Aaqid Akram MBChB (2013) Clinical Education Fellow COPD Aaqid Akram MBChB (2013) Clinical Education Fellow

Objectives What is it? How to diagnose it How to assess severity/progression How to manage it – Stable/Exacerbation

What is it? Chronic Bronchitis/emphysema Non reversible airflow obstruction Progressive airway and parenchymal damage Chronic inflammation Smoking Alpha-1-antitrypsin 3 million in UK (900 000 diagnosed) Progressive non reversible airway obstruction usually due to chronic inflammation secondary to smoking. Previously known as chronic bronchitis/emphysema. Approximately 900000 people have been diagnosed with COPD, but it is estimated approximately 3 million people have COPD in the UK. Alpha 1 antitrypsin deficiency can also cause COPD.

How to diagnose it >35 years old Weight loss Smokers Reduced exercise tolerance SOBOE Waking at night Chronic cough Ankle swelling Regular sputum production Fatigue Frequent winter “bronchitis” Occupational hazards Chest pain Wheeze Haemoptysis Signs + Symptoms of COPD Red symptoms should raise suspicion of alternate diagnosis.

Degree of breathlessness related to activities MRC Dyspnoea Score Grade Degree of breathlessness related to activities 1 SOB on strenuous exercise 2 SOB on hurrying or walking uphill 3 Walks slower than contemporaries due to SOB / Has to stop for breath at normal walking pace 4 Stops for breath walking 100 metres / few minutes on level ground 5 Cannot leave house / SOB on (un)dressing

Lung volumes

Spirometry Predicted Pre + Post bronchodilator therapy. (>400ml) FEV1 FVC FEV1/FVC Obstructive Restrictive

Volume (L) Time (s) 5 4 6 2 3 1 8 7 Normal Obstructive Restrictive FEV1 FVC

Flow Volume Measurement Exp Flow Rate (L/s) Volume (L) Maximal Expiratory Flow Forced Vital Capacity On exhalation, there is a rapid rise to the maximal expiratory flow followed by a steady, uniform decline until all the air is exhaled. a patient with obstructive airways disease, the peak expiratory flow (PEF) is reduced and the decline in airflow to complete exhalation follows a distinctive dipping (or concave) curve. In a severe airflow obstruction, particularly with emphysema, the characteristic ‘steeple pattern’ is seen in the expiratory flow trace. The pattern observed in the expiratory trace of a patient with restrictive defect is normal in shape but there is an absolute reduction in volume.

Other Tests CXR BMI FBC – polycythaemia/anaemia ? Alpha-1-antitrypsin (Age) Pulse Oximetry Sputum Culture (persistently purulent) PEFR (to exclude asthma)

COPD v Asthma COPD Asthma (Ex) Smoker Age <35 Chronic productive cough SOB Nigh time waking SOB/wheeze Diurnal/day to day variability Prednisolone 30mg 2 weeks. Think Asthma if: Large response to bronchodilator/prednisolone (>400 ml) Serial PEFR shows >20% diurnal/day to day variation It is not significant COPD if FEV1 and FEV1/FVC ratio return to normal with Drug Rx

Prognosis (BODE Index) BMI, Airflow Obstruction (Post bronchodilator), Dyspnoea, Exercise Capacity 1 2 3 B BMI >21 <22 O FEV1% Predicted >64 50-64 36-49 <36 D MMRC dyspnoea scale 0/1 4 E 6 Min Walk Distance (m) >349 250-349 150-249 <150

Post Bronchodilator FEV1/FVC Severity of Airflow Obstruction Predicted FEV1 % Severity of Airflow Obstruction <0.7 >79 Stage 1 Mild (symptoms required) 50-79 Stage 2 Moderate 30-49 Stage 3 Severe <30 (<50 + RF) Stage 4 Very Severe

When to Refer? Diagnostic uncertainty Bullous lung disease Rapid FEV1 decline Severe COPD Pulmonary rehab Second Opinion Lung transplant O2 Rx assessment <40 years old Cor Pulminale Frequent Infections Long term Neb Haemoptysis Long term PO steroid Symptoms > deficit

