COPD Flashcards
define COPD exacerbations, stages and symptoms
acute worsening of symptoms from patients usual stable state
may be infective or non-infective
each exacerbation increases the risk of future exacerbation
stage 1 - asymptomatic
stage 2 - dyspnoea
stage 3 - systemic disease comorbidities
stage 4 - respiratory failure, death
symptoms - worsening breathlessness, cough, increased sputum production, change in sputum colour - may be bacterial or viral infection
define COPD
umbrella term for:
emphysema - permanent enlargement of alveoli - destruction of their walls without obvious fibrosis
- progressive damage to lungs
- enlarged bronchioles, alveolar ducts and sacs
- loss of surfaces for gas exchange
- loss of elastic recoil -
- airway collapse esp on expiration
chronic bronchitis - chronic productive cough - inflammation leads to increased mucus production
- inflammatory process in response to inhaled irritants
- increased thickness of bronchial lining
- hypersecretion of mucus secreting glands
- less cilia
- impaired mucociliary clearance
describe the lungs in COPD
alveolar wall destruction and loss of elasticity
alveoli hyperinflation
smooth muscle contraction
airflow obstruction
airway remodelling and fibrosis
symptoms of COPD
breathlessness - particularly on exertion - progressive and persistent
persistent cough - usually sputum
chest infections - esp in winter
wheeze
chest tightness
less common symptoms:
fatigue
anxiety and depression
chest pain, weight loss
diagnosis of COPD
consider COPD if >35, a risk factor e.g. smoking and has 1 or more symptoms
spirometer used to confirm diagnosis of COPD - can calculate FEV1:FVC ratio
FEV1 - forced expiratory volume - vol of air patient is able to expel in 1 second
FVC - forced vital capacity
- total vol of air patient can forcibly exhale on breath
if FEV1:FVC ratio is <0.7 (70%)
- confirms obstructive airway disease
- could be asthma or COPD
what is the differences b/w obstructive, restrictive and mixed disorders in COPD?
obstructive disorders
- FEV1 reduced
- FVC normal
- FEV1:FVC reduced
- prolonged exhalation - normal vol exhaled but slowly
restrictive disorders
- FEV1 reduced
- FVC reduced
- FEV1:FVC normal or increased
- rapid exhalation - lasts 2-3 secs
mixed disorders
- FEV1 reduced
- FVC reduced
- FEV1:FVC reduced
- exhalation prolonged
what are the different stages of airflow obstruction?
if post bronchodilator FEV1:FVC is <0.7 - airflow obstruction disease
if FEV1 % predicted
>80% - stage 1 - mild obstruction
50-79% - stage 2 - moderate
30-49% - stage 3 - severe
<30% - stage 4 - very severe
what are the aims of COPD management
reduce symptoms
improve exercise tolerance
improve QoL
reduce severity+frequency of exacerbations
slow disease progression
reduce mortality
what are NICE guidelines (old)
breathlessness - offer SABA/SAMA
if FEV1 >50% - on exacerbation - LABA or LAMA
persistent exacerbations/breathlessness - LABA + ICS - combination inhaler
or LABA + LAMA if ICS not tolerated
if still not tolerated - triple therapy - LABA + ICS + LAMA
if FEV1 <50% - on exacerbation - LABA + ICS - combination inhaler
LABA + LAMA if ICS not tolerated
persistent exacerbations - triple therapy - LABA + ICS + LAMA
what are the GOLD guidelines (new)
- more patient focused and risk focused balancing symptom burden and exacerbation rate
1 or more moderate exacerbations not leading to hospitalisation - LABA or LAMA
2 or more moderate exacerbations or 1 or more severe exacerbation (leading to hospitalisation) - offer LABA+ ICS and LAMA
- triple therapy if blood eos is >300
link between ICS and pneumonia in COPD
COPD is a risk factor for development of pneumonia
- increased risk of hospitalisation and mortality
ICS associated with increased rate of penumonia
- dose related
- intra-class difference e.g. fluticasone propionate vs beclamethasone
ICS also associated with fragility fractures, skin thinning, diabetes, adrenal suppression
what is the case for ICS & LABA in COPD
ICS alone - not recommended
- does not modify FEV1 or mortality
- higher mortality rate with fluticasone propionate alone compared to ICS/LABA
ICS/LABA - not recommended
- single agent bronchodilator
triple therapy - ICS+LABA+LAMA
- recommended - improves health outcomes
what factors to consider when initiating ICS treatment
strongly favours ICS use:
eos count >300cells/uL
2 or more exacerbations per/yr
history of hospitalisation from exacerbations
history of concomitant asthma
favours use:
eos count 100 - 300
1 or more exacerbations
against use:
eos count <100
history of pneumonia
history of mycobacterial infection
why is adherence in COPD complex and what strategies can we use to improve it?
adherence is complex in COPD:
- comorbidities esp depression
- smoking status
- educational attainment
- severity of disease
multi-component strategies involving:
- inhaler technique optimisation
- selecting inhalers with similar inhalation technique
- motivational interviewing
- understanding of disease
- combination inhaler
- removing barriers - behaviour change
differentiation b/w COPD & asthma
not everyone with asthma is a smoker
symptoms are often < 35 for asthma
chronic productive cough is uncommon in asthma
breathlessness is variable in asthma
family history is common in asthma
