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• The background to the term is a close knit family.
Grandfather, aged 72, has always been the driving
force behind them. He lives with his wife,
daughter and son-in-law and their two children.
His wife is also 72, his daughter 46. The children
are 20 and 16.
•
• Grandfather developed lymphoma 10 months
ago and has responded well to treatment. Since
the grandfather’s illness you seem to be seeing
more of the family.
Grandmum,
• It is early September and the kids are back at work and school.
• Mrs A comes to see you with another attack of “her bronchitis”. At
66 she smokes 10/day and has a 40 pack year history. Her last
attack was just under a year ago. You notice she had a CXR after the
last one that showed large volume lungs and normal CTR.
• She shows you her Salbutamol MDI and asks for more, though it is
not seeming to be as effective as before for her chest especially
when she has a chest infection and wonders if she needs ‘the
magic treatment again’
• She is able to talk in full sentences but is wheezy
• Repeat prescriptions:
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–
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Salbutamol MDI 2 puffs qds prn . 2OP
ZeroAQS cream
Loratadine
Beclametasone N/S
Grandmum
• She tells you she has been bringing up a lot more ‘filthy-looking
spit’ and felt shivery last night.
• You have a look at the records whilst Mrs A is changing and note
there is
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–
–
–
a past ‘minor’ diagnosis of asthma in 1998 and
hand eczema in 1994 when working as a machine operator.
Most of her recent appointments have been for back pain and
OA knees – diagnosed last year – X rays confirm it
• Her latest BMI done 6 months ago was 34
• She has had no asthma check for over 10 years and her last PEFR
was 430L/m then
• She is currently working as a cleaner to supplement the pension she
has
Examination
•
•
•
•
•
•
•
•
Pefr 390
Sats 94%
Resp Rate 24
Temp 37.8
BP 141/83
Pulse 100 SR
Chest scattered creps in right MZ and base
You can see she is using accessory muscles
Definition of COPD
n
n
COPD, a common preventable and treatable
disease, is characterized by persistent airflow
limitation that is usually progressive and
associated with an enhanced chronic
inflammatory response in the airways and the
lung to noxious particles or gases.
Exacerbations and co-morbidities contribute
to the overall severity in individual patients.
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Mechanisms Underlying Airflow
Limitation in COPD
Small Airways Disease
Parenchymal Destruction
• Airway inflammation
• Airway fibrosis, luminal plugs
• Increased airway resistance
• Loss of alveolar attachments
• Decrease of elastic recoil
AIRFLOW LIMITATION
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Diagnose COPD
• A diagnosis of COPD should be considered in patients
over the age of 35 who have a risk factor (generally
smoking) and who present with
–
–
–
–
exertional breathlessness,
chronic cough,
regular sputum production,
frequent winter ‘bronchitis’ or wheeze
• The presence of airflow obstruction should be
confirmed by performing post-bronchodilator
spirometry. All health professionals involved in the care
of people with COPD should have access to spirometry
and be competent in the interpretation of the results
Global Strategy for Diagnosis, Management and Prevention of COPD
Risk Factors for COPD
Genes
Infections
Socio-economic
status
Aging Populations
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis of COPD
EXPOSURE TO RISK
FACTORS
SYMPTOMS
shortness of breath
tobacco
occupation
indoor/outdoor pollution
chronic cough
sputum
è
SPIROMETRY: Required to establish
diagnosis
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of Airflow Limitation:
Spirometry
 Spirometry should be performed after the
administration of an adequate dose of a shortacting inhaled bronchodilator to minimize
variability.
 A post-bronchodilator FEV1/FVC < 0.70 confirms
the presence of airflow limitation.
 Where possible, values should be compared to
age-related normal values to avoid overdiagnosis
of COPD in the elderly.
