Matt Wong + Sheila Murphy Dec 13 th 2011

 AKT MINI EXAM  NICE – COPD GUIDELINES  BTS ASTHMA GUIDELINES  INHALER TECHNIQUE  QOF  SPIROMETRY  CSA EXERCISE

 Which of the following are used in assessing the severity of COPD?  A. Body mass index (BMI)  B. Age  C. Medical Research Council (MRC) dyspnoea score  D. Smoking pack year history  E. Lung function

 Which of the following statements apply to COPD?  A. It is more common in those from upper social classes  B. It is often seen as a co-morbidity in patients with ischaemic heart disease and lung cancer  C. Mortality from COPD is evenly spread across the UK as a whole  D. The estimated prevalence of COPD in patients over 40 years of age is 9-10%

 What percentage of patients will die within 3 months of admission for a COPD-related condition?  A. 33%  B. 50%  C. 5%  D. 20%

 Pulmonary rehabilitation should be offered to:  A. All patients with moderate or severe COPD  B. All patients with COPD irrespective of their MRC score  C. Patients who are poorly motivated  D. All patients who meet the referral criteria regardless of their inhaled drug therapy  E. Patients with an MRC dyspnoea score of 3 or more unless they are on long-term oxygen therapy (LTOT)

 Which of the following statements about the role of inhaled corticosteroids in COPD are true?  A. In patients with moderate/ severe COPD (FEV1 <50% predicted), treatment of the lung inflammation with inhaled corticosteroids has not shown to be of benefit in reducing exacerbations  B. There is no evidence to suggest that early use of inhaled steroids in patients with COPD will reduce the decline in FEV1 seen over years  C. The use of inhaled corticosteroids has been shown to be of some benefit in reducing the decline in health status seen in patients with moderate/ severe COPD (FEV1 <50% predicted)  D. Osteoporosis is commonly seen in patients taking high dose inhaled corticosteroids

 Which of the following features suggest a patient should be admitted to hospital for management of their COPD exacerbation?  A. Cyanosis  B. Mild peripheral oedema  C. Low oxygen saturation (<90%)  D. Good level of activity  E. Significant co-morbidities

 Which of the following statements about oxygen therapy in COPD exacerbations are true?  A. It should be given to all patients  B. It should be started at 100% until the oxygen saturation is >95%  C. It should be monitored by pulse oximetry until access to full arterial or capillary blood gases are available  D. In patients on LTOT it should be given at the same rate as they receive at home

 1. A, C, E  2. B, D  3. E  4. B  5. C, D  6. A, C, E  7. C, D  8. 3  9. D

 Consider COPD in smokers >35 and with exertional SOB, chronic cough, regular sputum production, winter bronchitis, wheeze  No features of asthma – unproductive cough, diurnal variation, night-time waking with wheeze/breathlessness  Ask about: weight loss, fatigue, exercise tolerance, chest pain, night waking, haemoptysis, ankle swelling, occupational hazards

 Post-bronchodilator spirometry  CXR  FBC – anaemia/polycythaemia  BMI  FEV1/FVC < 0.7 = COPD  Stage 1-5  mild to very severe based on FEV1 %  >80% is mild  30% - 50% severe  People must be symptomatic to make diagnosis!

 Grade 1 – not troubled by SOB except on exercise  Grade 2 – SOB when hurrying/walking up hill  Grade 3 – walks slower on level ground due to SOB, or has to stop when walking at own pace  Grade 4 – stops for breath after 100m or a few mins on ground level  Grade 5 – too breathless to leave the house or breathless when dressing

 Smoking cessation for all  Start treatment once diagnosis confirmed  Pulmonary rehab  For those with disability/recent admission

 SABA : short acting B agonist  salbutamol  LABA : long acting B agonist  salmeterol  SAMA : short acting muscarinic antagonist  ipratropium  LAMA : long acting muscarinic antagonist  Tiotropium  ICS : inhaled corticosteroids  Beclometasone, fluticasone, budesonide

 Theophylline  If inhaled therapy ineffective/can’t be used  Oral steroids  Maintenance steroids not recommended, but if severe COPD may be necessary, aim for low dose and monitor for osteoporosis 30mg for 7-14 days in exacerbations  LTOT used for 15 hours/day  Assess need for LTOT if FEV1<30%, cyanosis, polycythaemia, peripheral oedema, raised JVP, sats < 92% on air  2 x ABGs 2 occasions, 3 weeks apart LTOT if PaO2 < 7.3kPa or 7.3 – 8 with complications

 Increase frequency of broncholdilator use/consider use of nebuliser  Prescribe oral abx if sputum purulent/clinical signs of peumonia  Steroid 30mg 7-14 days  Self-Management  Start abx/steroid if SOB increases/interferes with ADLs  Abx if sputum purulent  Adjust bronchodilator to control symptoms

 not able to cope at home  severe beathlessness, Sats <90%  general condition is poor/ deteriorating  cyanosis is present  worsening peripheral oedema  impaired level of consciousness  patients on LTOT  acute confusion  exacerbation has had a rapid rate of onset  significant comorbidity - cardiac disease and IDDM  changes on CXR  arterial pH level < 7.35  arterial PaO2 < 7 kPa

 Salbutamol CFC Free 100mcg/dose  3£ / 200 doses  Ipratropium 20 mcg  5£ / 200 doses  Salmeterol 50 mcg  29£ / 60doses/ 1 month  Salmeterol 50 mcg and fluticasone  35£ / 60 doses/ 1 month  Tiotropium  32£ / 30 doses/ 1 month

 Contains a pressurised inactive gas that propels a dose of drug in each 'puff'  ADV  most widely used inhaler  quick to use, small, and convenient to carry  DISADV  needs good co-ordination to press the canister, and breathe in fully at the same time

 Used with pressurised MDIs  The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed  Valve at the mouth end ensures that the drug is kept within the spacer until you breathe in. When you breathe out, the valve closes.  Adv – No need to have good co- ordination to use a spacer device.  A facemask can be fitted on to some types of spacers, instead of a mouthpiece. This is sometimes done for young children and babies who can then use the inhaler simply by breathing in and out normally through the mask.

 Alternatives to the standard MDI  Don't require you to press a canister on top  Bottom 3 are dry powder inhalers.  Dose is triggered by breathing in at the mouthpiece. You need to breathe in fairly hard to get the powder into your lungs. Accuhalers Clickhalers Easyhalers Novolizers Turbohalers diskhalers Twisthalers  ADV - Require less co-ordination than the standard MDI.  DISADV - They tend to be slightly bigger than the standard MDI. Autohaler

 Practice register of patients with COPD  % with COPD in whom diagnosis has been confirmed by spirometry with reversibility testing  % with COPD with record of smoking status in the previous 15m  % with COPD who smoke, who have been offered smoking cessation advice or referral to a specialist service, where available in last 15 months  % with COPD with a record of FEV1 in the previous 27m  % with COPD with record that inhaler technique has been checked in the preceding 27m  % with COPD who have had influenza immunisation in the preceding 1 September to 31 March  PROMPTS:  MRC Dysponea Score, FEV1, REVIEW EVERY 15m  OUR PRACTICE:  Inhaler technique, sats, smoking, exacerbations, immunisations, depression