CHRONIC OBSTRUCTIVE PULMONARY DISEASE

AIMS OF THIS SESSION To Understand the definition Discuss causes Discuss diagnosis Discuss Management/Medication Discuss Oxygen Therapy and enjoy!

DEFINITION COPD is characterised by airflow obstruction. COPD is characterised by airflow obstruction. air flow obstruction is usually progressive air flow obstruction is usually progressive It is not fully reversible It is not fully reversible does not change markedly over several months does not change markedly over several months. The disease is pre-dominantly caused by smoking. The disease is pre-dominantly caused by smoking.

COPD is an umbrella term for  Emphysema  Chronic Bronchitis  Severe Chronic Asthma NICE (2010) NICE (2010)

CHRONIC BRONCHITIS Continuous inflammation of the cells lining the bronchi Continuous inflammation of the cells lining the bronchi Mucous hypersecretion Mucous hypersecretion Destruction of the cilia, impairing mucous clearance leading to increased risk of infection Destruction of the cilia, impairing mucous clearance leading to increased risk of infection Diagnosed by the production of sputum and cough on most days for three months in two consecutive years

EMPHYSEMA Destructive of the alveoli and terminal bronchioles Destructive of the alveoli and terminal bronchioles Loss of elasticity of smaller airways Loss of elasticity of smaller airways Loss of patency of bronchioles Loss of patency of bronchioles

CAUSES OF COPD SMOKING: 90 % of cases,are caused by smoking 90 % of cases,are caused by smoking 15% are susceptible. 15% are susceptible. Lung function decline is 3 times faster Lung function decline is 3 times faster If smoking stops, at one year FEV1 decline is age related (Morgan & Britton 2003) If smoking stops, at one year FEV1 decline is age related (Morgan & Britton 2003) ALPHA 1 ANTITRIPSIN DEFICIENCY:GENETIC Found in only 1% of cases. Found in only 1% of cases. OCCUPATIONAL EXPOSURE TO RESPIRATORY POLLUTANTS: Chemicals, dust, atmospheric pollutants, inherited tendency

Nearly 30,000 deaths a year-accounting for 5% of all deaths, one death every 20 mins 850,000 diagnosed – only 33% Probably 2 million undiagnosed “Missing Millions”(BLF 2009) “Missing Millions”(BLF 2009) COPD is the fourth most common cause of death after heart disease, lung disease and cerebrovascular disease

COPD is the only leading cause of death that is increasing in prevalence with a total cost £850 million/yr- 24 million working days lost- Cigarette smoking is the major cause of COPD 90% Mortality from COPD is increasing in women while reaching a plateau in men Unless current trends are reversed, COPD may become the biggest public health problem. Death rate one of worst in Europe Death rate one of worst in Europe

DIAGNOSIS Over 35 Smoker or ex smoker no clinical features of asthma Have any of these symptoms ? exertional breathlessness chronic cough regular sputum production frequent winter “bronchitis” Wheeze (NICE 2010)

COPD OR ASTHMA ? COPD OR ASTHMA ?COPDAsthma Smoker/ex smoker Nearly all Possibly Symptoms under age of 35 RareCommon Chronic productive cough Progressive and persistent Variable Breathlessness Variable Night time waking with breathlessness and/or wheeze UncommonCommon Significant diurnal or day to day variation UncommonCommon

SPIROMETRY Spirometry measures the volume of air expired from the lungs during a single maximal forced expiration. The key measurements are:- Forced Vital capacity (FVC) Forced Expiratory Volume in one second (FEV1) FVC/FEV1 Ratio

CLASSIFICATION OF COPD MILDFEV1 >80% MODERATEFEV % SEVEREFEV % VERY SEVERE FEV1,30% NICE GUIDELINE (2010))

COPD produces symptoms, disability disability impaired quality of life- may respond to pharmacological therapies Airflow obstruction will not respond to these therapies so beware of a reliance on Spirometry.

SYMPTOMS ASSOCIATED WITH AN EXACERBATION   DYSPNOEA More breathless than normal Reduced exercise tolerance SPUTUM PRODUCTION   Increase in purulence   SPUTUM VOLUME Increase in normal amount   COUGH

INVESTIGATIONS Chest X ray Chest X ray Arterial blood gas – can aid medical diagnosis Arterial blood gas – can aid medical diagnosis ECG ECG FBC, Urea and Electrolytes FBC, Urea and Electrolytes Theophylline levels if appropriate Theophylline levels if appropriate Sputum microscopy/culture if purulent Sputum microscopy/culture if purulent

OBSERVATIONS/MONITORING OBSERVATIONS/MONITORING RESPIRATORY rate/rhythm/workload/equal RESPIRATORY rate/rhythm/workload/equal O2 Sats – 90-92% O2 Sats – 90-92% Colour skin, lips, nails(clubbing) Colour skin, lips, nails(clubbing) Patient able to speak in sentences/words or not at all Patient able to speak in sentences/words or not at all Temp/Pulse/BP Temp/Pulse/BP Confusion Confusion urine output urine output Peripheral oedema Peripheral oedema Depression/lethargy Depression/lethargy Assess need for NIV/IV Assess need for NIV/IV Not needed- PEFR Not needed- PEFR

TREATMENT Regular bronchodilator therapy Regular bronchodilator therapy (consider IV aminophylline if poor response to nebs) Continue/start Oral antibiotics Continue/start Oral antibiotics Continue/start oral Prednisolone Continue/start oral Prednisolone (continue inhaled steroids also as takes 7 – 10 days to kick in) Oxygen therapy as prescribed Oxygen therapy as prescribed (dependant on blood gas result and Sats O2) (dependant on blood gas result and Sats O2) Non invasive Ventilation Non invasive Ventilation

