COPD Alison Boland StR Respiratory medicine
Aims & Objectives
Overview of COPD
Recap basic knowledge
Update on COPD
Know when to use nebulisers and home oxygen therapy
The role of NIV in palliative setting / end stage COPD
Gain patient, carer and personal view about COPD
GOLD Definition
Airflow limitation
Not fully reversible
Progressive
Abnormal inflammatory response to noxious particles or gases
CHRONIC
Develops slowly
Early symptoms often go un-noticed
Symptoms present for much of the time
Progressive dyspnoea over time.
Worse on exercise
OBSTRUCTIVE
Narrowing of the bronchi
3 mechanisms:
•Bronchial walls become weakened•Mucus secretion into the bronchi.•Muscle spasm
Diagnose COPD: assessment of severity
• Assess severity of airflow obstruction using reduction in FEV1
NICE clinical guideline 12
(2004)
ATS/ERS 2004 GOLD 2008 NICE clinical guideline 101
(2010)
Post-bronchodilato
r FEV1/FVC
FEV1 % predicted
Post-bronchodilato
r
Post-bronchodilator
Post-bronchodilator
< 0.7 80% Mild Stage 1 (mild) Stage 1 (mild)*
< 0.7 50–79% Mild Moderate Stage 2 (moderate)
Stage 2 (moderate)
< 0.7 30–49% Moderate Severe Stage 3 (severe) Stage 3 (severe)
< 0.7 < 30% Severe Very severe Stage 4 (very severe)**
Stage 4 (very severe)**
* Symptoms should be present to diagnose COPD in people with mild airflow obstruction** Or FEV1 < 50% with respiratory failure
[new 2010]
Patient with COPD
Palliative care
Smoking Breathlessness & exercise limitation
Frequent exacerbations
Respiratory failure
Cor pulmonale
Abnormal BMI
Chronic productive
cough
Anxiety & depression
Managing stable COPD
Assess symptoms/problemsManage those that are present as below
Patients with COPD should have access to the wide range of skills available from a multidisciplinary team
Treatment options
Pharmacological
Bronchodilators
Steroids
Antibiotics
Mucolytics
Antitussives
Narcotics
Treatment options
Non – pharmacological
•Pulmonary rehabilitation•Oxygen •NIV•Surgery
Bullectomy
Lung volume reduction surgery
Lung transplantation
Managing stable COPD: inhaled therapies
SABA or SAMA as required*Breathlessness and exercise limitation
Exacerbations or persistent breathlessness
Persistent exacerbations or breathlessness
LABA LAMADiscontinue
SAMA________
Offer LAMA in preference to regular SAMA four times a
day
LABA + ICS in a combination
inhaler________
Consider LABA + LAMA if ICS
declined or not tolerated
LAMADiscontinue
SAMA________
Offer LAMA in preference to
regular SAMA four times a day
FEV1 ≥ 50% FEV1 < 50%
LABA + ICS in a combination
inhaler________
Consider LABA + LAMA if ICS
declined or not tolerated
LAMA + LABA + ICS in a combination
inhaler
Offer Consider* SABAs (as required) may continue at all stages
BronchodilatorsIndividual effects unpredictable
Inhaled:
•Salbutamol (‘Ventolin’)•Ipatropium (‘Atrovent’)•Salmeterol (Serevent)•Terbutaline (‘Bricanyl’)•Tiotropium (‘Spiriva’)•Indacterol (‘onbrez)
Oral: Theophyllines (‘Uniphyllin’, ‘Phyllocontin’)
Nebulisers
On maximum medical therapy
Use salbutamol only
1 month trial
No improvement in symptoms then stop
Indacaterol
Long acting Beta agonist
Rapid onset of action
24 hr duration of action
150micrograms od
Future use as add on to tiotropium
Phosphodiesterase inhibitors
Roflumilast
Severe COPD (FEV1 <50%)
Hx Chronic bronchitis, frequent exacerbations
500micrograms od
Reduces rate of moderate to severe exacerbations
Azithromycin
Macrolide antibiotic
Recurrent exacerbations
On maximum therapy
Long term 250mg x3 week
Caution re side effects
LTOT
FEV1 <50% predicted OR < 1.5l
Signs of cor pulmonalae
Sats <92%
PO2 <7.3 (8kPa)
Drying of nasal passages, oxygen toxicity,
Palliative care – target saturations not indicated
Ambulatory Oxygen
O2 use during exercise /ADL
LTOT patients
Objective evidence of desaturation on exercise
Non invasive ventilation
Home NIV
•Recurrent acute type 2 respiratory failures •Intolerance LTOT•Increased co2 with symptoms •Overlap OSA / Obesity hypoventialtion
End of life care
Chronic disease management
Stop smoking
Prn Bronchodilator
Annual flu jab
Pneumococcal vaccine (5yrs)
Regular exercise
Maintain weight normal range
NutritionUnderweight usually
BMI <20
Assess co morbidities
Social factors
Encourage snacking, Higher fat foods
Supplements after 1 month of above
Dietician advise
Key Messages
Consider Azithromycin in recurrent exacerbations
Prescribe short burst O2 with caution – expensive and little evidence
Pulmonary rehabilitation important multidisciplinary management
Finally remember how breathing through a straw felt!