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• COPD is an umbrella term for chronic bronchitis and emphysema
• Features of COPD include chronic productive cough, exertional dyspnoea, wheeze, right-sided heart failure and recurrent chest infections Right heart failure (as a result of cor pulmonale) can present as a raised JVP or peripheral oedema
• Obstruction in asthma is reversible, whereas obstruction in COPD is irreversible Reversible after administering a bronchodilator (e.g. salbutamol) Chronic asthma changes may not be reversible in extreme circumstances
• An FEV1/FVC ratio of <70% is indicative of obstructive lung disease [Prisonblues at the English-language Wikipedia, CC BY-SA 3.0 , via Wikimedia Commons]
• Patients <40 years old OR minimal smoking history with suspected COPD should be tested for alpha-1 antitrypsin deficiency [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• What investigations may be done for suspected COPD? Post-bronchodilator spirometry, CXR, FBC Obstructive flow loop (FEV1/FVC <70% is diagnostic of obstructive lung disease) CXR: hyperexpansion of the lungs, bullae, diaphragm flattening FBC: secondary polycythaemia caused by chronic hypoxia
• CXR of a patient with COPD may show: hyperinflation, bullae, diaphragm flattening Large bullae may mimic a pneumothorax CXR is important to rule out malignancy
• A FBC is done in patients with COPD to rule out secondary polycythemia Erythropoietin is increased due to chronically low O2 levels resulting in increased RBC production
• Post-bronchodilator FEV1 ≥80% of predicted in COPD is categorised as Mild (stage 1) Mild (Stage 1): ≥80% Moderate (Stage 2): 50-79% Severe (Stage 3): 30-49% Very Severe (Stage 4): <30% + FEV1/FVC ratio <70% [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• Post-bronchodilator FEV1 50-79% of predicted in COPD is categorised as Moderate (stage 2) Mild (Stage 1): ≥80% Moderate (Stage 2): 50-79% Severe (Stage 3): 30-49% Very Severe (Stage 4): <30% + FEV1/FVC ratio <70% [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• Post-bronchodilator FEV1 30-49% of predicted in COPD is categorised as Severe (stage 3) Mild (Stage 1): ≥80% Moderate (Stage 2): 50-79% Severe (Stage 3): 30-49% Very Severe (Stage 4): <30% + FEV1/FVC ratio <70% [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• Post-bronchodilator FEV1 <30% of predicted in COPD is categorised as Very severe (stage 4) Mild (Stage 1): ≥80% Moderate (Stage 2): 50-79% Severe (Stage 3): 30-49% Very Severe (Stage 4): <30% + FEV1/FVC ratio <70% [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• What genetic change predisposes someone to COPD? Alpha-1 antitrypsin deficiency
• The main cause of COPD is smoking Exposure to other respiratory irritants is also a risk factor cadmium dust and fumes.grain and flour dust.silica dust.welding fumes.isocyanates.coal dust.
• What non-pharmacological treatments/lifestyle changes are recommended for COPD patients? Smoking cessation & Pulmonary rehabilitation [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• COPD patients will recieve and annual influenza vaccination and a one-off pneumococcal vaccination [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• Inhaled therapies should only be offered to patients with COPD if there is breathlessness and exercise limitation [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• Initial inhaled therapy management of COPD is SABA or SAMA as needed [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• If an individual experiences exacerbations of COPD or is still limited by symptoms after initial inhaled therapy consider: Patients without asthmatic features or steroid responsiveness: 1st line: LABA + LAMA2nd line (persistent symptoms/exacerbations): triple therapy (LABA + LAMA + ICS)Patients with asthmatic features or steroid responsiveness: 1st line: LABA + ICS2nd line (persistent symptoms/exacerbations): triple therapy (LABA + LAMA + ICS) Triple therapy example: beclomethasone-dipropionate/formoterol/glycopyrronium - combined inhaler If t...