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Spirometry & COPD
•
•
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•
•
•
•
•
•
Confirm the diagnosis
Confirm an FEV/FVC ratio < 0.7 after bronchodilator
Grade the severity of the disease
Help differentiate asthma from COPD
Screening for COPD
Monitor disease progression
Help assess response to therapy
Aid in predicting prognosis and long term survival
Exclude COPD and prevent inappropriate treatment if
normal
Lung volumes
Spirometry
Maximal inspiration
Maximal expiration (“blast” expiration)
Continued expiration until maximal amount of air exhaled
(at least a 6 second exhalation in adults)
Get 3 readings –within 5% or 100mls of each other.
Use best values for FEV1,FVC and FEV1/ FVC Ratio.
Spirometry
• Clinically stable and free from a respiratory tract infection.
• Short acting bronchodilators should be withheld for the previous 6
hours, long acting bronchodilators for 12 hours, and sustained
release theophylline for 24 hours.
• FEV /FVC should be measured before and 15 - 20 minutes after
bronchodilator is given
• The bronchodilator should be given by metered dose inhaler, ideally
through a spacer.
• Possible dose protocols include 400 μ g salbutamol, up to 160 μg
ipratropium, or the two combined.
What is a good quality trace?
• The blow should continue until a volume plateau is
reached - this may take more than 12 seconds in
severe COPD.
• FVC and FEV1 readings should be within 5% or 100 ml
of each other.
• The expiratory volume-time graph should be smooth
and free from irregularities.
Spirometry: Normal Trace Showing FEV1
and FVC
FVC
5
Volume, liters
4
FEV1 = 4L
3
FVC = 5L
2
FEV1/FVC = 0.8
1
1
2
3
4
5
6
Time, sec
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Spirometry: Obstructive Disease
Normal
5
Volume, liters
4
3
FEV1 = 1.8L
2
FVC = 3.2L
Obstructive
FEV1/FVC = 0.56
1
1
2
3
4
5
6
Time, seconds
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Obsructive
Obstructive
Asthmatic
Grandmum
Assessment of COPD
 Assess symptoms
 Assess degree of airflow
limitation using spirometry
 Assess risk of exacerbations
 Assess comorbidities
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Assessment of COPD
 Assess symptoms
Assess degree of airflow limitation using spirometry
Assess risk
of exacerbations
COPD
Assessment Test (CAT)
Assess comorbidities
or
Clinical COPD Questionnaire (CCQ)
or
mMRC Breathlessness scale
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Modified MRC (mMRC)Questionnaire
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Classification of Severity of Airflow
Limitation in COPD*
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild
FEV1 > 80% predicted
GOLD 2: Moderate
50% < FEV1 < 80% predicted
GOLD 3: Severe
30% < FEV1 < 50% predicted
GOLD 4: Very Severe FEV1 < 30% predicted
*Based on Post-Bronchodilator FEV1
Assessment of COPD
 Assess symptoms
 Assess degree of airflow limitation using
spirometry
 Assess risk of exacerbations
Assess
comorbidities
Use history
of exacerbations and spirometry.
Two exacerbations or more within the last year
or an FEV1 < 50 % of predicted value are
indicators of high risk. Hospitalization for a COPD
exacerbation associated with increased risk of death.
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
Assess Risk of Exacerbations
To assess risk of exacerbations use history of
exacerbations and spirometry:
 Two or more exacerbations within the last
year or an FEV1 < 50 % of predicted value
are indicators of high risk.
 One or more hospitalizations for COPD
exacerbation should be considered high
risk.
© 2015 Global Initiative for Chronic Obstructive Lung Disease
(C)
(D)
≥2
or
> 1 leading
to hospital
admission
3
2
(A)
(B)
1
1 (not leading
to hospital
admission)
0
CAT < 10
CAT > 10
Symptoms
mMRC > 2
mMRC 0–1
Breathlessness
© 2015 Global Initiative for Chronic Obstructive Lung Disease
(Exacerbation history)
4
Risk
(GOLD Classification of Airflow Limitation))
Risk
Combined Assessment of COPD
Global Strategy for Diagnosis, Management and
Prevention of COPD
Combined Assessment of
COPD
When assessing risk, choose the highest risk
according to GOLD grade or exacerbation
history. One or more hospitalizations for COPD
exacerbations should be considered high risk.)
