COPD

Alison Boland

StR Respiratory medicine

Aims & Objectives

Overview of COPD

Recap basic knowledge

Update on COPD

Know when to use nebulisers and home oxygen therapy

The role of NIV in palliative setting / end stage COPD

Gain patient, carer and personal view about COPD

GOLD Definition

Airflow limitation

Not fully reversible

Progressive

Abnormal inflammatory response to noxious particles or gases

CHRONIC

Develops slowly

Early symptoms often go un-noticed

Symptoms present for much of the time

Progressive dyspnoea over time.

Worse on exercise

OBSTRUCTIVE

Narrowing of the bronchi

3 mechanisms:

•Bronchial walls become weakened•Mucus secretion into the bronchi.•Muscle spasm

Natural History

Activity

BREATHE THROUGH THE STRAW FOR A MINUTE

THNIK ABOUT HOW THIS FEELS.

Diagnosis

FEV1/FVC <70%

Post bronchodialator FEV1 <80% predicted.

FEV1/FVC more sensitive.

Diagnose COPD: assessment of severity

• Assess severity of airflow obstruction using reduction in FEV1

NICE clinical guideline 12

(2004)

ATS/ERS 2004 GOLD 2008 NICE clinical guideline 101

(2010)

Post-bronchodilato

r FEV1/FVC

FEV1 % predicted

Post-bronchodilato

r

Post-bronchodilator

Post-bronchodilator

< 0.7 80% Mild Stage 1 (mild) Stage 1 (mild)*

< 0.7 50–79% Mild Moderate Stage 2 (moderate)

Stage 2 (moderate)

< 0.7 30–49% Moderate Severe Stage 3 (severe) Stage 3 (severe)

< 0.7 < 30% Severe Very severe Stage 4 (very severe)**

Stage 4 (very severe)**

* Symptoms should be present to diagnose COPD in people with mild airflow obstruction** Or FEV1 < 50% with respiratory failure

[new 2010]

Patient with COPD

Palliative care

Smoking Breathlessness & exercise limitation

Frequent exacerbations

Respiratory failure

Cor pulmonale

Abnormal BMI

Chronic productive

cough

Anxiety & depression

Managing stable COPD

Assess symptoms/problemsManage those that are present as below

Patients with COPD should have access to the wide range of skills available from a multidisciplinary team

Treatment options

Pharmacological

Bronchodilators

Steroids

Antibiotics

Mucolytics

Antitussives

Narcotics

Treatment options

Non – pharmacological

•Pulmonary rehabilitation•Oxygen •NIV•Surgery

Bullectomy

Lung volume reduction surgery

Lung transplantation

Managing stable COPD: inhaled therapies

SABA or SAMA as required*Breathlessness and exercise limitation

Exacerbations or persistent breathlessness

Persistent exacerbations or breathlessness

LABA LAMADiscontinue

SAMA________

Offer LAMA in preference to regular SAMA four times a

day

LABA + ICS in a combination

inhaler________

Consider LABA + LAMA if ICS

declined or not tolerated

LAMADiscontinue

SAMA________

Offer LAMA in preference to

regular SAMA four times a day

FEV1 ≥ 50% FEV1 < 50%

LABA + ICS in a combination

inhaler________

Consider LABA + LAMA if ICS

declined or not tolerated

LAMA + LABA + ICS in a combination

inhaler

Offer Consider* SABAs (as required) may continue at all stages

BronchodilatorsIndividual effects unpredictable

Inhaled:

•Salbutamol (‘Ventolin’)•Ipatropium (‘Atrovent’)•Salmeterol (Serevent)•Terbutaline (‘Bricanyl’)•Tiotropium (‘Spiriva’)•Indacterol (‘onbrez)

Oral: Theophyllines (‘Uniphyllin’, ‘Phyllocontin’)

Inhaler technique!!

Steroids

Inhaled – Seretide, Symbicort

Oral prednisolone

Do not modify long term decline in FEV1

Oral therapy

Theophylline

Carbocisteine

Opioids

Anti anxiolytics

Nebulisers

On maximum medical therapy

Use salbutamol only

1 month trial

No improvement in symptoms then stop

New(ish) therapies

Indacterol

Roflumilast

(Azithromycin)

Indacaterol

Long acting Beta agonist

Rapid onset of action

24 hr duration of action

150micrograms od

Future use as add on to tiotropium

Phosphodiesterase inhibitors

Roflumilast

Severe COPD (FEV1 <50%)

Hx Chronic bronchitis, frequent exacerbations

500micrograms od

Reduces rate of moderate to severe exacerbations

Azithromycin

Macrolide antibiotic

Recurrent exacerbations

On maximum therapy

Long term 250mg x3 week

Caution re side effects

Oxygen provision

Long term oxygen therapy

Ambulatory oxygen

Short burst oxygen

LTOT

FEV1 <50% predicted OR < 1.5l

Signs of cor pulmonalae

Sats <92%

PO2 <7.3 (8kPa)

Drying of nasal passages, oxygen toxicity,

Palliative care – target saturations not indicated

Ambulatory Oxygen

O2 use during exercise /ADL

LTOT patients

Objective evidence of desaturation on exercise

Short burst oxygen

Or Palliative O2

To relieve SOB

Excludes LTOT & ambulatory oxygen users

HOOF

HOOF

Non invasive ventilation

Home NIV

•Recurrent acute type 2 respiratory failures •Intolerance LTOT•Increased co2 with symptoms •Overlap OSA / Obesity hypoventialtion

End of life care

Chronic disease management

Stop smoking

Prn Bronchodilator

Annual flu jab

Pneumococcal vaccine (5yrs)

Regular exercise

Maintain weight normal range

NutritionUnderweight usually

BMI <20

Assess co morbidities

Social factors

Encourage snacking, Higher fat foods

Supplements after 1 month of above

Dietician advise

Pulmonary rehab

Pulmonary rehab

SOB waking on level ground at normal pace

2hr sessions, 6 weeks

Motivated patients

Patient views about COPD

Key Messages

Consider Azithromycin in recurrent exacerbations

Prescribe short burst O2 with caution – expensive and little evidence

Pulmonary rehabilitation important multidisciplinary management

Finally remember how breathing through a straw felt!

Any Questions?