COPD
Aaqid Akram MBChB (2013)
Clinical Education Fellow
Objectives
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What is it?
How to diagnose it
How to assess severity/progression
How to manage it – Stable/Exacerbation
What is it?
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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
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>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
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Predicted
Pre + Post bronchodilator therapy. (>400ml)
FEV1
FVC
FEV1/FVC
Obstructive
Restrictive
Volume (L)
6
Normal
FEV1
5
Obstructive
4
3
Restrictive
2
FVC
1
0
1
2
3
4
5
6
7
8
Time (s)
Exp Flow
Rate (L/s)
Flow Volume Measurement
Maximal Expiratory Flow
Forced Vital Capacity
Volume (L)
Other Tests
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CXR
BMI
FBC – polycythaemia/anaemia
? Alpha-1-antitrypsin (Age)
Pulse Oximetry
Sputum Culture (persistently purulent)
PEFR (to exclude asthma)
COPD v Asthma
COPD
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
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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
Severity
Post
Bronchodilator
FEV1/FVC
Predicted FEV1 %
<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
Severity of Airflow Obstruction
When to Refer?
• Diagnostic
uncertainty
• Severe COPD
• Second Opinion
• O2 Rx assessment
• Cor Pulminale
• Long term Neb
• Long term PO steroid
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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
SABA or SAMA
LABA or LAMA (FEV1>50%) /
(LABA+ICS) or LAMA (FEV1<50%)
(LABA+ICS) + LAMA
Drug Type
Generic Name
Brand Name
Colour
Short Acting Beta₂ Agonist (SABA)
Salbutamol
Salamol/Ventolin
Blue
Terbutaline
Bricanyl
Blue
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
Beclomethasone
Clenil Modulite/QVAR
Brown
Budesonide
Flixotide
Brown
Fluticasone
Pulmicort
Brown
Formeterol/Budesonide
Symbicort
Red
Salmeterol/Fluticasone
Seretide
Purple
Vilanterol/Fluticasone
Relvar Ellipta
Yellow
Long Acting Beta₂ Agonist (LABA)
Inhaled Corticosteroid (ICS)
LABA+ICS (one inhaler)
Oral Rx
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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
ABCDE
O2 (88-92%)
Salbutamol 5mg + Ipratropium 500mcg nebs (air driven)
Check ABG – change O2 accordingly
CXR
ECG
IV access + FBC/U+E
Prescribe and administer steroids – 30mg prednisolone/100mh hydrocortisone
Abx if pyrexial, purulent sputum or evidence of consolidation
?Need for NIV / HDU / ICU
Non Invasive Ventilation
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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
Consider ICU Input
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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
Any Questions?
Basically…. Smoking’s bad for you
Objectives Were:
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What is it?
How to diagnose it
How to assess severity/progression
How to manage it – Stable/Exacerbation