COPD – UPDATE

Dr Raj K RajakulasingamHomerton University Hospital & QMUL

Definition of COPD

• Airflow obstruction is defined as reduced FEV1/FVC ratio (< 0.7)

• It is no longer necessary to have an FEV1 < 80% predicted for definition of airflow obstruction

• If FEV1 is ≥ 80% predicted, a diagnosis of COPD should only be made in the presence of respiratory symptoms, for example breathlessness or cough

• COPD produces symptoms, disability and impaired quality of life which may respond to pharmacological and other therapies that have limited or no impact on the airflow obstruction.

FEV1 = forced expiratory volume in 1 secondFVC = forced vital capacity

Natural History

•The Fletcher-Peto Diagram, illustrating the effects of smoking on rate of decline in FEV1

Diagnose COPD

Consider a diagnosis of COPD for people who are:• over 35, and• smokers or ex-smokers, and• have any of these symptoms:

- exertional breathlessness- chronic cough- regular sputum production,- frequent winter ‘bronchitis’ - Wheeze

• And no clinical features of asthma

[2004]

Diagnose COPD: Spirometry• Perform spirometry if COPD seems likely [2004]

• The presence of airflow obstruction should be confirmed by performing post-bronchodilator spirometry [new 2010]

• Consider alternative diagnoses or investigations in: - older people without typical symptoms of COPD where the FEV1/FVC ratio is < 0.7- younger people with symptoms of COPD where

the FEV1/FVC ratio is ≥ 0.7 [new 2010]

• All health professionals involved in the care of people with COPD should have access to spirometry and be competent in the interpretation of the results [2004]

Differentiating COPD from asthma: 2

• If diagnostic uncertainty remains, the following findings should be used to help identify asthma:

- FEV1 and FEV1/FVC ratio return to normal with drug therapy

- a very large (>400ml) FEV1 response to bronchodilators or to 30mg prednisolone daily for 2 weeks

- serial peak flow measuremenst showing significant (20% or greater) diurnal or day-to-day variability

- remaining diagnostic uncertainty may be resolved by referral for more detailed investigations

[2004]

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-bronchodilator

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

Managing stable COPD: Promote effective inhaled therapy

In people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as required, offer the following as maintenance therapy:

•if FEV1 ≥ 50% predicted: either LABA or LAMA

•if FEV1 < 50% predicted: either LABA+ICS in a combination inhaler, or LAMA

Offer LAMA in addition to LABA+ICS to people with COPD who remain breathless or have exacerbations despite taking LABA+ICS,irrespective of their FEV1

ICS = inhaled corticosteroidLABA = long-acting beta2 agonist

LAMA = long-acting muscarinic agonist[new 2010]

Managing stable COPD: inhaled therapies

COPD - ICS

Dose of ICS should be equivalent to 1 mg/day

Low dose ineffective.

Managing stable COPD: Oxygen

• Clinicians should be aware that inappropriate oxygen therapy inpeople with COPD may cause respiratory depression

• Use appropriate oxygen therapy:

• Long-term oxygen therapy• Ambulatory• Short burst

Managing stable COPD: pulmonary rehabilitation

Pulmonary rehabilitation

An individually tailored multidisciplinary programme of care to optimise patients’ physical and social performance and autonomy

Tailor multi-component, multidisciplinary interventions to individual patient’s needs

Hold at times that suit patients, and in buildings with good access

Offer to all patients who consider themselves functionally disabled by COPD

Make available to all appropriate people, including those recently hospitalised for an acute exacerbation

[new 2010]

Multidisciplinary working

• COPD care should be delivered by a multidisciplinary team that includes respiratory nurse specialists

• Consider referral to specialist departments (not just respiratory physicians)

[2004]

Specialist department Who might benefit?Physiotherapy Advice about excessive sputum

Dietetic advice People with BMI that is high, low or changing over time

Occupational therapy People needing help with daily living activities

Social services People disabled by COPD

Multidisciplinary palliative care teams

People with end-stage COPD (and their families and carers)

Thank you for listening