COPD

• When deciding oxygen saturation target in COPD, raised bicarbonate indicates chronic CO2 retention
• COPD is a long term progressive condition characterised by:

  • Airway obstruction
  • Chronic bronchitis
  • Emphysema
• The MRC dyspnoea scale can be used to quantify the patients breathlessness and the effect on their ADLs
• Diagnosis of COPD is based off clinical presentation and spirometry

  Spirometry will show an obstructive pattern with a FEV1:FVC ratio of less than 0.7
• Patients with COPD will have little or no response to bronchodilator reversibility testing
• The FEV1 can classify severity of COPD

  Very severe COPD will have a FEV1 less than 30% of predicted
• Patients with COPD will have a normal or increased total lung volume due to hyperinflation
• Typical presentation of COPD:

  • SOB - initially exertional but can progress to resting dyspnoea
  • Chronic cough with sputum production - usually colourless
  • Wheeze
  • Recurrent infections especially in the winter
  • Fatigue
  • Headache due to CO2 retention
• COPD does not cause finger clubbing or haemoptysis - explore different cause
• Investigations for COPD:

  • Spirometry - obstructive picture
  • CXR - often normal but can show hyperinflation and bullae, used to exclude other pathology
  • BMI - cachexia
  • FBC - polycythaemia (chronic hypoxia), anaemia and infection
• An ECG and echo in COPD can look for features of heart failure and cor pulmonale

  Cor pulmonale can cause tall P waves on an ECG
• On inspection of a patient with COPD:

  • Tachypnoea
  • Tripod position - use of accessory muscles
  • Wheeze on auscultation
  • Barrell chest - hyperinflation
  • Decreased cricosternal distance
  • Peripheral cyanosis
  • Hoovers chest sign - lower ribs move inward during inspiration
  • Cor pulmonale can cause oedema, raised JVP and right parasternal heave
  • CO2 retention flap
• Patients with COPD, especially young patients, can be tested for serum alpha-1 antitrypsin
• General management of COPD:

  • Smoking cessation
  • Pneumococcal and flu vaccine
  • Pulmonary rehab
• Pharmacological management of COPD:

  1. SABA or SAMA
  2. LABA + LAMA - ICS can be added instead of LAMA if features of reversibility
  3. LABA + LAMA + ICS - trimbow combination inhaler
• Patients with severe COPD can be offered:

  • SABA or SAMA nebulisers
  • Carbocisteine - oral mucolytic
  • Oral corticosteroids
  • LTOT
• Complications of COPD:

  • Hypercapnic respiratory failure (low oxygen, raised carbon dioxide)
  • Secondary polycythaemia - raised haemoglobin due to chronic hypoxaemia
  • Cor polmonale
  • Bronchiectasis
  • Osteoporosis - long term steroid use, smoking
  • Sleep disturbance
• Management of ECOPD in community:

  • Increase dose and frequency of SABA
  • 30mg of prednisolone for 5 days
  • Consider antibiotics
  • Offer amoxicillin 500mg TDS for 5 days
  • Sputum sample if no improvement
• Common pathogens for IECOPD:

  • S. pneumoniae
  • H. Influenzae
• Management of ECOPD in hospital:

  • Nebulised bronchodilators
  • Controlled O2 therapy
  • IV hydrocortisone and/or oral prednisolone
  • Antibiotics if signs of infection
  • Physiotherapy to aid sputum clearance
• Antibiotics first line:

  • Amoxicillin, clarithromycin or doxycycline
• Consider long-term oxygen therapy for people with COPD who do not smoke and who:

  • have a partial pressure of oxygen in arterial blood (PaO2) below 7.3 kPa when stable OR
  • have a PaO2 above 7.3 and below 8 kPa when stable, if they also have 1 or more of the following:
  • secondary polycythaemia
  • peripheral oedema
  • pulmonary hypertension
• Chronic bronchitis is defined as a productive cough for at least 3 months in 2 consecutive years
• Risk factors:

  • Tobacco smoking - associated with 80% of COPD cases
  • Indoor air pollution
  • Alpha-1 antitrypsin deficiency - autosomal dominant condition
• FEV1 is used to classify the severity of COPD:

  • Mild >80%
  • Moderate 50-80%
  • Severe 30-50%
  • Very severe <30%
• Chest X-ray: hyperinflation:

  • >6 anterior ribs or >10 posterior ribs visible in the mid-clavicular line
  • Flattened diaphragm
  • Hyperlucent lungs
• Surgical management:

  • Lung volume reduction surgery
  • Lung transplantation