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Stage 2: Supporting Life > Management of COPD > Flashcards

Management of COPD Flashcards

1
Q

How would you treat mild COPD exacerbation?

A

SABDs only

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2
Q

How would you treat moderate COPD exacerbation?

A

SABDs + oral antibiotics/glucocorticoids

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3
Q

How would you treat severe COPD exacerbation?

A

Hospital admission/respiratory failure

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4
Q

What is involved in hospital management of COPD exacerbations?

A

1) Controlled oxygen therapy
2) SABDs
3) Systemic glucocorticoids (steroids)
4) Antibiotics
5) Ventilatory support
6) Assess and treat associated co-morbidities/complications and prevent iatrogenic harm

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5
Q

Describe controlled oxygen therapy in hospital for COPD exacerbations

A
  • Initial target sats of 88-92%
  • 24% or 28% Venturi mask
  • Review pH and PaCO2
  • Reassess
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6
Q

Describe use of SABDs in hospital for COPD exacerbations

A
  • pMDI + spacer = nebuliser

- Beta 2 agonists + anticholinergic therapy

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7
Q

Describe use of systemic glucocorticoids in hospital for COPD exacerbations

A
  • Oral dose = IV dose
  • 5-7 day course (normally 30mg of oral prednisolone)
  • Reduces risk of early relapse/treatment failure and length of stay
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8
Q

Describe use of antibiotics in hospital for COPD exacerbations

A
  • Usually oral for 5-7 days
  • If sputum purulent or severe exacerbation send for culture
  • Choice depends on local microbial resistance → usually macrolide/doxycycline (penicillin)
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9
Q

What are the two types of ventilatory support for COPD exacerbations?

A

1) Non-invasive

2) Intubation and invasive ventilation

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10
Q

Which type of ventilation is the preferred treatment?

A

Non-invasive

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11
Q

When is ventilatory support indicated?

A
  • Acute respiratory acidosis (PaCO2 > 6, pH < 7.35)
  • Signs of fatigue and increasing work of breathing
  • Persistent hypoxaemia
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12
Q

What is the effect of non-invasive ventilation?

A

1) Improves hypercapnia and acidosis
2) Decreases RR and work of breathing
3) Improves mortality, length of stay and intubation rate
4) Reduces complication related to invasive ventilation e.g. VAP
5) Can be given on HDU or appropriately staffed respiratory ward

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13
Q

How does non-invasive ventilation work?

A

Delivers pressurised air at an inspiratory and expiratory pressure usually with supplemental oxygen to reduce work of breathing

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14
Q

When is invasive ventilation indicated?

A

1) When someone is unable to tolerate NIV → too acidotic or drowsy/delirious so can’t work with ventilators
2) NIV failure

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15
Q

What might cause someone to not be able to tolerate NIV, therefore requiring invasive ventilation?

A

1) Post cardiorespiratory arrest
2) Reduced consciousness
3) Haemodynamic instability/arrhythmia
4) Life threatening hypoxaemia
5) Aspiration/vomiting

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16
Q

What do you need to consider when intubating for ventilation?

A
  • Patient’s wishes → ideally would have wanted to talk to patient and family before crisis about wishes for intubation/ICU
  • Reversibility of precipitating event
  • Complications
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17
Q

What is the most important co-morbidity to address?

A

Tobacco addiction

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18
Q

How would you address smoking in someone with an acute COPD exacerbation?

A
  • Offer v brief advice and smoking cessation referral
  • Treat acute nicotine withdrawal by prescribing nicotine replacement therapy (otherwise treatment will be more difficult due to lower compliance)
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19
Q

How else do you have to address and treat associated co-morbidities/complications and prevent iatrogenic harm?

A
  • Fluid balance/replacement, diuretics bc of peripheral oedema (also consider echo to check for HF)
  • Thrombo-prophylaxis/anticoagulants (to prevent iatrogenic VTE)
  • Nutrition
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20
Q

What is the most effective treatment for COPD?

A

Intensive smoking cessation counselling + pharmacotherapy

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21
Q

What is the only treatment (apart from LTOT) that reduces mortality in COPD?

A

Stopping smoking aka treating tobacco dependence

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22
Q

What are the effects of stopping smoking in COPD?

A

1) Reduces mortality
2) Reduces hospital admissions
3) Improves asthma outcomes and efficacy of steroids in asthma
4) Within 1 year, risk of MI < 50% of smokers
5) Within 2 years, risk of stroke = non-smoker risk

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23
Q

What tool should be used as part of a respiratory assessment to aid stopping smoking?

A

CO monitor

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24
Q

How should you prescribe NRT?

A

Long acting medication + something short acting to treat cravings

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25
Q

What are the goals for treatment of stable COPD?

A

1) Reduce symptoms → relieve symptoms, improve exercise tolerance, improve health status
2) Reduce risk → prevent disease progression, prevent and treat exacerbations, reduce mortality

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26
Q

What is a high value COPD treatment?

A

Vaccination

1) Flu
2) Pneumococcal → reduces bacteraemia and invasive pneumococcal disease

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27
Q

What is pulmonary rehabilitation?

A

26h of contact with a respiratory specialist team involving aerobic and muscle strengthening exercises and 30 mins of education about COPD per session

28
Q

What are the benefits of pulmonary rehabilitation?

A

Reduces admissions, improves exercise capacity and improves health related QoL

29
Q

What are the effects of bronchodilators?

A

1) Alter smooth muscle tone
2) Reduce dynamic hyperinflation
3) Improve exercise limitations

30
Q

How do beta 2 agonists work?

