COPD New Guidelines Flashcards
What are the 5 common symptoms of COPD in people aged over 35 with a risk factor?
- Breathlessness
- Chronic/recurrent cough
- Regular sputum production
- Frequent LRTIs
- Wheeze
What diagnostic test is used to diagnose COPD?
Spirometry
What would be the results of spirometry to confirm a diagnosis of COPD?
A post bronchodilator FEV1/FVC less than 0.7 confirms persistent airflow obstruction.
Consider other causes in older people without typical symptoms of COPD who have an FEV1/FVC ratio less than 0.7.
Consider COPD in younger people who have symptoms of COPD, even when their FEV1/FVC ratio is above 0.7.
What is cor pulmonale?
Cor pulmonale is right heart failure secondary to lung disease, and is caused by pulmonary hypertension as a consequence of hypoxia.
What other investigations should be carried out?
- Chest X-ray
- FBC
- Sputum culture
- Serial home peak flow measurements - to exclude asthma as a diagnosis
- ECG and serum natriuretic peptides - if cardiac or pulmonary hypertension is suspected
- CT thorax - if symptoms seem disproportionate to spirometry measurements
- Serum alpha-1-antitrypsin
What are the stages of spirometry , indicating the severity of airflow obstruction?
Stage 1- mild
Stage 2 - moderate
Stage 3 - severe
Stage 4 - Very severe
What is stage 1 airflow obstruction?
FEV1 80% of predicted value or higher.
What is Stage 2 airflow obstruction?
moderate — FEV1 50–79% of predicted value.
What is stage 3 airflow obstruction?
severe — FEV1 30–49% of predicted value.
What is stage 4 airflow obstruction?
very severe — FEV1 less than 30% of predicted value or FEV1 less than 50% with respiratory failure.
When should a patient with COPD be referred to a respiratory specialist?
- Suspected Lung Cancer
- There is diagnostic uncertainty
- COPD is very severe or rapidly worsening
- Cor pulmonale is suspected
- The person is less than 40 years of age and/or there is a family history of alpha-1-antitrypsin deficiency.
- They have frequent infections
What non-pharmacological therapies should be offered to all COPD patients?
- Offer treatment and support to stop smoking
- Offer pneumococcal and influenza vaccinations
- Offer pulmonary rehabilitation if indicated
- Offer development of a personalised self-management plan
When should inhaled therapies be offered to COPD patients?
- If all interventions have been offered and inhaled therapies are required to relieve breathlessness and exercise limitation
- People have been trained to use an inhaler and can demonstrate satisfactory technique
What is offered first line to symptomatic COPD patients?
a short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is first-line treatment
What determines the next step for patients who remain breathless or have exacerbations despite using SABAs or SAMAs?
Whether the patient has ‘asthmatic features/ features suggesting steroid responsiveness.
How is asthmatic/steroid responsiveness determined?
- Any previous, secure diagnosis of asthma or atopy
- A higher blood eosinophil count
- Substantial variation in FEV1 over time (at least 400 ml)
- Substantial diural variation in peak expiratory flow (at least 20%)
If a patient with COPD has no asthmatic features or features suggesting steroid responsiveness but are still symptomatic despite using a SABA or SAMA what should their next step be?
- add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA)
if already taking a SAMA, discontinue and switch to a SABA
If a patient with COPD has asthmatic features or features suggesting steroid responsiveness but are still symptomatic despite using a SABA or SAMA what should their next step be?
LABA + inhaled corticosteroid (ICS)
SABA or SAMA as required
If these secondary pharmaceutical interventions are still resulting in day-to-day symptoms affecting quality of life or resulting in 1 severe or 2 moderate exacerbations each year then what should we consider?
if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS
if already taking a SAMA, discontinue and switch to a SABA
What are spacers?
Spacers are plastic devices with a mouthpiece at one end and an aperture for a metered-dose inhaler (MDI) to be inserted at the other
What is the indication for spacers?
- They do not require the same level of coordination as an MDI alone and allow carers to help people with cognitive impairment or functional problems.
- They increase the proportion of the drug delivered to the airways and reduce the amount of drug deposited in the oropharynx (thereby reducing local adverse effects and systemic absorption).
- They are useful in people with poor inhaler technique.
When is oral theophylline considered in the management of stable COPD?
NICE only recommends theophylline after trials of short and long-acting bronchodilators or to people who cannot used inhaled therapy
the dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed
What should be monitored in patients that take oral theophyalline?
- Plasma levels and interactions must be monitored and doses adjusted appropriately
- Particular caution is required if prescribing theophylline to older people due to differences in pharmacokinetics, increased incidence of comorbidities and interactions with multiple medications
When should oral mucolytic therapy be considered in COPD patients?
Consider mucolytic therapy if a person with stable COPD develops a chronic cough productive of sputum.
Only continue the mucolytic if there is symptomatic improvement (such as a reduction in the frequency of cough and sputum production).
Mucolytics should not be used routinely to prevent exacerbations in people with stable COPD.
