COPD X

Question 1

Describe the spirometry and symptology required for diagnosis of COPD.

Answer 1

Spirometry: FEV1 <80% and FEV1/FVC <70% post bronchodilator - confirm presence of persistent airflow limitation Symptoms: SOB, cough, increased sputum production

Question 2

What are the 8 key aspects of COPD management?

Answer 2

1. Vaccination 2. Smoking cessation 3. Nutrition 4. Managing comorbidities 5. Pharmacotherapy 6. Pulmonary rehab 7. Action plan 8. Self management

Question 3

Risk factors for COPD.

Answer 3

*** SMOKING *** - relationship exists between amount of tobacco smoked and rate of decline in FEV1 Other risk factors: parental smoking, genetic factors, asthma, SES status, nutritional and environmental factors

Question 4

Pitfalls of spirometry

Answer 4

May under diagnose younger patients and over diagnosed elderly patients

Question 5

Is it COPD or Asthma?

Answer 5

• asthma is diagnosed by increased FEV1 > 12% and by > 200ml post bronchodilator - if FEV1 improves by > 400ml this would suggest underlying asthma or co-existing asthma and COPD

Question 6

Which other investigations would you order to r.o other pathologies which are not COPD?

Answer 6

• CXR - haematology/biochemistry - complex lung function tests - EST - ECG - TTE

Question 7

How is severity of COPD confirmed?

Answer 7

MILD - FEV1 60-80% predicted - few symptoms, SOB with moderate exertion - little or now effect on daily activities MODERATE - FEV1 40-59% predicted - SOB when walking on level ground - increasing limitation of ADLs - recurrent chest infections - exacerbations requiring steroids/antibiotics SEVERE - FEV1 <40% - SOB on minimal exertion - severely limited ADLs - increasing frequency and severity of exacerbations

Question 8

What are the 5 most prevalent comorbidities in patients with COPD?

Answer 8

1. HTN 2. Hyperglycaemia 3. Atherosclerosis 4. Dyslipidaemia 5. Osteoporosis

Question 9

What does COPD- X stand for?

Answer 9

Case finding/confirm diagnosis Optimise function Prevent deterioration Develop plan of care Manage eXacerbations

Question 10

What are the physical activity recommendations for patients with COPD?

Answer 10

• aim to walk for at least 150min/week (30min/day x 5 a week) - instruction patients to walk until the feel too breathless to continue, have a rest and then resume walking

Question 11

Describe the non-pharmacological strategies recommended to optimise COPD.

Answer 11

• smoking cessation - pulmonary rehab, all symptomatic patients should be referred - regular physical activity - self management and support groups

Question 12

What are the 2 main aims of pharmacological treatment in COPD?

Answer 12

1. treat symptoms 2. reduce risk fo severe exacerbations and deterioration

Question 13

What is the evidence behind the current COPD pharmacological agents?

Answer 13

1. SABA/SAMA –> provide short term relief of SOB 2. LAMA/LABA –> may improve lung function, symptoms, quality of life and exacerbation frequency 3. ICS/LABA –> may reduce exacerbation frequency and improve QOL ** Triple therapy results in reduced rate of moderate of severe COPD exacerbations, better lung function and quality of life in comparison to dual therapy.

Question 14

Does LABA/LAMA combination work better than single LAMA or LABA inhalers?

Answer 14

Yes! Used in combination results are better than monotherapy.

Question 15

What things would trigger you to consider altering pharmacotherapy in COPD?

Answer 15

• exertional dyspnoea - functional status - history of exacerbations - patient preference

Question 16

When should you re-assess alteration of pharmacotherapy in COPD?

Answer 16

6 weeks would be reasonable

Question 17

What is the risk of ICS?

Answer 17

Increased risk of pneumonia

Question 18

What are some non-pharmacological options for symptomatic management?

Answer 18

• handheld fans - use of breathlessness recovery positions r.e. forward lean

Question 19

When should you consider adding LAMA/LABA?

Answer 19

In patients who are on SABA who have persistent dysnpea you should consider adding LABA or LAMA or both LAMA/LABA.

Question 20

When would you consider LAMA/LABA dual therapy?

Answer 20

In patients with a SABA and a either mono LABA or LAMA who have ongoing symptoms of breathlessness.

Question 21

What is triple therapy and when is it indicated?

Answer 21

• triple therapy = ICS/LAMA/LABA - indicated for patients with repeat exacerbations and more severe COPD symptoms that are not managed on dual LABA/LAMA therapy

Question 22

Describe the stepwise management of stable COPD.

Answer 22

1. Confirm diagnosis and severity 2. Optimise with non-pharmacological interventions 3. Optimise with pharmacological interventions > start with SABA or SAMA for symptom relief > consider adding LABA or LAMA if ongoing sx > from here could consider LABA/LAMA combination > if still symptomatic consider adding ICS ** should always assess adherence and technique prior to changing pharmacotherapy **

Question 23

When to consider referral to respiratory physician?

Answer 23

Question 24

At what saturations would you consider referral for home O2?

Answer 24

Stable COPD with SpO2 <92%

Question 25

What is the greatest risk factor for COPD exacerbation?

Answer 25

A recent history of exacerbation (within the last `12 months).

Question 26

What is the pneumococcal immunising advice for patients with COPD?

Answer 26

Question 27

Does vaccination reduce hospitalisation for patients with COPD?

Answer 27

No! Neighter influenza or pneumococcal vaccination reduces hospitalisation but they both reduce risk of exacerbation.

Question 28

Name 4 mucolytics.

Answer 28

N-acetylcysteine

Erdosteine

Carboxysteine

Ambroxol

Question 29

What defines an exacerbation of COPD?

Answer 29

• change in baseline dyspnoea, cough and or sputum production
• greatest predictor is recent hx of exacerbation as FEV1 reduces with each exacerbation
• triggers: viral or bacterial infection left heart failre, stress and air pollution

Question 30

What are the aims of early diagnosis and treatmeant of exacerbations?

Answer 30

• reduce hospitalisation and maintrain baseline FEV1/function
• a delay (>24Hrs) in exacerbation doubles the chance of hospital admission
• hence the aim of a COPD action plan

Question 31

When should a COPD patient be hospitalised?

Answer 31

• marked increase in symptoms
• in adequate response to community management
• inability to walk between rooms when previously mobile
• inability to eat or sleep due to SOB
• unable to manage at home
• altered mental status suggestive or hypercapnia
• hypoxaemia or cor pulmonale

Question 32

Describe the use of inhaled bronchodilators in COPD exacerbations.

Answer 32

• effective for initial treatment of exacerbation
• need to increase SABA –> 4-8 puffs every 3-4 hours and titrate to response

** note 4-8 puffs via spacer is equivalent to a 2.5mg neb **

• if SABA needed more than 3 hourly patient needs to seek medical attention

Question 33

What role do oral corticosteroids play in COPD exacerbations?

Answer 33

• reduce severity and shorten recovery from exacerbation
• 30-50mg daily mane for 5 days, nil tapering required

Question 34

Indication for antibiotics in COPD exacerbations.

Answer 34

• consider Abx if febrile, increased sputum volume and change in colour of sputum
• amoxicillin 500mg Q8H or 1g Q12H

OR

• doxycycline 100mg daily for 5 days
• if response to Abx not adequate optimise bronchodilators and oral steroid therapy and reassess diagnosis

Question 35

Indication for NIV in COPD exacerbations

Answer 35

• CPAP or BiPAP may be required
• indication: pH < 7.35, pCO2 > 45 (i.e. type 2 respiratory failure)