Patient
Characteristic
Spirometric
Classification
Exacerbations
per year
CAT
mMRC
A
Low Risk
Less Symptoms
GOLD 1-2
≤1
< 10
0-1
B
Low Risk
More Symptoms
GOLD 1-2
≤1
> 10
>2
C
High Risk
Less Symptoms
GOLD 3-4
>2
< 10
0-1
D
High Risk
More Symptoms
GOLD 3-4
>2
> 10
© 2015 Global Initiative for Chronic Obstructive Lung Disease
>2
Global Strategy for Diagnosis, Management and Prevention of COPD
Assess COPD Comorbidities
COPD patients are at increased risk for:
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Cardiovascular diseases
Osteoporosis
Respiratory infections
Anxiety and Depression
Diabetes
Lung cancer
Bronchiectasis
These comorbid conditions may influence mortality and
hospitalizations and should be looked for routinely, and
treated appropriately.
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Differential Diagnosis:
COPD and Asthma
COPD
ASTHMA
•
Onset in mid-life
• Onset early in life (often childhood)
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Symptoms slowly progressive
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Long smoking history
Symptoms vary from day to day
Symptoms worse at night/early morning
Allergy, rhinitis, and/or eczema also present
Family history of asthma
© 2015 Global Initiative for Chronic Obstructive Lung Disease
GOLD spirometric criteria for COPD severity
Mild COPD
• FEV1/FVC < 0.7
• FEV1 ≥ 80% predicted
The patient may not be
aware that their lung
function is abnormal
Moderate COPD
• FEV1 /FVC < 0.7
• 50% ≤ FEV1 < 80%
predicted
Symptoms progress
with SOB typically
developing on exertion
Severe COPD
• FEV1 /FVC < 0.7
• 30% ≤ FEV1 < 50%
predicted
SOB worsens and often
limits patients’ daily
activities. Exacerbations
begin
Very Severe COPD
• FEV1 /FVC < 0.7
• FEV1< 30% predicted
Or < 50% predicted plus
chronic respiratory failure
quality of life
is very appreciably
impaired and
exacerbations may be Life
threatening.
Therapeutic Options: Inhaled
Corticosteroids

Regular treatment with inhaled corticosteroids improves symptoms, lung
function and quality of life and reduces frequency of exacerbations for
COPD patients with an FEV1 < 60% predicted.

Inhaled corticosteroid therapy is associated with an increased risk of
pneumonia.

Withdrawal from treatment with inhaled corticosteroids may lead to
exacerbations in some patients.

Symbicort Turbohaler® 200/6 — two inhalations twice daily.or 400/12 — one
inhalation twice daily.

Seretide 500 Accuhaler® (salmeterol 50 micrograms plus fluticasone propionate
500 micrograms) — one inhalation twice daily.
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Therapeutic Options:
Phosphodiesterase-4 Inhibitors
Roflumilast
 In patients with severe and very severe

COPD (GOLD 3 and 4) and a history of
exacerbations and chronic bronchitis, the
phospodiesterase-4 inhibitor, roflumilast,
reduces exacerbations treated with oral
glucocorticosteroids.
NICE recommend only for severe COPD and
in the context of clincial
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Oral therapy
• Corticosteroids:
– Maintenance use not normally recommended.
– Advanced COPD may need maintenance oral corticosteroids if
treatment cannot be stopped after exacerbation.
– Keep the dose as low as possible, monitor for osteoporosis and offer
prophylaxis.
• Theophylline:
– Offer only after trials of short- and long-acting bronchodilators or to
people who cannot use inhaled therapy.
– Theophylline can be used in combination with beta2 agonists and
muscarinic antagonists.