• Patients with COPD who have had trials of short and long acting bronchodilators or are unable to use inhaled therapies may be offered oral theophylline Phosphodiesterase inhibitor - relaxes smooth muscle [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• The dose of theophylline should be reduced if co-prescribed with macrolides or fluoroquinolones Phosphodiesterase inhibitor - relaxes smooth muscle Interaction with macrolides can cause cardiac complications including (torsades de pointes - type of VT) [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• Patients with COPD who continue to have exacerbations while on standard treatments may be offered prophylactic ABX (azithromycin) Prior to prescription: conditions such as bronchiectasis, aytipical infections and TB should be ruled out LFT and ECG need to be done prior to prescription [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• Azithromycin can cause QT prolongation, so an ECG must be performed before administering
• COPD patients with a chronic productive cough may be offered mucolytics If symptoms improve, prescription is continued e.g. carbocisteine [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• What is the symptomatic management of Cor Pulmonale in COPD patients? Diuretics (e.g. Loop diuretic) Consider LTOT (long term oxygen therapy) [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• Assessment for long term oxygen therapy in patients with COPD involves 2x ABG done 3 weeks apart [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• Patients with COPD should be offered LTOT if they have a PO2 <7.3kPa or PO2 7.3-8kPa and secondary polycythaemia, peripheral oedema or pulmonary hypertension LTOT: Long term oxygen therapy Normal PO2: 7.5-10.0 [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• LTOT is not offered to patients who smoke LTOT: Long term oxygen therapy [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• LTOT must be administered for at least 15 hours each day for there to be a survival benefit in COPD patients LTOT: Long term oxygen therapy [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• The most common bacterial cause of a COPD exacerbation is Haemophilus influenzae Bacterial causes: Haemophilus influenzaeStreptococcus pneumoniaeMoraxella catarrhalis [NICE [2018] Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing Evidence review. Available from https://www.nice.org.uk/guidance/ng114/evidence/]
• Nearly half of COPD exacerbations are caused by viruses; the most common is rhinovirus
• COPD exacerbations with an increase in sputum are likely due to an infective cause
• Patients with COPD exacerbations may experience confusion if they are hypoxic
• What is the out of hospital management of COPD exacerbations? Increase bronchodilators, prednisolone (5 days), consider ABX (if there are signs of pneumonia) Consider administering bronchodilators via a nebuliser Prednisolone 30mg daily for 5 days First line abx: Doxycyline, amoxicillin or clarithromycin [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• Exacerbations of COPD should be treated in hospital if oxygen saturations are less than 90% Criteria for admission: Severe breathlessnessAcute confusion or impaired consciousnessCyanosisOxygen saturation less than 90% on pulse oximetrySocial reasonsSignificant comorbiditiy (e.g. insulin dependent diabetic, cardiac disease) [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• How are COPD exacerbations managed in secondary care? Oxygen, nebulised bronchodilators, prednisolone (or IV hydrocortisone) Placement Top Tip: Important to distinguish pneumonia vs COPD, because prednisolone/IV hydrocortisone should be promptly given in COPD exacerbations Aim for oxygen sats between 88-92% initially or 94-98% if pCO2 is normal Bronchodilators should be: beta agonist (e.g. salbutamol) and muscarinic antagonist (e.g. ipratropium) Oral 5 day prednisolone [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from...
• Oxygen saturation target for exacerbations should be 88-92%. If pCO2 is normal, this should be adjusted to 94-98% COPD patients can enter a hypoxic respiratory drive as opposed to a hypercapnic respiratory drive. This means, if too much oxygen is given, they do not have the respiratory drive and slow down the breathing, causing pCO2 to build up. If pCO2 is normal, this means they still have a hypercapnic respiratory drive, thus can tolerate higher levels of oxygen.
• Acute exacerbations of COPD that dont respond to nebulised bronchodilators may be treated with IV theophylline [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• Patients who develop type 2 respiratory failure during a COPD exacerbation should be given non-invasive ventilation (BiPaP) if they have hypercapnic ventilatory failure [NICE [2019] Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115] Available from https://www.nice.org.uk/guidance/ng115/chapter/Recommendations]
• Bacterial pneumonia is the most common type of pneumonia Pneumonias can be caused by: bacteria, viruses, fungi