Chronic Obstructive Pulmonary Disease (COPD) is characterised by airflow obstruction that is not fully reversible, with a reduced FEV1/FVC ratio of less than 0.7.
NICE recommends that a diagnosis of COPD is considered in patients older than 35 with a risk factor (generally smoking) who present with one or more of the following:
- exertional breathlessness
- chronic cough
- regular sputum production
- frequent winter ‘bronchitis’
- wheeze
Investigations
- Spirometry - obstructive pattern; done post bronchodilator
- Severity of COPD
- Mild – FEV1 ≥ 80% predicted
- Moderate – FEV1 50 – 79% predicted
- Severe – FEV1 30 – 49% predicted
- Very severe – FEV1 <30% predicted or < 50% predicted with respiratory failure
- CXR
- FBC - looking for polycythaemia/anaemia
- BMI calculation
Management
- General management
- Stop smoking
- Offer NRT, varenicline or bupropion
- Medications
- Inhaled therapy
- Short-acting beta 2 agonists (SABA) for symptomatic relief
- Preventative therapy:
- FEV1 ≥ 50% predicted: long-acting beta 2 agonist (LABA) or long-acting muscarinic antagonist (LAMA)
- FEV1< 50% predicted: either LABA with inhaled corticosteroid or LAMA
- Oral theophylline if patient unable to use inhalers or in addition to if adequate control not achieved with inhalers
- Plasma levels must be monitored
- Dose must be reduced if macrolide or fluroquinolone antibiotics prescribed
- Mucolytic drugs
- Long term oxygen therapy
- Indications:
- PaO2 less than 7.3kPa in stable COPD
- PaO2 less than 8kPa if stable and one of:
- secondary polycythaemia
- nocturnal hypoxaemia (=sats <90% for more than 30% of the time)
- peripheral oedeam
- pulmonary hypertension
- Need at least 2 ABGs done at least 3 weeks apart
- Need O2 for 15 hours per day, greatest benefits if used for 20 hours per day
- Consider lung volume reduction surgery
- If single large bulla on CT and FEV1 <50% predicted or
- breathless and marked restriction in daily living and all of the following criteria met:
- FEV1 more than 20% predicted
- PaCO2 less than 7.2 kPa
- upper lobe predominant emphysema
- TLCO more than 20% predicted
- Management of an exacerbation
- Oral corticosteroids – prednisolone 30mg od for 7 to 14 days
- Nebulised salbutamol and ipratropium bromide
- If infective, antibiotics – empirically a macrolide or tetracycline
- IV theophylline if inadequate response to nebulisers
- NIV for persistent hypercapnic ventilatory failure
- Consider if ongoing acidosis after one hour of standard medical treatment
- If pH <7.26 higher risk of NIV failure so should be managed in high dependency setting
- Initial IPAP 10cm H20, titrated in increments of around 5cm H20 each 10 minutes to usual target IPAP of 20cm H20
- EPAP 4-5cms H2O
- ABGs at 1 hour, 4 hours and 12 hours as a minimum
Last updated: April 2013
Small print gem: spacers should not be cleaned more than monthly and should be allowed to air dry. Frequent cleaning or towel-drying decreases their effectiveness due to a build-up of static
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