– Take care in
• older people (pharmacokinetics),
• comorbidities
• interactions with other medications.
– Reduce the theophylline dose if macrolide or fluoroquinolone
antibiotics (or other drugs known to interact) are prescribed to treat
an exacerbation.
• Mucolytic therapy:
– Consider in people with a chronic productive cough
and continue use if symptoms improve.
– Do not routinely use to prevent exacerbations.
• Not recommended include antioxidant therapy
(alpha-tocopherol and beta-carotene
supplements), antitussive therapy and
prophylactic antibiotic therapy.
• Continuous prophylactic antibiotics: results in a
clinically significant benefit in reducing
exacerbations in COPD.
Pulmonary rehab

All COPD patients benefit from exercise training programs
with improvements in exercise tolerance and symptoms of
dyspnea and fatigue.

Although an effective pulmonary rehabilitation program is 6
weeks, the longer the program continues, the more effective
the results.

If exercise training is maintained at home, the patient's
health status remains above pre-rehabilitation levels.

Pulmonary rehabilitation should be made available to all
appropriate people with COPD (generally MRC 3 and worse)
including those who have had a recent hospitalisation for an acute
exacerbation
Definitions
Asthma
Asthma is a heterogeneous disease, usually characterized by chronic airway
inflammation. It is defined by the history of respiratory symptoms such as wheeze,
shortness of breath, chest tightness and cough that vary over time and in intensity,
together with variable expiratory airflow limitation. [GINA 2014]
COPD
COPD is a common preventable and treatable disease, characterized by persistent
airflow limitation that is usually progressive and associated with enhanced chronic
inflammatory responses in the airways and the lungs to noxious particles or gases.
Exacerbations and comorbidities contribute to the overall severity in individual
patients. [GOLD 2015]
Asthma-COPD overlap syndrome (ACOS) [a description]
Asthma-COPD overlap syndrome (ACOS) is characterized by persistent airflow
limitation with several features usually associated with asthma and several features
usually associated with COPD. ACOS is therefore identified by the features that it
shares with both asthma and COPD.
GINA 2014, Box 5-1
Usual features of asthma, COPD and
ACOS
Feature
Asthma
COPD
ACOS
Age of onset
Usually childhood but can
commence at any age
Usually >40 years
Usually ≥40 years, but may
have had symptoms as
child/early adult
Pattern of
respiratory
symptoms
Symptoms vary over time
(day to day, or over longer
period), often limiting
activity. Often triggered by
exercise, emotions
including laughter, dust, or
exposure to allergens
Chronic usually continuous
symptoms, particularly
during exercise, with ‘better’
and ‘worse’ days
Respiratory symptoms
including exertional dyspnea
are persistent, but variability
may be prominent
Lung function
Current and/or historical
variable airflow limitation,
e.g. BD reversibility, AHR
FEV1 may be improved by
therapy, but post-BD
FEV1/FVC <0.7 persists
Airflow limitation not fully
reversible, but often with
current or historical
variability
Lung function
between
symptoms
May be normal
Persistent airflow limitation
Persistent airflow limitation
GINA 2014, Box 5-2A (1/3)
Usual features of asthma, COPD and
ACOS (continued)
Feature
Asthma
Past history or Many patients have
family history allergies and a personal
history of asthma in
childhood and/or family
history of asthma
COPD
History of exposure to
noxious particles or gases
(mainly tobacco smoking or
biomass fuels)
ACOS
Frequently a history of
doctor-diagnosed
asthma
(current or previous),
allergies, family history of
asthma, and/or a history of
noxious exposures
Time course
Often improves
Generally slowly progressive
spontaneously or with
over years despite treatment
treatment, but may result in
fixed airflow limitation
Symptoms are partly but
significantly reduced by
treatment. Progression is
usual and treatment needs
are high.
