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COPD

Diagnosis​

Consider COPD in smokers aged over 40 years with recurrent antibiotics for chest infections. Other risk factors include occupational exposure and alpha-1 antitrypsin deficiency

Presenting with symptoms of progressive dyspnoea, chronic productive cough, and wheeze

Diagnose with post-bronchodilator spirometry: FEV1/FVC < 70% with progressive respiratory symptoms is diagnostic of COPD, though may under-diagnose in women and younger patients

Assess for co-morbid asthma? diurnal variation, atopy, bronchodilator reversibility > 12% implies element of asthma

WHO Suggests Alpha-1 Antitrypsin levels in all new diagnoses

Grading​

GOLD Modified ABCD assessment Tool - patients get a numerical grade and letter category. The number quantifies degree of airflow limitation, the letter assesses exacerbation frequency and functional limitation. Modified MRC Dyspnoea Scale

COPD Assessment Test (CAT) - measures impact of symptoms on QOL

Management​

Smoking Cessation​

Smoking cessation slows rate of decline in FEV1

Start prescription two weeks before chosen stop date

  • Nicotine Replacement Therapy: 8-12 weeks, then slow taper over up to 9 months
  • Bupropion: 7-9 weeks, not in pregnancy, c.i. in seizure disorder
  • Varenicline: 12+12 weeks, not in pregnancy, previous suspected links with suicidality/depression, current evidence suggests no reason to withhold from patients with mental health issues

Pulmonary Rehabilitation​

  • Programme of physical exercise and information
  • Improves dyspnoea, health status, and exercise tolerance
  • Should be started within four weeks of an acute hospital admission

NICE Algorithm​

GOLD Algorithm​

Key points:

  • LAMA superior to LABA in exacerbation prevention
  • Prolonged ICS use increases pneumonia risk - therefore LABA/LAMA preferable to LAMA+ICS in patients with recurrent exacerbations
  • Before escalation review inhaler technique and adherence
  • Also prescribe 'rescue' pack of oral antibiotics and steroids for exacerbations

If insufficient, consider:

  • Roflumilast - Oral PDE4 inhibitor; given if FEV1<50% and admission in previous year; a secondary care drug
  • Macrolide (ie azithromycin) od or 3x/week to reduce exacerbation frequency
  • Consider ICS cessation as increases risk of pneumonia (see guideline)

Home Oxygen​

Indication for referral

  • SpO2 <= 92%
  • FEV1 < 30%
  • Cyanosis
  • Secondary polycythaemia
  • Peripheral oedema
  • Raised JVP

Symptomatic Treatment​

  • Dyspnoea
    • Opioids
    • Fans
    • Neuromuscular electrical stimulation
    • Chest Wall Vibration
    • Pulmonary Rehabilitation
  • Mucus
    • Carbocysteine
    • NAC
  • Nutritional Support

References​

RCGP eLearning