Session 8 Flashcards
What is COPD?
• A disease characterised by – Persistent respiratory symptoms – Airflow limitation
• Due to airways and/or alveolar abnormalities
• Caused by significant exposure to noxious particles or gases
COPD is an “Umbrella Term”
• Not one disease but a syndrome
• Number of distinct pathologies – Usually co-exist
• Treatments are similar in most aspects
Aetiology of COPD
Smoking Biomass exposure Genetic (alpha one anti trypsin) Air pollution Illicit drug use
Epidemiology of COPD
Panopto
Pathophysiology of Disease
Small Airways Disease • Airway inflammation • Airway fibrosis, luminal plugs • Increased airway resistance
Parenchymal Destruction • Loss of alveolar attachments • Decrease of elastic recoil
both lead to airflow limitation
Chronic bronchitis
Emphysema
How is COPD diagnosed?
Look at symptoms
spirometry - required to establish diagnosis
Look at risk factors: Host factors, tobacco, occupation, indoor/outdoor pollution
Symptoms of COPD
slide 16 lec 1
Measuring dyspnoea
slide 17
Signs of COPD
- Often few or none especially at rest – Clinical observation and on exertion – Purse lip breathing – Hyperinflation or a barrel-shaped chest – Prolonged expiratory phase
- On examination – Maybe wheeze on auscultation – In advanced cases • Cyanosis (rarely) • Cor pulmonale (right sided heart failure)
How is spirometry used to diagnose COPD?
Confirm Airflow Obstruction
use panopto
Other investigations to look at COPD?
- Chest X-Ray not diagnostic – May suggest hyperinflation – Mandatory to exclude other diagnoses (e.g. cancer)
- High-resolution computed tomography (HRCT) – Detailed assessment of the degree of emphysema. – If suspicion of bronchiectasis – Not required for routine assessment of COPD.
- Full pulmonary function tests – Static lung volumes can assess for hyperinflation – Gas transfer to look at alveolar destruction
- If suspicion of respiratory failure (e.g. SpO2 <92%) – Arterial Blood Gas
- Alpha-1-antitrypsin blood test for younger patients or atypical lower lobe emphysema
Exacerbations of COPD
– At least one symptom of at least one major symptom (increased dyspnoea, sputum volume and sputum purulence) and one minor symptom (upper respiratory exacerbation in previous five days, wheezing, cough, fever or 20% increase in respiratory rate or heart rate)
– COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy
– A sustained worsening of the patient’s condition, from the stable state and beyond normal day-to-day variations, that is acute in onset and necessitate a change in regular medication in a patient with underlying COPD
– An acute event characterised by a worsening of the patients’ respiratory symptoms that is beyond normal day-to-day variations, and leads to a change in medication
Epidemiology of Exacerbations of COPD
- Hospitalisation – 115,000 admissions/year in England – 16,000 deaths within 90 days of admission – Second most common cause of admission – Highest cause of readmission
- HQIP/RCP National COPD audit: 2014 – 11.9% mortality at 90 days (4.3% inpatient) – 43% readmitted at 90 days
Who’s at risk of a COPD Exacerbation?
- Previous exacerbations – Always strongest risk factor – “Frequent exacerbator” phenotype
- Disease severity – Airflow obstruction – MRC dyspnoea score
- Gastro-oesophageal reflux
- Pulmonary hypertension
- Respiratory Failure
Aetiology of Exacerbations
Common Bacteria Haemophilus influenzae (11%) Streptococcus pneumoniae (10%) Moraxella catarrhalis (10%) Haemophilus parainfluenzae (10%) Pseudomonas aeruginosa (4%) (20-30% patient chronically colonised)
Common Viral pathogens Rhinoviruses (23%) Coronavirus RSV (6%-11%) Influenza (5-28%) Parainfluenza Adenovirus
Atypical organisms Myoplasma pneumoniae (14%) Chlamydia spp (8.9%)
Environmental Factors Pollution (PM10 and PM2.5) (9%)
Eosinophilic Eosinophils (>0.30)
Is an Exacerbation a Type?
panopto slide 28
Treatment of COPD
Goals for Treatment
• Improve Symptoms – Relieve dyspnoea – Improve exercise tolerance – Improve health related quality of life
• Reduce Risk – Slow disease progression – Prevent and treat exacerbations – Reduce mortality
*Improves both symptoms and risk
Improves Symptoms
• Pulmonary Rehabilitation* • Bronchodilators (long-acting and short acting)* – Beta 2 agonists (LABA or SABA) – Anti-muscarinics (LAMA or SAMA) – Methylxanthines • Mucolytics* • Refractory dyspnoea management – Low dose opiates – Airflow therapy (fan) – Cognitive behaviour therapy/psychological input • Lung volume reduction surgery* • Lung transplant* • Palliative Care
Improves risk
• Smoking cessation* • Oxygen therapy – Long term oxygen therapy (LTOT) – Ambulatory oxygen therapy (ABOT)* • Anti-inflammatories* – Inhaled corticosteroids (ICS) – Long-term macrolides – Phosphodiesterase type 4 inhibitor (PDE inhibitor) • Non-invasive ventilation • Future/research in next 5 years – Monoclonal antibodies targeting inflammatory pathways • e.g. IL-5, IL-33, TSLP
COPD value pyramid
slid 32
Doing what, slows the rate of Lung Function Decline in patients with COPD?
What are the benefits of doing this and how might a patient do it?
Quitting smoking
Smoking cessation
• Reduces mortality (very little else does) • Improves symptoms • Slows down loss of lung function • Reduces exacerbations • The drugs work better
• It’s never too late to stop smoking – Nicotine replacement therapy – Champix – Behavioural support – (Vaping)
What is Pulmonary Rehabilitation?
“Pulmonary rehabilitation can be defined as an interdisciplinary programme of care for patients with chronic respiratory impairment that is individually tailored and designed to optimise each patient’s physical and social performance and autonomy. Programmes comprise individualised exercise programmes and education.”
• Exercise – 6-8 week course – Hospital or community basis – 2 supervised sessions/week – 1 unsupervised/week • Education programme • Referral or ongoing plan onto maintenance therapy