A

Stimulate beta adrenergic receptors, increasing cAMP

31
Q

What are examples of SABAs used as required in COPD?

A

Salbutamol, terbutaline

32
Q

What is first line treatment in COPD?

A

Bronchodilators (opposite to asthma)

33
Q

What are examples of LABAs (12 or 24h) used in COPD?

A
  • Formoterol, Salmeterol (bd) →
  • Indacterol (od)
  • Olodaterol
34
Q

What are the benefits of LABAs?

A

Improve FEV1, lung volumes, dyspnoea, heath status, exacerbation rate and admissions

35
Q

What are possible side effects of beta 2 agonists?

A

Increased HR, arrhythmias, hypokalaemia (hyper?)

36
Q

How do antimuscarinics work?

A

They block ACh on M3 receptor on airway smooth muscle

37
Q

Do you prescribe short or long acting antimuscarinics in COPD?

A

Long acting (LAMA) → only prescribe SAMA if in big emergency bc evidence shows LAMAs are much better

38
Q

What is an example of a LAMA?

A

Tiotropium

39
Q

What is the effect of LAMAs?

A
  • Improves symptoms, health status, effectiveness of PR, exacerbations, admissions
  • No effect on lung function decline → all about controlling symptoms, exercise tolerance and reducing exacerbations
40
Q

What is LAMA more effective than LABA at?

A

Reducing exacerbations

41
Q

What bronchodilator treatment is generally given in COPD?

A

Combination LAMA/LABA (long-acting dual bronchodilator inhalers)

42
Q

What are the effects of combination LAMA/LABA?

A
  • Aim to increase bronchodilation with lower risk of side effects than increasing dose of single bronchodilator
  • Increase FEV1 and reduce symptoms
  • Reduce exacerbations compared with monotherapy
43
Q

When are ICS used to treat COPD?

A

In patients with moderate/severe COPD + exacerbations or if the patient also has asthma

44
Q

How is ICS used to treat COPD?

A
  • In combination with LABA
  • Monotherapy not licensed or indicated
  • Never first line treatment (opposite to asthma)
  • All licensed doses of ICS for COPD are by definition high dose
45
Q

What is the effect of ICS + LABA?

A

Improves FEV1, health status and reduces exacerbation frequency

46
Q

What is the main harm/side effect of ICS?

A

Increased risk of pneumonia (70%)

47
Q

What are other side effects of inhaled corticosteroids in COPD?

A
  • TB
  • Bone fracture
  • Skin thinning/easy bruising
  • Cataract
  • Diabetes
  • Oropharyngeal e.g. thrush
48
Q

What is the maximum lung deposition from a metered dose inhaler?

A

15%

49
Q

Why must you prescribe a spacer with an MDI?

A
  • A large volume spacer doubles deposition up to 30%
  • Reduces side effects in the throat
  • > 90% cannot use an inhaler
50
Q

What is possible surgical treatment for COPD?

A

Interventional bronchoscopy and surgery → removing area of emphysematous lung (bullectomy), blocking ventilation to that area using valve or lung coil or lung transplant

51
Q

What does oxygen treat?

A

Hypoxia (NOT breathlessness)

52
Q

What should oxygen be prescribed with?

A

1) Target saturations
2) Range of flow rates to achieve this
3) Delivery system/interface
4) Instructions for monitoring

53
Q

When are target sats >94%?

A

For most patients in an acute situation

54
Q

When are target sats 88-92%?

A

In patients at risk of hypercapnic respiratory failure → history of type 2 RF/chronic hypoxia, obesity hyperventilation, CF, NM disease

55
Q

To what patients should you not give oxygen?

A

Patients who hyperventilate or who have elevated bicarbonate on oxygen?

56
Q

What is oxygen therapy?

A

Administration of oxygen at concentrations higher than those at room air

57
Q

What are the aims of oxygen therapy?

A
  • Reducing hypoxaemia
  • Improving survival
  • Decreasing ventilatory load
  • Decreasing pH and myocardial load
  • REducing arrhythmias
  • Reducing secondary polycythaemia
  • Improving sleep quality
  • Reducing disability
  • Improving neurophysical health
58
Q

What are the two types of home oxygen therapy?

A

1) LTOT → use at least 15h-20h a day

2) Ambulatory oxygen therapy used when exercising in patients who have evidence of exercise desaturation

59
Q

Who is given home oxygen therapy?

A

People with chronic hypoxia

60
Q

Patients with what can be considered for home oxygen therapy?

A

1) V severe airflow obstruction (FEV1 < 30% predicted) → severe COPD, risk of chronic hypoxia
2) Cyanosis (SaO2 < 92%)
3) Polycythaemia
4) Peripheral oedema
5) Signs of cor pulmonale

61
Q

Why should the majority of oxygen be used at night?

A

Most desaturation occurs nocturnally (however those with only nocturnal desaturation show no survival benefit with nocturnal oxygen)

62
Q

What is the aim of giving oxygen?

A
  • To protect pulmonary vasculature and RV bc chronic hypoxia caused pulmonary hypertension which causes RV failure → death
  • Prevents risk in PAP and less polycythaemia
63
Q

Who can’t you prescribe oxygen to?

A

Current smoker bc of fire risk

64
Q

When is oxygen therapy not indicated?

A

SaO2 > 92%

65
Q

What can be used to help with breathlessness esp. in palliative setting?

A

1) Fan therapy → moving air around distribution of trigeminal nerve reduces sensation of breathlessness
2) Benzodiazepines
3) Opioids

Stage 2: Supporting Life (30 decks)

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