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