COPD Emergency Department Junior Medical Staff Teaching August 2015

Chronic Obstructive Pulmonary Disease Definition Causes Pathophysiology Management of stable COPD Acute exacerbation COPD Causes Assessment of AE COPD Differential diagnosis Management of AE COPD Prognosis What’s topical for COPD?

COPD Definition Airflow obstruction (FEV1/FVC < 0.7) which is not fully reversible No marked change over several months Usually progressive To make diagnosis: History, examination, investigations (No single diagnostic test)

Causes Smoking (and passive smoking) Occupational/Environmental Exposures Genetic ( including Alpha-1-AT deficiency ) Others :

Pathophysiology

Management of Stable COPD Pharmacological (inhaled bronchodilators and oral drugs eg theophylline, tiopropium, prophylactic antibiotics) Long Term Oxygen Therapy Pulmonary Rehab/Physiotherapy Treat associated problems (depression, pulmonary hypertension, nutrition, etc) Patient education Home NIV Surgery (bullectomy, lung volume reduction, lung transplantation)

Acute Exacerbation of COPD British Thoracic Society/NICE guideline CG101

Frequency of acute exacerbations increase as severity of underlying COPD increases

Causes of AE COPD Infective – Bacterial Strep pneumoniae H. influenzae Moraxella catarrhalis (Staph aureus, Pseudomonas aeruginosa) – Viral Rhinovirus, parainfluenza, influenza, RSV, coronavirus, adenovirus) Pollutants nitrogen dioxide, particulates, sulfur dioxide, ozone

Assessment of acute exacerbation of COPD: Symptoms Signs Investigations

Symptoms Worsening breathlessness Cough Increased sputum production Change in sputum colour Marked reduction in activities of daily living Patient may present with acute exacerbation of undiagnosed COPD Consider in patients aged over 35 with a risk factor (usually smoking) Patient may present with acute exacerbation of undiagnosed COPD Consider in patients aged over 35 with a risk factor (usually smoking) British Thoracic Society (COPD Guideline) Estimated 3 million people in UK have COPD and 2 million of these undiagnosed

Signs Pursed lip breathing Use of accessory muscles at rest Acute confusion Peripheral oedema

NICE CG 101

FBC u&e (theophylline level – if on methylxanthine) (blood culture – if pyrexial) Sputum to microbiology (If purulent) ECG – sinus tachycardia, arrhythmia, right ventricular hypertrophy, ischaemia

Management: Oxygen Oxygen to achieve a target SpO 2, 88-92% for acutely ill patients at risk of hypercapnic respiratory failure – ringed on chart (method of delivery and concentration prescribed on chart) Use pulse oximetry and ABG to guide therapy British Thoracic Society: Emergency oxygen use in adult patients guideline, October 2008

Management: other drugs Nebulised short acting bronchodilators Salbutamol (2.5mg or 5mg) Ipratropium (500mcg) Air driven if CO 2 increased or pH decreased Supplemental oxygen via nasal canula if required Corticosteroids (to all unless contraindicated) Antibiotics if increased volume/more purulent sputum, consolidation on CXR, clinical signs of pneumonia, pyrexia NHS Grampian: Infection Management Guidelines: Empirical antibiotic therapy, October 2014: Severe infective exacerbation of COPD: Cotrimoxazole 960mg IV 12hourly Second line – Clarithromycin 500mg IV 12hourly NHS Grampian: Infection Management Guidelines: Empirical antibiotic therapy, October 2014: Severe infective exacerbation of COPD: Cotrimoxazole 960mg IV 12hourly Second line – Clarithromycin 500mg IV 12hourly

Management: other drugs Theophylline IV only if inadequate response to nebulised bronchodilators Doxapram (respiratory stimulant) only when NIV unavailable or inappropriate

Management: other treatments Respiratory physiotherapy including use of positive expiratory pressure masks to help to clear sputum

Non-Invasive Ventilation (NIV) “NIV should be used as treatment of choice for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy”

Respiratory failure Type 1 paO 2 <8kPa paCO 2 reduced or normal Type 1 paO 2 <8kPa paCO 2 reduced or normal Type 2/hypercapnic (hypoventilation) paO 2 < 8kPa paCO 2 > 6.1kPa Type 2/hypercapnic (hypoventilation) paO 2 < 8kPa paCO 2 > 6.1kPa

On the wall in ED resus:

Before starting NIV Clearly documented treatment plan to include how to deal with failure of NIV Ceiling of treatment Whether escalation to intubation and mechanical ventilation will be appropriate Decision should include patient and carers if possible

Assess level of care needed: Home – Hospital-at-Home – Assisted discharge schemes Admission – level of care (palliative to ICU) Age or FEV 1 should not be used in isolation to assess suitability: Functional status BMI Oxygen requirement when stable Co-morbidities Patient’s wishes General condition poor/deteriorating Social circumstances…..

Prognosis AE COPD admissions, after 3 months: 34% re-admitted 14% dead

What’s topical? COPD Care Bundle Research Project University of Bristol and British Thoracic Society Evaluating impact of admission and discharge care bundles for patients admitted with COPD on various outcomes. Admission care bundle:

What’s topical? Admission care bundle: Pilot study (November 2012 to December 2013): using admission care bundle did not significantly change length of admission or mortality

What’s topical? Hospital-at-Home Run by community respiratory teams in some areas

Questions?

Summary: Chronic Obstructive Pulmonary Disease Definition Causes Pathophysiology Management of stable COPD Acute exacerbation COPD Causes Assessment of AE COPD Differential diagnosis Management of AE COPD Prognosis What’s topical for COPD?