What is the biggest cause of COPD?
Smoking - offer smoking cessation
When can a diagnosis of COPD be considered in patients over the age of 35? - what risk factors?
(generally a smoker) and presenting with 1 or more of the following symptoms:
- exertional breathlessness
- chronic cough
- regular sputum production
- frequent winter ‘bronchitis’
- wheeze
What diagnostic tests are carried out?
- Spirometry
- Chest Radiograph (CXR)
- FBC to identify anaemia or polycythaemia
- BMI
What else should be looked out for when thinking about a COPD diagnosis?
- weight loss
- reduced exercise tolerance
- waking at night with breathlessness
- ankle swelling
- fatigue
- occupational hazards
- chest pain
- haemoptysis (coughing up blood)
*last 2 symptoms are uncommon in COPD - raise possibility of alternative diagnosis
What is given as initial empirical treatment in COPD to relieve symptoms of breathlessness and exercise limitation?
Short acting beta2 agonist (SABA) or Short acting muscarinic antagonists (SAMA)
What is recommended in patients with moderate or severe airflow obstruction if diagnosis is in doubt?
- Trial of high dose ICS or oral corticosteroid
What should be checked before initiating new therapy?
inhaler compliance and technique
What are the side effects of ICS that patients should be aware of?
- oral thrush
- non-fatal pneumonia
Why is it important to measure the post-bronchodilator spirometry?
- To check for possible asthma diagnosis, shown with reversibility - this differentiates from COPD
What are the aims of treatment in COPD?
- Reduce breathlessness
2. Reduce exacerbation frequency
People with stable COPD who remain breathless or have exacerbations despite using SABA as required can be offered what?
OD LAMA in preference to QDS SAMA
What is the maintenance therapy in patients with stable COPD who remain breathless etc with FEV1 > 50% predicted?
- If FEV > 50% predicted: LABA or LAMA
- SAMA discontinued when LAMA started
- FEC < 50%: either LABA+ICS or LAMA
In a pt with stable COPD but still breathlessness, when would LABA+ICS be recommended as maintenance therapy?
- when FEV1 < 50% predicted
- could also use LAMA instead
In patients with stable COPD and an FEV1 > 50% who remain breathless or have exacerbations despite maintenance therapy with LABA, what can be considered as further treatment?
- LABA+ICS combination inhaler
- LAMA in addition to LABA when ICS not tolerated/contraindicated
LAMA should be added to LABA+ICS therapy if pt remains breathless/exacerbations irrespective of what?
Irrespective of FEV1
When would maintenance dose of oral corticosteroid be used?
In advanced COPD
What must be considered in those on long term oral corticosteroid treatment?
- monitor for development of osteoporosis.
- those >65yrs should be started on prophylactic treatment without monitoring
When should mucolytic therapy be used?
In patients with a chronic cough productive of sputum
LABA and LAMA are recommended in what patients?
- Pts who remain breathless or have exacerbations despite:
- using SABAs as needed and have
- FEV1 less than 50% predicted and
- have declined/ cannot tolerate ICS
What is triple therapy?
SABA prn + LABA/ICS combo + LAMA
*offered if patient remains breathless or has continuous exacerbations (e.g. 2 in a year)
What 5 things should be considered in the management of an acute exacerbation of COPD
- Antibiotics (duration of and 5 days post, oral where possible)
- Steroids (prednisolone 30mg 7-14 days + CONTINUE patients ICS if they have it) - based on severity, response and previous treatment
- Bronchodilators nebulised driven by AIR (not oxygen) [STOP any tiotropium]. Salbutamol 2.5mg 4 hourly + ipratropium QDS [max] 500micrograms
- VTE risk assessment
- Oxygen sats target lower than asthma at 88-92%
What is the target O2 saturation in COPD exacerbation?
88-92%
What are the antibiotics (GMMMG) used in acute exacerbation of COPD?
- First line: Doxycycline po 200mg stat followed by 100mg OD for 5 days
- amoxicillin and clarithromycin also used
- second line: co-amoxiclav po 625mg TDS for 5 days
- maintenance antibiotics: first line azithromycin 250mg three times a week (prophylactic) in non-smokers *more risk criteria
What is licenced as an adjunct to existing bronchodilator therapy in patients with severe COPD associated with chronic bronchitis and a history of frequent exacerbations?
- rofluminast
