COPD Aaqid Akram MBChB (2013) Clinical Education Fellow
Jan 17, 2016
COPD
Aaqid Akram MBChB (2013)Clinical Education Fellow
Objectives
• What is it?• How to diagnose it• How to assess severity/progression• How to manage it – Stable/Exacerbation
What is it?
• Chronic Bronchitis/emphysema• Non reversible airflow obstruction• Progressive airway and parenchymal damage• Chronic inflammation• Smoking• Alpha-1-antitrypsin• 3 million in UK (900 000 diagnosed)
How to diagnose it
• >35 years old• Smokers• SOBOE• Chronic cough• Regular sputum
production• Frequent winter
“bronchitis”• Wheeze
• Weight loss• Reduced exercise
tolerance• Waking at night• Ankle swelling• Fatigue• Occupational hazards• Chest pain• Haemoptysis
MRC Dyspnoea Score
Grade Degree of breathlessness related to activities
1 SOB on strenuous exercise
2 SOB on hurrying or walking uphill
3 Walks slower than contemporaries due to SOB /Has to stop for breath at normal walking pace
4 Stops for breath walking 100 metres / few minutes on level ground
5 Cannot leave house / SOB on (un)dressing
Lung volumes
Spirometry
• Predicted• Pre + Post bronchodilator therapy. (>400ml)• FEV1• FVC• FEV1/FVC• Obstructive• Restrictive
Volume (L)
Time (s)
5
4
6
2
3
1
0 1 8765432
Normal
Obstructive
Restrictive
FEV1
FVC
Flow Volume MeasurementExp Flow Rate (L/s)
Volume (L)
Maximal Expiratory Flow
Forced Vital Capacity
Other Tests
• CXR• BMI• FBC – polycythaemia/anaemia• ? Alpha-1-antitrypsin (Age)• Pulse Oximetry• Sputum Culture (persistently purulent)• PEFR (to exclude asthma)
COPD v AsthmaCOPD Asthma
(Ex) Smoker
Age <35
Chronic productive cough
SOB
Nigh time waking SOB/wheeze
Diurnal/day to day variability
Think Asthma if:• Large response to bronchodilator/prednisolone (>400 ml)• Serial PEFR shows >20% diurnal/day to day variation
It is not significant COPD if FEV1 and FEV1/FVC ratio return to normal with Drug Rx
Prognosis (BODE Index)
BMI, Airflow Obstruction (Post bronchodilator), Dyspnoea, Exercise Capacity
0 1 2 3
B BMI >21 <22
O FEV1% Predicted >64 50-64 36-49 <36
D MMRC dyspnoea scale 0/1 2 3 4
E 6 Min Walk Distance (m) >349 250-349 150-249 <150
SeverityPost
Bronchodilator FEV1/FVC
Predicted FEV1 % Severity of Airflow Obstruction
<0.7 >79 Stage 1 Mild (symptoms required)
<0.7 50-79 Stage 2 Moderate
<0.7 30-49 Stage 3 Severe
<0.7 <30 (<50 + RF) Stage 4 Very Severe
When to Refer?
• Diagnostic uncertainty
• Severe COPD• Second Opinion• O2 Rx assessment• Cor Pulminale• Long term Neb• Long term PO steroid
• Bullous lung disease• Rapid FEV1 decline• Pulmonary rehab• Lung transplant• <40 years old• Frequent Infections• Haemoptysis• Symptoms > deficit
Management
• Smoking Cessation – NRT / Bupropion / Varenicicline / Support
• Nutrition – supplements• Anxiety / Depression• Physiotherapy – breathing techniques /
expectoration. • Pulmonary rehabilitation• Vaccinations – pneumococcal / influenza• Air travel – LTOT / FEV1<50% / pneumothorax
Inhaled Rx
(LABA+ICS) + LAMA
LABA or LAMA (FEV1>50%) / (LABA+ICS) or LAMA (FEV1<50%)
SABA or SAMA
Drug Type Generic Name Brand Name Colour
Short Acting Beta₂ Agonist (SABA) Salbutamol Salamol/Ventolin Blue
Terbutaline Bricanyl Blue
Long Acting Beta₂ Agonist (LABA) Indacaterol Onbrez Green
Salmeterol Serevent Green
Short Acting Muscarinic Antagonist (SAMA) Ipratropium Atrovent/Respontin/Rinatec
Long Acting Muscarinic Antagonist (LAMA) Tiotropium Spiriva
Glycopyrronium Seebri
Aclidinium Eklira Genuair
Inhaled Corticosteroid (ICS) Beclomethasone Clenil Modulite/QVAR Brown
Budesonide Flixotide Brown
Fluticasone Pulmicort Brown
LABA+ICS (one inhaler) Formeterol/Budesonide Symbicort Red
Salmeterol/Fluticasone Seretide Purple
Vilanterol/Fluticasone Relvar Ellipta Yellow
Oral Rx
• Methylxanthines – (Theo/Amino)phylline• Corticosteroids – not routinely recommended• Mucolytic therapy – Carbocisteine • Prophylactic Abx – not recommended• Phosphodiesterase 4 inhibitors – if on trials
Long Term O2 Therapy
• LTOT – 15 to 20 hours per day• Stable + PaO2 < 7.3 kPa• Stable + PaO2< 8 kPa + one of:– Secondary polycythaemia– Nocturnal hypoxaemia– Peripheral oedema– Pulmonary hypertension
Pulmonary Hypertension/Cor Pulmonale
• Pulmonary hypertension:– Increased blood pressure in lung vasculature
• Cor Pulmonale: – Right heart failure due to lungs– Due to sustained pulmonary hypertension– Symptoms of back pressure –
SOB/Chronic wet cough/Wheezing/Raised JVP + engorged facial veins/ Hepatomegaly/Peripheral oedema/Ascities/Parasternal heave/Loud pulm 2nd HS
Exacerbation of COPD
?Need for NIV / HDU / ICU
Abx if pyrexial, purulent sputum or evidence of consolidation
Prescribe and administer steroids – 30mg prednisolone/100mh hydrocortisone
IV access + FBC/U+E
ECG
CXR
Check ABG – change O2 accordingly
Salbutamol 5mg + Ipratropium 500mcg nebs (air driven)
O2 (88-92%)
ABCDE
Non Invasive Ventilation
• Bi-Level Ventilatory support• Potentially reversible exacerbation• Type 2 RF• Respiratory acidosis (pH<7.36 / PaCO2>5.9)• Despite Max medical Rx for 1 hour• Able to co-operate with mask• IPAP – 10• EPAP – 4
NIV – Exclusion Criteria/CI
• Pneumothorax • End stage malignancy • Acute myocardial infarction • Multi-organ failure • Cranio-facial abnormalities/Trauma• Normo-capnoeic metabolic acidosis • Impaired consciousness (GCS <8)• Patient declines use – refused consent• Haemodynamically Unstable• Irreversible condition• Unable to Co-operate with mask/no improvement
Consider ICU Input
Any Questions?
Basically…. Smoking’s bad for you
Objectives Were:
• What is it?• How to diagnose it• How to assess severity/progression• How to manage it – Stable/Exacerbation