definition

persistent airflow limitation that is usually proressive and associated with enhanced chronic inflammatory response in the airways and lung to noxious particles or gases

not fully reversible

doesn’t change over several months

  • symptoms:

    • dyspnoea

    • chronic cough

    • chronic sputum production

  • epsidoes of acute worsening (exacerbations) often ovvur

Diagnosis

  • Consider and perform spirometry if ≥40yo:

    • dyspnoea that is

      • progressive

      • characteristically worse with exercise

      • persistent

    • Chronic cough

    • Chronic sputum produciton

    • exposre to risk factors

    • family history of copd

spirometry

  • FEV1/FVC \< 0.70 - confirms presence of persistent airflow limitation

differential diagnosis:

  • COPD

    • onset mid life

    • slowly progressive

    • history of smoking/exposure

  • Asthma

    • onset early in life

    • symptoms vary widely day - day

    • worse @ night/early morning

    • atopy

    • fhx astham

  • CHF

    • volume restriction compared to obstructive

    • CR

  • Bronchiectasis

    • large volumes of purulent sputum

    • cxr

    • associated with bacterial infection

  • Tb

    • onset all ages

    • cxr

    • micro

  • Obliterative bronchiolitis

    • younger

    • non smokers

    • histoyr of RA, acute fume exposure

    • seen after lung/bone marrow transplantaion

  • Diffuse panbronchiolitis

    • asian

    • male and nonsmoker

    • chronic sinusitis

    • cxr/CT - small cetnrilobular nodular opacities and hyperinflation

Causes

  • tobacco

  • indoor air pollution

    • biomass fuel used for cooking and heating

  • occupational dusts and chemicals

  • outdoor air pollution

  • any factors that affects lung growth during gestation and childhood

    • Low birth weight

    • respiratory infections

Assessment

symptoms

  • validated questionairres

    • CAT

    • Clinical copd questionairre

    • mMRC

Degree of airflow limitation

  • GOLD 1

    • mild

    • fev1 ≥ 80% predicted

  • GOLD 2

    • moderate

    • 50% ≤ FEV1 ≤ 80%

  • GOLD 3

    • severe

    • 30% ≤ FEVI ≤ 50%

  • GOLD 4

    • Very severe

    • FEV1 \<30%

Risk of exacerbations

  • acute event characterised by worsening of patient’s respiratory symptoms

  • beyond normal day-day variations

  • leads to a change in medication

  • best predictor = frequent exacernation (≥ 2/year)

  • history of previous treated events

  • hospitalisation for copd exac. is associated with poor prognosis

    • inc. risk of death

Assess comorbidities

  • CVS

  • osteoporosis

  • depresison/anxiety

  • skeletal muscle dysfunction

  • metabolic sydnrome

  • lung cancer

Combined assessment

| GOLD | | | exacerbations |

| :---- | :----: | :----\: | :-----: |

| 4: \<30% | C | D | ≥ 2 |

| 3: 30% ≤ FEV1 ≤ 50%| ICS + LABA or LAAC | ICS + LABA and/or LAMA | |

| --- || - |

| 2: 50% ≤ FEV1 ≤ 80% | A | B | 1 + no hospital |

| 1 : FEV1 > 80% | SABA or SAMA | LABA and/or LAMA | 0 |

| --- || - |

| | mMRC 0-1 | mMRC ≥ 2 | |

| symptoms ||||

management

smoking cessation

  • brief (3-minute) period of counseling to urge = quit rates 5-10%

  • NRT

  • pharmacotherapy

  • most effective treatment for patients wtih COPD

  • only intervention to impact mortality

  • intensive counselling plus pharmacotherapy = most cost effective intervention

smoking prevention

occupational exposure

  • primary prevention

indoor and outdoor air pollution

Physical exercise

  • all COPD patients benefit from regular physical activity

  • encouraged to remain active

Pharmacological

  • reduce symptoms

  • reduce frequency and severity

  • improve health status

  • improve exercise tolerance

  • needs to be patient-specific

Bronchodilators

  • inhaled therapy preferred

  • choice depends on availability

  • prn/regular

  • LA convienient

    • more effective maintained symptom relief

  • tiotropium improves effectivelness of pulmonary rehab

  • combining may improve efficacy and decrease risk of side effects compared to increasing dose of single bronchodilator

LABA

  • improve lung function and health relate QoL, decrease dyspnoea, symptom scores, need for rescue and exacerabtions

Inhaled corticosteroids

  • if fev1 ≤ 60% predicted

  • regular inhaled corticosteroids improves:

    • symptoms

    • lung function

    • QoL

    • decrease frequency of exacerbations

  • associated with increase risk of pneumonia

  • withdrawal may lead to exacerbations

  • long-term monotherapy not recommended

Combination inhaled corticosteroid/bronchodilator therapy

  • (LABA)

  • more effective than either individual componenet:

    • improves lung function

    • health status

  • decrease exacerbations in patinets with moderate - very severe COPD

  • combination associated increase risk of pneumonia

  • add combo to tiotropium = additional benefit

Oral corticosteroids
  • long term treatment not recommended
Phophodiesterase-4 inhibitiors

  • GOLD3/4 with exacerbations

    • roflumilast decrease exacerbations
Methylxanthines (theophylline)

  • less effective

  • less well tolerated than LABA

  • modest bronchodilator effect

  • addition of theophylline to salmeterol produces increase FEV1 and relief of SOB compared to salmerterol alnoe

Other

  • Vaccines

    • pneumococcal ≥65yo

      • reduce CAP in \<65yo with FEV1 \< 40% predict

      • BMJ learning = “all patients”

    • influenza

  • Abx

    • not recommended except rx of infectious exacerbations

Rehabilitation

  • all stages of disease benefit from exercise training programs

  • improvements in:

    • exercise tolerance

    • symptoms of dyspnoea

    • fatigue

  • sustained even after a simgle pulmonary rhabiliation program

  • minimum length = 6/52

O2

  • >15hrs /day

  • increase survival with severe, resting hypoxaemia

  • LTOT:

    • paO2 \< 7.3kPA (55mmHg) or SaO2 ≤ 88% wiht or wihtout hypercapniea

      • twice over 3w period

    • paO2 between 7.3 and 8 (60mmHg) or spo2 ≤ 88% if evidence of:

      • pulmonary hypertension

      • periperhal oedema

        • suggesting CHF

      • polycythemia

Surgical

  • lung volume reduction surgery

  • upper-lobe predominant emphysema

Exacerbations

assessment

  • CXR

  • ecg

  • (ABG)

  • FBC

  • purulent sputum

  • biochemisty

  • spirometry not useful during exacerbation

Treatment

  • O2

  • Bronchodilators

    • SABA +/- SAAC

  • Systemic corticosteroids

    • shorten recovery

    • improve lung function

    • reduce risks of:

      • early relapse

      • treatment failure

      • length of hospital stay

    • 40mg od for 5 days

  • Antibiotics

    • all 3:

      • increase dyspnoea

      • increase sputum production

      • increase sputum purulence

    • or sputum purulence + 1 other

    • mechanical

  • Indications for hospital admission

    • intesntity of symptoms

    • severe underlying COPD

    • onset new phsyical signs

    • failure of exacerbation to respond to initial medical managmeent

    • serious comorbidities

    • frequent exacaerbations

    • older age

    • insufficient home supprot

COPD and comorbdiities

Cardiovascular disease

  • cardioselective beta-blockers are not contraindicated in COPD

Osteoporosis

Anxiety/depression

Lung cancer