Download COPD

COPD
Emergency Department
Junior Medical Staff Teaching
August 2015
Chronic Obstructive Pulmonary
Disease
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Definition
Causes
Pathophysiology
Management of stable COPD
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Acute exacerbation COPD
Causes
Assessment of AE COPD
Differential diagnosis
Management of AE COPD
Prognosis
• What’s topical for COPD?
COPD Definition
• Airflow obstruction (FEV1/FVC < 0.7) which is
not fully reversible
• No marked change over several months
• Usually progressive
To make diagnosis:
History, examination, investigations
(No single diagnostic test)
Causes
Smoking
(and passive smoking)
Others:
Occupational/Environmental
Genetic
Exposures
(including Alpha-1-AT deficiency)
Pathophysiology
Management of Stable COPD
• Pharmacological (inhaled bronchodilators and oral
drugs eg theophylline, tiopropium, prophylactic
antibiotics)
• Long Term Oxygen Therapy
• Pulmonary Rehab/Physiotherapy
• Treat associated problems (depression, pulmonary
hypertension, nutrition, etc)
• Patient education
• Home NIV
• Surgery (bullectomy, lung volume reduction, lung
transplantation)
Acute Exacerbation of COPD
British Thoracic Society/NICE guideline CG101
Frequency of acute exacerbations
increase as severity of underlying
COPD increases
Causes of AE COPD
• Infective
– Bacterial
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Strep pneumoniae
H. influenzae
Moraxella catarrhalis
(Staph aureus, Pseudomonas aeruginosa)
– Viral
• Rhinovirus, parainfluenza, influenza, RSV,
coronavirus, adenovirus)
• Pollutants
nitrogen dioxide, particulates, sulfur dioxide, ozone
Assessment of acute exacerbation of
COPD:
Symptoms
Signs
Investigations
Symptoms
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Worsening breathlessness
Cough
Increased sputum production
Change in sputum colour
Marked reduction in activities of daily living
Patient may present with acute exacerbation of undiagnosed COPD
Consider in patients aged over 35 with a risk factor (usually
smoking)
Estimated 3 million people in UK have COPD and 2 million of these undiagnosed
British Thoracic Society (COPD Guideline)
Signs
Pursed lip breathing
Use of accessory muscles at rest
Acute confusion
Peripheral oedema
NICE CG 101
Sputum to microbiology
(If purulent)
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FBC
u&e
(theophylline level – if on methylxanthine)
(blood culture – if pyrexial)
ECG – sinus tachycardia, arrhythmia,
right ventricular hypertrophy,
ischaemia
Management:
Oxygen
• Oxygen to achieve a target SpO2, 88-92% for
acutely ill patients at risk of hypercapnic
respiratory failure – ringed on chart (method of
delivery and concentration prescribed on chart)
• Use pulse oximetry and ABG to guide therapy
British Thoracic Society: Emergency oxygen use in adult patients guideline, October 2008
Management: other drugs
• Nebulised short acting bronchodilators
• Salbutamol (2.5mg or 5mg)
• Ipratropium (500mcg)
Air driven if CO2 increased or pH decreased
Supplemental oxygen via nasal canula if required
• Corticosteroids (to all unless contraindicated)
• Antibiotics if increased volume/more purulent sputum, consolidation
on CXR, clinical signs of pneumonia, pyrexia
NHS Grampian: Infection Management Guidelines: Empirical antibiotic therapy,
October 2014: Severe infective exacerbation of COPD:
Cotrimoxazole 960mg IV 12hourly
Second line – Clarithromycin 500mg IV 12hourly
Management: other drugs
• Theophylline IV only if inadequate response
to nebulised bronchodilators
• Doxapram (respiratory stimulant) only when
NIV unavailable or inappropriate
Management: other treatments
• Respiratory physiotherapy including use of
positive expiratory pressure masks to help to
clear sputum
Non-Invasive Ventilation (NIV)
“NIV should be used as treatment of choice
for persistent hypercapnic ventilatory failure
during exacerbations despite optimal medical
therapy”
Respiratory failure
Type 1
paO2<8kPa
paCO2 reduced or normal
Type 2/hypercapnic
(hypoventilation)
paO2 < 8kPa
paCO2 > 6.1kPa
On the wall in ED resus:
Before starting NIV
• Clearly documented treatment plan to include
how to deal with failure of NIV
• Ceiling of treatment
• Whether escalation to intubation and
mechanical ventilation will be appropriate
• Decision should include patient and carers if
possible
Assess level of care needed:
• Home – Hospital-at-Home
– Assisted discharge schemes
• Admission – level of care (palliative to ICU)
Age or FEV1 should not be used in isolation to
assess suitability:
Functional status
BMI
Oxygen requirement when stable
Co-morbidities
Patient’s wishes
General condition poor/deteriorating
Social circumstances…..
Prognosis
AE COPD admissions, after 3 months:
34% re-admitted
14% dead
What’s topical?
• COPD Care Bundle Research Project 2015-2016
University of Bristol and British Thoracic Society
Evaluating impact of admission and discharge care
bundles for patients admitted with COPD on various
outcomes.
Admission care bundle:
What’s topical?
Admission care bundle:
Pilot study (November 2012 to December 2013): using
admission care bundle did not significantly change
length of admission or mortality
What’s topical?
• Hospital-at-Home
Run by community respiratory teams in some
areas
Questions?
Summary: Chronic Obstructive
Pulmonary Disease
•
•
•
•
Definition
Causes
Pathophysiology
Management of stable COPD
•
•
•
•
•
•
Acute exacerbation COPD
Causes
Assessment of AE COPD
Differential diagnosis
Management of AE COPD
Prognosis
• What’s topical for COPD?