What do you want to check before seeing a known COPD patient?
- Smoking status (need to know if smoking cessation advice needed. Can’t smoke and have O2 therapy as it can cause fires)
- Last COPD review (usual annual COPD checks with a nurse)
- Last O2 sats (check if they’ve deteriorated)
- Previous hospital admissions
- Current and past medications (can check for interactions)
- Allergies and intolerances
How do you calculate pack year?
Number of packs of cigarettes smoked per day (20 cigarette packs) X years that person has smoked that number of cigarettes
What is a rescue pack?
A supply of steroids to be started if they person with COPD notices increased SOB affecting their activities of daily living (ADLs) or an antibiotics if they have more or discoloured sputum. The person should be advised to seek medical attention if they start, or are unsure if they should start, medication and should have written information about this.
What can COPD exacerbations be split into?
- Mild: controllable with increased usual medications
- Moderate: needs systemic corticosteroids and/or antibiotics
- Severe: needs hospitalisation
What are bacterial causes of COPD exacerbations?
- H.influenza
- Staph aureus
- S.pneumoniae
What are viral causes of COPD exacerbations?
- Influenza
- Rhinoviruses
- Parainfluenza
- Respiratory Syncital Viruses (RSV)
When would you consider hospital admission for acute exacerbations of COPD?
- Severe breathlessness, rapid onset of symptoms, acute confusion, cyanosis, worsening peripheral oedema, or impaired consciousness.
- The person is unable to cope or lives alone.
- A reduction in activities of daily living, is confined to bed, or is on long-term oxygen therapy (LTOT).
- Significant comorbidity.
- Low oxygen saturation (less than 90%) on pulse oximetry. Give oxygen (if available) while awaiting transfer to hospital. Refer to local protocols or follow instructions on the person’s oxygen alert card if available. Otherwise, use a 28% Venturi mask at a flow rate of 4 L/min, and aim for an oxygen saturation of 88–92%.
If the oxygen saturation remains below 88%, change to nasal cannulae at 2–6 L/min or a simple mask at 5 L/min with target saturation of 88–92%, and request an emergency ambulance.
If the oxygen saturation decreases after starting oxygen therapy, change to a 24% Venturi mask at a flow rate of 2 L/min. - Hospital-at-home and assisted-discharge schemes (where locally available) should be used as an alternative way of caring for people who would otherwise need to be admitted or stay in hospital.
What are worried about if O2 sats are below 88%?
More concerned about hypoxia than CO2 retention as hypoxia kills faster than hypercarbia.
What is the management for COPD patients?
- SABA
- LABA + ICS (asthmatic features) OR LABA + LAMA (if taking SAMA switch to SABA)
- LABA + ICS + LAMA (asthmatic features)
What are the features of asthmatic/steroid responsiveness in COPD patients?
- any previous, secure diagnosis of asthma or of atopy
- a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
- substantial variation in FEV1 over time (at least 400 ml)
- substantial diurnal variation in peak expiratory flow (at least 20%)