Management Smoking Cessation – NRT / Bupropion / Varenicicline / Support Nutrition – supplements Anxiety / Depression Physiotherapy – breathing techniques / expectoration. Pulmonary rehabilitation Vaccinations – pneumococcal / influenza Air travel – LTOT / FEV1<50% / pneumothorax

Inhaled Rx SABA or SAMA LABA or LAMA (FEV1>50%) / (LABA+ICS) + LAMA LABA or LAMA (FEV1>50%) / (LABA+ICS) or LAMA (FEV1<50%) SABA or SAMA Increased risk of severe pneumonia with fluticasone.

Short Acting Beta₂ Agonist (SABA) Salbutamol Salamol/Ventolin Blue Drug Type Generic Name Brand Name Colour Short Acting Beta₂ Agonist (SABA) Salbutamol Salamol/Ventolin Blue Terbutaline Bricanyl Long Acting Beta₂ Agonist (LABA) Indacaterol Onbrez Green Salmeterol Serevent Short Acting Muscarinic Antagonist (SAMA) Ipratropium Atrovent/Respontin/Rinatec Long Acting Muscarinic Antagonist (LAMA) Tiotropium Spiriva Glycopyrronium Seebri Aclidinium Eklira Genuair Inhaled Corticosteroid (ICS) Beclomethasone Clenil Modulite/QVAR Brown Budesonide Flixotide Fluticasone Pulmicort LABA+ICS (one inhaler) Formeterol/Budesonide Symbicort Red Salmeterol/Fluticasone Seretide Purple Vilanterol/Fluticasone Relvar Ellipta Yellow

Oral Rx Methylxanthines – (Theo/Amino)phylline Corticosteroids – not routinely recommended Mucolytic therapy – Carbocisteine Prophylactic Abx – not recommended Phosphodiesterase 4 inhibitors – if on trials

Long Term O2 Therapy LTOT – 15 to 20 hours per day Stable + PaO2 < 7.3 kPa Stable + PaO2< 8 kPa + one of: Secondary polycythaemia Nocturnal hypoxaemia Peripheral oedema Pulmonary hypertension

Pulmonary Hypertension/Cor Pulmonale Increased blood pressure in lung vasculature Cor Pulmonale: Right heart failure due to lungs Due to sustained pulmonary hypertension Symptoms of back pressure – SOB/Chronic wet cough/Wheezing/Raised JVP + engorged facial veins/ Hepatomegaly/Peripheral oedema/Ascities/Parasternal heave/Loud pulm 2nd HS

Exacerbation of COPD ABCDE O2 (88-92%) ?Need for NIV / HDU / ICU Abx if pyrexial, purulent sputum or evidence of consolidation Prescribe and administer steroids – 30mg prednisolone/100mh hydrocortisone IV access + FBC/U+E ECG CXR Check ABG – change O2 accordingly Salbutamol 5mg + Ipratropium 500mcg nebs (air driven) O2 (88-92%) ABCDE

Non Invasive Ventilation Bi-Level Ventilatory support Potentially reversible exacerbation Type 2 RF Respiratory acidosis (pH<7.36 / PaCO2>5.9) Despite Max medical Rx for 1 hour Able to co-operate with mask IPAP – 10 EPAP – 4

NIV – Exclusion Criteria/CI Consider ICU Input Pneumothorax End stage malignancy Acute myocardial infarction Multi-organ failure Cranio-facial abnormalities/Trauma Normo-capnoeic metabolic acidosis Impaired consciousness (GCS <8) Patient declines use – refused consent Haemodynamically Unstable Irreversible condition Unable to Co-operate with mask/no improvement T1RF - Pulmonary Oedema, Pneumonia without COPD, Acute Asthma

Basically…. Smoking’s bad for you Any Questions? Basically…. Smoking’s bad for you

Objectives Were: What is it? How to diagnose it How to assess severity/progression How to manage it – Stable/Exacerbation