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