COPD Flashcards
When do you start LTOT in patients with COPD?
if 2 measurements of pO2 < 7.3 kPa
or a pO2 of 7.3-8kPa and one of the following:
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension
What is the most common organism causing infective exacerbations of COPD?
Haemophilus influenzae
Clinical features of an acute exacerbation of COPD?
- increase in dyspnoea, cough, wheeze
- there may be an increase in sputum suggestive of an infective cause
- patients may be hypoxic and in some cases have acute confusion
NICE guidelines for acute exacerbations?
- increase the frequency of bronchodilator use and consider giving via a nebuliser
- give prednisolone 30 mg daily for5 days
- it is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE do not support this approach. They recommend giving oral antibiotics’if sputum is purulent or there are clinical signs of pneumonia’
- the BNF recommends one of the following oral antibiotics first-line:amoxicillin or clarithromycin or doxycycline.
When is admission recommended?
- severe breathlessness
- acute confusion or impaired consciousness
- cyanosis
- oxygen saturation less than 90% on pulse oximetry.
- social reasons e.g. inability to cope at home (or living alone)
- significant comorbidity (such as cardiac disease or insulin-dependent diabetes)
Oxygen therapy + COPD patients?
- COPD patients are at risk of hypercapnia - therefore an initial oxygen saturation target of 88-92% should be used
- prior to the availability of blood gases, use a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis
- adjust target range to 94-98% if the pCO2 is normal
Nebulised bronchodilator + COPD patients
- beta adrenergic agonist: e.g. salbutamol
- muscarinic antagonists: e.g. ipratropium
What medication might be considered for patients not responding to nebulised bronchodilators?
IV theophylline
What type of prophylaxis is recommended in COPD patients who meet certain criteria and continue to have exacerbations?
Azithromycin prophylaxis
According to the most recent NICE guidelines, you should consider azithromycin (usually 250 mg 3 times a week) for people with COPD if they do not smoke, have optimised non-pharmacological management and inhaled therapies, relevant vaccinations and (if appropriate) have been referred for pulmonary rehabilitation and experience frequent (typically 4 or more per year) exacerbations with sputum production.
What tests should be done before starting prophylactic Azithromycin?
LFTs and ECG to exclude QT prolongation should be done as azithromycin can prolong the QT interval
What type of respiratory failure are patients with COPD prone to develop?
type 2 resp failure
If this develops then non-invasive ventilation may be used
types of non-invasive ventilation used + when?
Patients with COPD are prone to develop type 2 respiratory failure. If this develops thennon-invasive ventilationmay be used
- Typically used for COPD with respiratory acidosis pH 7.25-7.35
- The BTS guidelines state that NIV can be used in patients who are more acidotic (i.e. pH < 7.25) but that a greater degree of monitoring is required (e.g. HDU) and a lower threshold for intubation and ventilation should be used
bilevel positive airway pressure (BiPaP) is typically used with initial settings:
- Expiratory Positive Airway Pressure (EPAP): 4-5 cm H2O - Inspiratory Positive Airway Pressure (IPAP): RCP advocate 10 cm H20 whilst BTS suggest 12-15 cm H2O
Long term management of COPD steps
It is essential for people to stop smoking. Continuing to smoke will progressively worsen their lung function and prognosis. They can be referred to smoking cessation services for support to stop.
Patients should have the pneumococcal and annual flu vaccine.
STEP 1:
Short acting bronchodilators: beta-2 agonists (salbutamol or terbutaline) or short acting antimuscarinics (ipratropium bromide).
STEP 2:
If they do not have asthmatic or steroid responsive features they should have a combined long acting beta agonist (LABA) plus a long acting muscarinic antagonist (LAMA). “Anoro Ellipta”, “Ultibro Breezhaler” and “DuaKlir Genuair” are examples of combination inhalers.
If they have asthmatic or steroid responsive features they should have a combined long acting beta agonist (LABA) plus an inhaled corticosteroid (ICS). “Fostair“, “Symbicort” and “Seretide” are examples of combination inhalers. If these don’t work then they can step up to a combination of a LABA, LAMA and ICS. “Trimbo” and “Trelegy Ellipta” are examples of LABA, LAMA and ICS combination inhalers.
In more severe cases additional options are:
- Nebulisers (salbutamol and/or ipratropium)
- Oral theophylline
- Oral mucolytic therapy to break down sputum (e.g. carbocisteine)
Long term prophylactic antibiotics (e.g. azithromycin) - Long term oxygen therapy at home
Long term oxygen therapy is used for severe COPD that is causing problems such as chronic hypoxia, polycythaemia, cyanosis or heart failure secondary to pulmonary hypertension (cor pulmonale). It can’t be used if they smoke as oxygen plus cigarettes is a significant fire hazard.
Low pO2 indicates ?
hypoxia and respiratory failure
Normal pCO2 with low pO2 indicates?
Type 1 respiratory failure
only one is affected