Chest X-ray
-
Usually normal
Severe hyperinflation and
other changes of COPD
Similar to COPD
Exacerbations can be
reduced by treatment. If
present, comorbidities
contribute to impairment
Exacerbations may be more
common than in COPD but
are reduced by treatment.
Comorbidities can contribute
to impairment.
Exacerbations Exacerbations occur, but
risk can be substantially
reduced by treatment
GINA 2014, Box 5-2A (2/3)
•
History Suggests
• COPD and
FEV1 < 80% predicted
• FEV1/FVC < 70%
If no
doubt
Diagnose COPD
And follow COPD
guidelines
If FEV1
improves
< 400 mls
If still
In doubt
If in doubt
Bronchodilator
Reversibility
400 mcg Salbutamol or
equivalent Terbutaline
If FEV1 improves
> 400 mls
Asthma likely to be
present
Steroid
reversibility
Oral Prednisolone
30 mg daily for
2 weeks
If FEV1 improves
> 400 mls
If FEV1
improves
< 400 mls
These recommendations are based on the British Thoracic Society
(BTS) guideline Managing passengers with stable respiratory disease
planning air travel[British Thoracic Society, 2011].
Fitness to fly assessment
The recommendations on the fitness to fly assessment in primary care
are based on information from the Civil Aviation Authority (CAA) [Civil
Aviation Authority, 2015] and the British Thoracic Society (BTS)
guideline Managing passengers with stable respiratory disease
planning air travel[British Thoracic Society, 2011].
The BTS identifies people with a forced expiratory volume in 1 second
(FEV1) of less than 30% predicted, and those with pulmonary
hypertension, as requiring assessment with a history and examination
as a minimum.
The CAA states that assessment of whether a person can walk 50 m or
climb a flight of stairs without significant breathlessness is the single,
most practical fitness to fly test.
The BTS states that neither resting sea-level oxygen saturations, nor
FEV1 in those with respiratory disease accurately predict hypoxaemia
or complications during air travel.
Assessments available re. fitness to fly
• The walk test:
– Involves asking the person to walk for a standardised length of
time (usually 6 or 12 minutes).
– Failure to complete the test and/or moderate to severe
respiratory distress measured on a visual analogue scale
indicates a possible need for in-flight oxygen.
• The hypoxic challenge test:
– Measures the person's response to a simulated aircraft cabin
environment.
– In this investigation, 15% oxygen is administered and the person
is monitored continuously by pulse oximetry.
– A partial pressure of arterial oxygen (PaO2) of 6.6 kPa or an
oxygen saturation of 85% is used as the cut-off value below
which supplemental oxygen is recommended for air travel.
Cor pulmonale
• Consider in people who have peripheral oedema, a
raised venous pressure, a systolic parasternal heave, a
loud pulmonary second heart sound
• Exclude other causes of peripheral oedema
• Perform pulse oximetry, ECG and echocardiogram if
features of cor pulmonale
• Assess need for LTOT
• Treat oedema with diuretic
• Angiotensin-converting enzyme inhibitors, calcium
channel blockers, alpha-blockers are not recommended
• Digoxin may be used where there is atrial fibrillation
Natural History
•The Fletcher-Peto Diagram, illustrating the effects of
smoking on rate of decline in FEV1
referral
– Haemoptysis
– Diagnostic uncertainty
– Very severe or worsening COPD (for example if the forced
expiratory volume in 1 second [FEV1] is less than 30% predicted, or
there is a rapid decline in FEV1) — to confirm the diagnosis and
optimize therapy.
– A suspicion of cor pulmonale — to confirm the diagnosis and
optimize therapy.
– Onset of symptoms at an age younger than 40 years, or a family
history of alpha1-antitrypsin deficiency — to confirm the genetic
diagnosis and access treatment and family screening.
– Frequent infections — to exclude bronchiectasis.
– A pattern of symptoms disproportionate to spirometry — to
exclude other pathologies.
– Oxygen therapy .
– Nebulizer therapy or long-term oral corticosteroids.
