1. COPD Alison Boland StR Respiratory medicine

2. Aims & Objectives Overview of COPD Recap basic knowledge Update on COPD Know when to use nebulisers and home oxygen therapy The role of NIV in palliative setting / end stage COPD Gain patient, carer and personal view about COPD

3. GOLD Definition Airflow limitation Not fully reversible Progressive Abnormal inflammatory response to noxious particles or gases

4. CHRONIC Develops slowly Early symptoms often go un-noticed Symptoms present for much of the time Progressive dyspnoea over time. Worse on exercise

5. OBSTRUCTIVE Narrowing of the bronchi 3 mechanisms: Bronchial walls become weakened Mucus secretion into the bronchi. Muscle spasm

6. Natural History

7. Activity BREATHE THROUGH THE STRAW FOR A MINUTE THNIK ABOUT HOW THIS FEELS.

9. Diagnosis FEV1/FVC <70% Post bronchodialator FEV1 <80% predicted. FEV1/FVC more sensitive.

10. Diagnose COPD: assessment of severity Assess severity of airflow obstruction using reduction in FEV 1 NICE clinical guideline 12 (2004) ATS/ERS 2004GOLD 2008NICE clinical guideline 101 (2010) Post- bronchodilator FEV 1 /FVC FEV 1 % predicted Post- bronchodilator < 0.780%MildStage 1 (mild)Stage 1 (mild)* < 0.750–79%MildModerateStage 2 (moderate) < 0.730–49%ModerateSevereStage 3 (severe) < 0.7< 30%SevereVery severeStage 4 (very severe)** * Symptoms should be present to diagnose COPD in people with mild airflow obstruction ** Or FEV 1 < 50% with respiratory failure [new 2010]

11. Patient with COPD Palliative care SmokingBreathlessness & exercise limitation Frequent exacerbations Respiratory failure Cor pulmonale Abnormal BMI Chronic productive cough Anxiety & depression Managing stable COPD Assess symptoms/problems Manage those that are present as below Patients with COPD should have access to the wide range of skills available from a multidisciplinary team

12. Treatment options Pharmacological Bronchodilators Steroids Antibiotics Mucolytics Antitussives Narcotics

13. Treatment options Non – pharmacological Pulmonary rehabilitation Oxygen NIV Surgery Bullectomy Lung volume reduction surgery Lung transplantation

15. Managing stable COPD: inhaled therapies SABA or SAMA as required* Breathlessness and exercise limitation Exacerbations or persistent breathlessness Persistent exacerbations or breathlessness LABALAMA Discontinue SAMA ________ Offer LAMA in preference to regular SAMA four times a day LABA + ICS in a combination inhaler ________ Consider LABA + LAMA if ICS declined or not tolerated LAMA Discontinue SAMA ________ Offer LAMA in preference to regular SAMA four times a day FEV 1 ≥ 50% FEV 1 < 50% LABA + ICS in a combination inhaler ________ Consider LABA + LAMA if ICS declined or not tolerated LAMA + LABA + ICS in a combination inhaler OfferConsider * SABAs (as required) may continue at all stages

16. Bronchodilators Individual effects unpredictable Inhaled: Salbutamol (‘Ventolin’) Ipatropium (‘Atrovent’) Salmeterol (Serevent) Terbutaline (‘Bricanyl’) Tiotropium (‘Spiriva’) Indacterol (‘onbrez) Oral: Theophyllines (‘Uniphyllin’, ‘Phyllocontin’)

17. Inhaler technique!!

18. Steroids Inhaled – Seretide, Symbicort Oral prednisolone Do not modify long term decline in FEV1

19. Oral therapy Theophylline Carbocisteine Opioids Anti anxiolytics

20. Nebulisers On maximum medical therapy Use salbutamol only 1 month trial No improvement in symptoms then stop

21. New(ish) therapies Indacterol Roflumilast (Azithromycin)

22. Indacaterol Long acting Beta agonist Rapid onset of action 24 hr duration of action 150micrograms od Future use as add on to tiotropium

23. Phosphodiesterase inhibitors Roflumilast Severe COPD (FEV1 <50%) Hx Chronic bronchitis, frequent exacerbations 500micrograms od Reduces rate of moderate to severe exacerbations

24. Azithromycin Macrolide antibiotic Recurrent exacerbations On maximum therapy Long term 250mg x3 week Caution re side effects

25. Oxygen provision Long term oxygen therapy Ambulatory oxygen Short burst oxygen

26. LTOT FEV1 <50% predicted OR < 1.5l Signs of cor pulmonalae Sats <92% PO2 <7.3 (8kPa) Drying of nasal passages, oxygen toxicity, Palliative care – target saturations not indicated

27. Ambulatory Oxygen O2 use during exercise /ADL LTOT patients Objective evidence of desaturation on exercise

28. Short burst oxygen Or Palliative O2 To relieve SOB Excludes LTOT & ambulatory oxygen users

30. HOOF

32. Non invasive ventilation Home NIV Recurrent acute type 2 respiratory failures Intolerance LTOT Increased co2 with symptoms Overlap OSA / Obesity hypoventialtion End of life care

33. Chronic disease management Stop smoking Prn Bronchodilator Annual flu jab Pneumococcal vaccine (5yrs) Regular exercise Maintain weight normal range

34. Nutrition Underweight usually BMI <20 Assess co morbidities Social factors Encourage snacking, Higher fat foods Supplements after 1 month of above Dietician advise

35. Pulmonary rehab

36. SOB waking on level ground at normal pace 2hr sessions, 6 weeks Motivated patients

37. Patient views about COPD

38. Key Messages Consider Azithromycin in recurrent exacerbations Prescribe short burst O2 with caution – expensive and little evidence Pulmonary rehabilitation important multidisciplinary management Finally remember how breathing through a straw felt!

39. Any Questions?