COPD Dr MAMATHA SARTHI GPST3

What is COPD? COPD is characterized by airflow obstruction which is usually progressive, and not fully reversible. Tobacco smoking is the major risk factor for the development of COPD. Complications include disability and reduced quality of life.

COPD COPD is a syndrome of obstructive airflow limitation which is often caused by more than one pathological process. Commonly emphysema and bronchitis coexist. Types of COPD include: chronic bronchitis emphysema chronic obstructive airways disease chronic airflow limitation some cases of chronic asthma bronchiectasis involvement of the lung in rheumatoid arthritis

PATHOLOGY pathological changes in turn results in the following physiological abnormalities: mucous hypersecretion ciliary dysfunction airflow limitation and hyperinflation/air trapping gas exchange abnormalitiesseen in advanced disease characterised by arterial hypoxaemia with or without hypercapnia results from an abnormal distribution of ventilation/perfusion ratios  pulmonary hypertension

CLINICAL FEATURES Breathlessness chronic cough - may be intermittent and may be unproductive regular sputum production frequent winter “bronchitis” wheeze (1)

SIGNS hyperinflated chest wheeze or quiet breath sounds purse lip breathing use of accessory muscles paradoxical movement of lower ribs peripheral oedema cyanosis raised JVP cachexia (1) pink puffers" and "blue bloaters“-no longer considered clinically useful.

Classification Classification of severity of airflow limitation in CO PD in patients with FEV1/ FVC <0.7 Gold 1 Mild ≥ 80% Gold 2 Moderate 50-79% Gold 3 Severe 30-49% Gold 4 Very Severe < 30%

INVESTIGATIONS lung function tests: the chest radiograph may show: there is an obstructive ventilatory impairment - FEV1 < 80% predicted the forced expiratory ratio (FEV1/FVC) is less than 70% the residual volume is high total lung capacity is increased the chest radiograph may show: hyperinflation of the lungs bullae the full blood count - to identify anaemia or polycythaemia the ECG may show cor pulmonale:tall P waves right bundle branch block right ventricular hypertrophy

Investigations (MUST) A chest X-ray should be arranged to exclude other pathology; a full blood count should be taken to identify anaemia or secondary polycythaemia. The person should be offered initial inhaled treatment such as a short-acting beta-2 agonist or a muscarinic antagonist — additional treatments may be added depending on the person's response. An annual influenza vaccination and a once-only pneumococcal vaccination should be arranged. Post-bronchodilator spirometry should be measured to confirm the diagnosis of COPD In COPD, the ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC ratio) is less than 0.7.

Differntial diagnosis asthma bronchiectasis congestive cardiac failure carcinoma of the bronchus truberculosis obliterative bronchiolitis bronchopulmonary dysplasia

Diagnosis A diagnosis of COPD can be made if the person meets all of the following criteria: Age older than 35 years. Presence of a risk factor, for example current smoker, history of smoking, or occupational exposure to chemicals or dust. Typical symptoms, such as exertional breathlessness, chronic cough, wheeze, regular sputum production, recurrent chest infection. Signs of COPD include cyanosis, raised jugular venous pressure, cachexia, a hyperinflated chest, use of accessory muscles, pursed lip breathing, wheeze or quiet breath sounds, and peripheral oedema.

Treatment See the Management of COPD sheet provided

All patients diagnosed with COPD should receive  Smoking Cessation advice at each consultation if appropriate. Pulmonary Rehabilitation Spacers if needed-Check inhaler technique at each clinical review Referral to COPD team if appropriate  Exacerbation management card offered through COPD team Annual influenza vaccination  Pneumococcal vaccination once only Annual pulse oximetry for all patients , a baseline reading should be taken at diagnosis. Pulse oximetry if symptoms of severe exacerbation, FEV1 < 35% predicted or clinical signs suggestive of respiratory failure/right heart failure. Referral to Home Oxygen Team once patient is stable if SaO2 persistently ≤ 92% on breathing air. Stand-by course of antibiotics and steroids as part of a self management plan Depression screening using a validated tool as necessary Dietetic advice if BMI abnormal Consider osteoporosis prophylaxis for patients on long term oral steroids (Prednisolone 7.5mg daily or equivalent for longer than 3 months) End of Life care as appropriate Steroid card should be given to all patients on high dose ICS

REFERRAL Referral should be considered, if appropriate: To a respiratory specialist, for assessment for oxygen therapy if symptoms are severe or refractory, if an occupational cause is suspected, or if there are symptoms of cor pulmonale. For pulmonary rehabilitation if the person is functionally disabled by COPD, or has had a recent hospitalization for an acute exacerbation. To a physiotherapist if the person has excessive sputum, to learn the use of positive expiratory pressure masks, and the 'active cycle of breathing' technique. To social services and occupational therapy if they have difficulties with activities of daily living. To psychological services if the person has anxiety or depression related to symptoms of COPD.

Useful Contact numbers  Community COPD Team ACE gateway Tel: 0300 0032 144  Pulmonary Rehabilitation referrals need to be made via email to:  Home Oxygen Teamacecic.communitygateway@nhs.net  Chest Unit CHUFT, Tel: 01206 746461 /746462 Fax: 01206 742080  Respiratory Nurses, CHUFT, Tel: 01206 742261

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