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

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

3. 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 ( diagnosed)
Progressive non reversible airway obstruction usually due to chronic inflammation secondary to smoking. Previously known as chronic bronchitis/emphysema. Approximately 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.

4. 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.

5. 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

6. Lung volumes

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

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

9. 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.

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

11. 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

12. 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
<150

13. 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

14. 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

16. 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

17. 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.

18. 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

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

20. 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

22. 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

23. 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

24. 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

26. 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

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

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