What other condition do you consider in people >40 or with a FHx
Alpha-1-Antitrypsin deficiency
In COPD patients, you should rule out Cor Pulmonale.
List signs and symptoms of this
Peripheral Oedema
Raised JVP, Systolic Parasternal heave
Hepatomegaly, Loud pulmonary 2nd heart sound
List investigations that should be done in COPD pt
- CXR: Rule out Lung cancer, Bronchiectasis, TB, HF (Normal CXR does not rule these out)
- FBC: Rule out Anaemia, Polycythaemia, Raised WCC, Eosinophilia
- Spirometry, Sputum culture, PEFR readings, ECG, Natiuretic Pepide, Echo, Serum Alpha-1-Antitrypsin, CT Thorax, O2
Describe Asthma-COPD Overlap syndrome
NICE calls this Asthma features/ features suggesting steroid responsiveness
- Pts developing COPD may have some ‘reversible airways disease’ or ‘steroid responsiveness’
- Includes: Previous diagnosis of Asthma/ Atopy, Raised blood Eosinophils, Substantial variation in FEV1 over time, or substantial variation in PEF (20%)
Name 3 circumstance where Asthma-COPD Overlap Syndrome can happen
- Person has confirmed Asthma and continues smoking/ exposure to occupation RFs
- Person has other Atopic conditions and develops COPD
- Pt with COPD has raised Eosinophil count
Pulmonary Rehab is one aspect of non-pharmacological management of COPD.
When can and when can’t you refer a pt for this?
Refer if;
- Functionally disabled by COPD
- Recent hospitalisation for Acute exacerbation
Don’t refer if;
- Unable to walk
- Have Unstable Angina or a recent MI
Outline the pharmacological treatment of COPD if Breathless + Exercise limitations
SABA or SAMA (Stop SAMA if a LAMA is started at any point)
Outline pharmacological treatment of COPD if;
- Short Acting Bronchodilators aren’t sufficient
- AND No asthmatic/ steroid responsiveness features
(1st and 2nd line)
1: LABA + LAMA
2;
- If 1 severe/ 2 moderate exacerbations in 1yr: Add ICS
- If daily QoL affected: 3mth trial of ICS
How often should ICS use be reviewed?
Annually (Pneumonia risk)
Outline pharmacological treatment of COPD if;
- Short Acting Bronchodilators aren’t sufficient
- AND Have asthmatic/ steroid responsiveness features
- Consider offering LABA + ICS
- If affecting QoL daily/ 1 severe or 2 moderate COPD exacerbations in 1y: Add LAMA
COPD exacerbations are commonly infective, but sputum samples aren’t routinely taken.
List non-severe symptoms
- Increased SoB/ Sputum vol. and purulence
- RR, HR 20% above baseline
- Cough, Wheeze
- Idiopathic fever, URTI <5days ago
COPD exacerbations are commonly infective, but sputum samples aren’t routinely taken.
List severe symptoms
- Marked SoB and TachyP
- New-onset Cyanosis/ Peripheral Oedema/ Confusion/ Drowsiness
- Pursed-lip breathing, Accessory muscle use
What do you do in a COPD exacerbation whilst waiting for admission?
If Sats <90%;
- Give O2 and monitor with Pulse Oximeter (refer to local protocols or instructions on pt’s O2 alert card)
- Otherwise, 24/28% O2 via Venturi mask. Target: 88-92%
Outline how do you treat a COPD exacerbation if hospital admission isn’t needed?
- Increased SABA dose/frequency
- Rescue Packs (ABs + Steroids)
- Consider Oral Corticosteroids if significantly increased SoB (30mg Prednisolone for 5days)
- Consider need for antibiotics (Sputum, Complication risk)
Outline the use of Abx in treating a COPD exacerbation, if needed
- Amoxicillin 500mg TDS 5days
- OR Doxycycline 200mg day 1, 100mg 4days
- OR Clarithromycin 500mg BDS for 5days
- Sputum culture + susceptibility testing. Alternate 1st line AB
- If high risk of treatment failure: Co-amoxiclav 500/125mg TDS for 5 days
Outline the follow-up of a pt with a COPD exacerbation
- 6wks after exacerbation onset
- Assess symptoms, adherence, technique.
- Offer short course of Oral Abx/CSs to keep at home as part of ACTION PLAN, if still at risk of exacerbation
Describe end-stage COPD
- Severe, worsening decline in symptoms, QoL and Functioning.
- Acute exacerbations common, increased risk of death.
- Good palliative care is vital
Which symptoms need managing in end-stage COPD
- Cough, SoB, Secretions
- Pain
- Insomnia, Anxiety, Depression
List some drug treatments for SoB in End-stage COPD
Other than O2
- Opiates/ Benzodiazepines
- Tricyclic antidepressants
- Major tranquillisers