– Lung surgery (for example, for a person with bullous lung disease
who is still symptomatic on maximal treatment).
referral
• Oxygen saturation less than or equal to 92% breathing air.
• NB failure:
– Type 1 Hypoxaemic respiratory failure : PaO2 of <8 kPa (60 mm Hg)
with normal or low arterial carbon dioxide tension (PaCO2).
– Type 2 Hypercapnic respiratory failure is the presence of a
PaCO2 >6 kPa (45 mm Hg) and PaO2 <8 kPa.
• Very severe airflow obstruction (forced expiratory volume in
1 second [FEV1] less than 30% predicted).
• Cyanosis.
• Secondary polycythaemia (erythrocytosis) PCV >55: Hb >16.
• Peripheral oedema.
• Raised jugular venous pressure.
Palliative
Palliative
• Palliative setting
• Opioids should be used when appropriate for the
palliation of breathlessness in people with endstage COPD unresponsive to other medical
therapy
• Use benzodiazepines, tricyclic antidepressants,
major tranquillisers and oxygen to treat
breathlessness
• Provide access to multidisciplinary palliative care
teams and hospices
Therapeutic Options: Smoking Cessation
 Even a brief (3-minute) period of counseling to urge a
smoker to quit results in smoking quit rates of 5-10%.
Much better than self-generated strategy
 Nicotine replacement therapy (nicotine gum, inhaler,
nasal spray, transdermal patch, sublingual tablet, or
lozenge) as well as pharmacotherapy with varenicline,
bupropion, and nortriptyline reliably increases longterm smoking abstinence rates and are significantly
more effective than placebo.
© 2015 Global Initiative for Chronic Obstructive Lung Disease
Smoking Cessation
•
•
•
•
•
Ask – every time
Importance
Optimism
Catch them saying something positive and go with this
Offer it and do it – whatever it is:
– NRT: gum/ lozenges/Inhalator/micro-tabs/ mouth spray/
nasal spray/ patches
– Varenicline (Champix)
– Bupropion (Zyban)
• Remember the cycle of change – where is the most
neglected point..?
Smoking Cessation (guidance)
• Consider offering a combination of nicotine patches and another
form of NRT (such as gum, inhalator, lozenge or nasal spray) to
people who show a high level of dependence on nicotine or who
have found single forms of NRT inadequate in the past.
• Do not offer NRT, bupropion or varenicline in any combination.
• Do not favour one medication over another. The clinician and
patient should choose the one that seems most likely to succeed.
• When deciding which therapies to use and in which order, discuss
the options with the patient and take the following into account:
– Whether a first offer of referral to the NHS Stop Smoking Service has
been made.
– Contra-indications and the potential for adverse effects.
– The patient's personal preferences.
– The availability of appropriate counselling or support.
– The likelihood that the patient will follow the course of treatment.
– Their previous experience of smoking cessation aids.
Varenicline(Champix)
Bupropion (Zyban)
• Varenicline = α4β2 nicotinic acetylcholine receptor partial agonist. This
means that it both blocks and stimulates the receptor to which it is
attracted. should be
–
–
–
–
–
started 1-2 weeks before the target stop date.
initiated at 500 micrograms (one tablet) daily 3/7
500 micrograms twice-daily 4/7
1 mg twice-daily for 11 weeks.
If the patient cannot tolerate the higher dose reduce to 500 micrograms
twice-daily.
– A further 12-week course of 1 mg twice-daily can be considered for patients
who have stopped smoking but feel they still need further pharmacological
support.
• Bupropion is an atypical antidepressant similar to diethylpropion, an
appetite suppressant; it inhibits reuptake of dopamine, noradrenaline
(norepinephrine) and serotonin in the CNS and is a non-competitive
nicotine receptor antagonist
– 2 week lead in with increasing dose before quit date
– Side effects: Fits (1:1000) Insomnia, dry mouth, anorexia, nausea