therapies

Question 10

NICE Guidelines COPD

Question 11

Risk of giving ICS to a patient with COPD and asthmatic features with low eosinophil levels (means they don’t have asthma only features)

Answer 11

= Risk of PNEUMONIA
= Leads to hosp admission
= They already have high risk of chest infection.

Question 12

Example of
SABA?
SAMA?
LABA?
LAMA?

Answer 12

Salbutamol
Ipratropium
Formeterol/Salmeterol
Tiotropium

Question 13

What are the types of Inhaled antimuscarinics + examples?

MHRA advice?
Cautions?
SE?
Contraindications?

Answer 13

• SAMA: Ipratropium bromide (paramedics often use in a nebulised form)
• LAMA: Tiotropium, Umeclidinium, Glycopyronnium
• MHRA/CHM advice: risk of inhalation of capsule if placed in the mouthpiece of the inhaler
• Cautions: bladder outflow obstruction, paradoxical bronchospasm, prostatic hyperplasia, angle-closure glaucoma, cystic fibrosis
• S/E: constipation, arrhythmia, cough, dizziness, dry mouth, headache, nausea
• Contra-indicated in patients with hypersensitivity to atropin

Question 14

Management of exacerbation:
What are 3 things that increase during an exacerbation?

Answer 14

increased dyspnea, increased sputum volume, increased sputum purulence

Question 15

Management of exacerbation:
How does this happen?
What o2 levels should be aimed for?

Answer 15

• Short-acting (SAMA, SABA) usually at higher doses through nebuliser
• Withhold LAMA treatment if a SAMA is given
• Hydrocortisone was traditionally the drug of choice in severe life-threatening asthma
• Short course of oral prednisolone along with other therapies
• Antibiotics where there are signs of infections, in immunocompromised, co-morbidities

Oxygen
* Aim for 94-98% oxygen saturation- not too high!
* 88-92% oxygen saturation for patients at risk of hypercapnic respiratory failure

Question 16

Prevention of exacerbations:

Answer 16

1. Pulmonary exacerbations
   - improved dyspnea, health status and exercise tolerance
   - reduces hospitalisation among pts who have had a recent exacerbation
   - leads to a reduction in symptoms of anxiety and depression
   - leads to a reduction in symptoms of anxiety and depression
2. Education and self-management
   - both together improves health status and decreases hospitalisations and emergency department visits
3. Integrated Care programs
   -have no demonstrated benefit at this time

Question 17

What is a description of Cystic Fibrosis?
What are the main clinical signs?
What do its complications include?

Answer 17

• It is a genetic disorder affecting the lungs, pancreas, liver, intestine, and reproductive organs.
• Main clinical signs: pulmonary disease, with recurrent infections and the production of copious viscous sputum, and malabsorption due to pancreatic insufficiency.
• Complications include hepatobiliary disease, osteoporosis, cystic fibrosis-related diabetes, and distal intestinal obstruction syndrome.

Question 18

What are the aims of treatment in Cystic Fibrosis? (4)

Answer 18

• Preventing and managing lung infections
• Loosening and removing thick, sticky mucus from the lungs
• Preventing or treating intestinal obstruction
• Providing sufficient nutrition and hydration

Lung function is a key predictor of life expectancy in people with cystic fibrosis and optimising lung function is a major aim of care.

Question 19

What is the non-drug treatment for COPD?

Answer 19

• Provide advice on airway clearance, nebuliser use, musculoskeletal disorders,
  physical activity, and urinary incontinence (by specialist physiotherapists).
• Regular exercise improves both lung function and overall fitness

Question 20

What is the drug treatment for COPD?

Answer 20

• Treatment is based on the
  prevention of lung infection and the maintenance of lung function.
• Patients, who have clinical
  evidence of lung disease, the frequency of routine review should
  be based on their clinical
  condition.
• Adults should be reviewed at leastevery 3 months.
• More frequent review is required immediately after diagnosis.

Question 21

What mucolytics are offered for COPD patients?

Answer 21

• Patients with cystic fibrosis who have evidence of lung disease should be offered a mucolytic.
• Dornase alfa is the first choice mucolytic.
• If there is an inadequate response, dornase alfa and hypertonic sodium chloride, or hypertonic sodium chloride alone should be considered.
• Mannitol dry powder for inhalation is recommended as an option when dornase alfa is unsuitable, when lung function is rapidly declining, and if other osmotic drugs are not considered appropriate.

Question 22

What are examples of a Pulmonary Infection?

Answer 22

Staphylococcus aureus: Offer an antibacterial oral or IV

Pseudomonas aeruginosa: Offer an oral antibacterial in combination with an inhaled antibacterial.

Aspergillus fumigatus complex: Offer an antifungal drug only to
suppress chronic complex respiratory infection in patients with
declining pulmonary status