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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: – – – – 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 – – – – 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 • • • • • • • • • 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: • • • • • • • 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) • • Symptoms slowly progressive • • • • 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