NURSING MANAGEMENT NURSING MANAGEMENT Liase with multi disciplinary team members to provide specialised care. Disease process/progression Disease process/progression Inhalers/medication Inhalers/medication Smoking cessation Smoking cessation Nutrition Nutrition

Pulmonary rehab/Community Matron/Breathlessness clinic/Support group Pulmonary rehab/Community Matron/Breathlessness clinic/Support group Vaccinations Vaccinations Physiotherapist-Breathing exercises, expectoration, coping mechanisms, energy conservation Physiotherapist-Breathing exercises, expectoration, coping mechanisms, energy conservation Benefits Benefits Further exacerbations- Exacerbation self management plan and standby antibiotics and steroids Further exacerbations- Exacerbation self management plan and standby antibiotics and steroids

PRE DISCHARGE MANAGEMENT Spirometry Spirometry Blood gas Blood gas Full knowledge of treatment – correct inhaler technique Full knowledge of treatment – correct inhaler technique Self management plan re antibiotics and steroids at home Self management plan re antibiotics and steroids at home FU appt-with Respiratory Nurses if O2 indicated FU appt-with Respiratory Nurses if O2 indicated Refer to Pulmonary rehab Refer to Pulmonary rehab Check smoking status Check smoking status

END of LIFE? Palliative care register Advanced directives/PPC/Assessment of concerns Hospice/day hospital

COMPLICATIONS OF COPD. COMPLICATIONS OF COPD. RESPIRATORY FAILURE   COR PULMONALE POLYCYTHAEMIA PULMONARY EMBOLI DEPRESSION / ANXIETY

RESPIRATORY FAILURE TYPE 1 Respiratory Failure PaO2 below 8Kpa(60.80mmHg) with normal/low PaCO2 TYPE 2 Respiratory Failure: PaO2, below 8kpa(60.8mmHg) and increased PaCO2 above 6.5kPa( 49.4mmHg)

AIMS OF THERAPY AIMS OF THERAPY Prevent further disease progression Prevent further disease progression Relieve symptoms Relieve symptoms Improve exercise capacity Improve exercise capacity Maintain best quality of life Maintain best quality of life Prevent exacerbations Prevent exacerbations

MEDICATIONS Bronchodilators should be the initial treatment Assess effectiveness by improvement in symptoms ADL exercise capacity rapidity of relief of symptoms Note - FEV1 will not reflect any significant improvement

MEDICATIONS If symptoms persist add Long acting anticholinergic. Long acting anticholinergic. Long-acting B2 agonist Long-acting B2 agonist

MEDICATIONS Inhaled steroids - for all COPD pts? Inhaled steroids - for all COPD pts? Methylxanthines Methylxanthines Antidepressants Antidepressants Mucolytics Mucolytics

TREATMENT FACTORS AFFECTING CONCORDANCE OF INHALED MEDICATIONS Drug regime Drug regime - Too complex - Frequency of dosing - Unsuitable inhaler ie rheumatic, elderly Lack of noticeable immediate benefit eg inhaled steroids and long acting bronchodilators Lack of noticeable immediate benefit eg inhaled steroids and long acting bronchodilators Multiple prescription charges Multiple prescription charges

NON TREATMENT FACTORS Lack of understanding of treatment inc lack of clear instructions Lack of understanding of treatment inc lack of clear instructions Fear of side effects Fear of side effects Dislike/distrust of health service Dislike/distrust of health service Reluctance to accept diagnosis Reluctance to accept diagnosis Preference for alternative therapies Preference for alternative therapies Lack of social support/family circumstances Lack of social support/family circumstances Language, reading or eyesight difficulties Language, reading or eyesight difficulties

LONG TERM OXYGEN THERAPY LTOT is considered in patients with PaO2 of 7.3kPa when stable or PaO2 of 7.3 – 8kPa with one of the following : secondary polycytheamia nocturnal hypoxaemia, peripheral oedema or pulmonary hypertension Severe airflow obstruction – FEV1<30%

Performed in secondary care Performed in secondary care Initial - 6 weeks post exacerbation, clinically stable Initial - 6 weeks post exacerbation, clinically stable Second assessment – 3-4 weeks later with trial of oxygen Second assessment – 3-4 weeks later with trial of oxygen LTOT should be used for at least 15hrs/day via a concentrator installed by company ASSESSMENT ASSESSMENT

SHORT BURST OXYGEN SHORT BURST OXYGEN No evidence to support its use in COPD. Used more for symptom relief in fibrosis /palliative care symptom relief in fibrosis /palliative care for short bursts only for short bursts only by cylinder by cylinder Can be prescribed by GP Can be prescribed by GP

AMBULATORY OXYGEN AMBULATORY OXYGEN Evidence of desaturation on exercise Evidence of desaturation on exercise 6 min walk test monitored by saturations. 6 min walk test monitored by saturations. Lightweight cylinders +/- conserver device Lightweight cylinders +/- conserver device

CHRONIC OBSTRUCTIVE PULMONARY DISEASE End

RESPIRATORY NURSES ALISON CALVERT RLI/WGH EXT 3608/5611 MOBILE SARAH JEWELL FGH PAGER VIA SWITCH EXT 1502 HELEN BOOTH RLI BLEEP 767 EXT 3608