COPD

1. COPD Alison Boland StR Respiratory medicine

2. Aims & Objectives • Overview of COPD • Recap basic knowledge • Update on COPD • Know when to use nebulisers and home oxygen therapy • The role of NIV in palliative setting / end stage COPD • Gain patient, carer and personal view about COPD

3. GOLD Definition • Airflow limitation • Not fully reversible • Progressive • Abnormal inflammatory response to noxious particles or gases

4. CHRONIC • Develops slowly • Early symptoms often go un-noticed • Symptoms present for much of the time • Progressive dyspnoea over time. • Worse on exercise

5. OBSTRUCTIVE • Narrowing of the bronchi • 3 mechanisms: • Bronchial walls become weakened • Mucus secretion into the bronchi. • Muscle spasm

6. Natural History

7. Activity • BREATHE THROUGH THE STRAW FOR A MINUTE • THNIK ABOUT HOW THIS FEELS.

9. Diagnosis • FEV1/FVC <70% • Post bronchodialator FEV1 <80% predicted. • FEV1/FVC more sensitive.

10. Diagnose COPD: assessment of severity • Assess severity of airflow obstruction using reduction in FEV1 * Symptoms should be present to diagnose COPD in people with mild airflow obstruction ** Or FEV1 < 50% with respiratory failure [new 2010]

11. Managing stable COPD Patient with COPD Assess symptoms/problems Manage those that are present as below Patients with COPD should have access to the wide range of skills available from a multidisciplinary team Palliative care

12. Treatment options Pharmacological Bronchodilators Steroids Antibiotics Mucolytics Antitussives Narcotics

13. Treatment options • Non – pharmacological • Pulmonaryrehabilitation • Oxygen • NIV • Surgery • Bullectomy • Lung volume reduction surgery • Lung transplantation

15. Managing stable COPD: inhaled therapies Breathlessness and exercise limitation SABA or SAMA as required* FEV1 ≥ 50% FEV1 < 50% Exacerbations or persistent breathlessness LABA LAMA Discontinue SAMA ________ Offer LAMA in preference to regular SAMA four times a day LABA + ICS in a combination inhaler ________ Consider LABA + LAMA if ICS declined or not tolerated LAMA Discontinue SAMA ________ Offer LAMA in preference to regular SAMA four times a day Persistent exacerbations or breathlessness LABA + ICSin a combination inhaler ________ Consider LABA + LAMA if ICS declined or not tolerated LAMA + LABA + ICS in a combination inhaler * SABAs (as required) may continue at all stages Offer Consider

16. Bronchodilators Individual effects unpredictable • Inhaled: • Salbutamol (‘Ventolin’) • Ipatropium (‘Atrovent’) • Salmeterol (Serevent) • Terbutaline (‘Bricanyl’) • Tiotropium (‘Spiriva’) • Indacterol (‘onbrez) • Oral: Theophyllines (‘Uniphyllin’, ‘Phyllocontin’)

17. Inhaler technique!!

18. Steroids • Inhaled – Seretide, Symbicort • Oral prednisolone • Do not modify long term decline in FEV1

19. Oral therapy • Theophylline • Carbocisteine • Opioids • Anti anxiolytics

20. Nebulisers • On maximum medical therapy • Use salbutamol only • 1 month trial • No improvement in symptoms then stop

21. New(ish) therapies • Indacterol • Roflumilast • (Azithromycin)

22. Indacaterol • Long acting Beta agonist • Rapid onset of action • 24 hr duration of action • 150micrograms od • Future use as add on to tiotropium

23. Phosphodiesterase inhibitors • Roflumilast • Severe COPD (FEV1 <50%) • Hx Chronic bronchitis, frequent exacerbations • 500micrograms od • Reduces rate of moderate to severe exacerbations

24. Azithromycin • Macrolide antibiotic • Recurrent exacerbations • On maximum therapy • Long term 250mg x3 week • Caution re side effects

25. Oxygen provision • Long term oxygen therapy • Ambulatory oxygen • Short burst oxygen

26. LTOT • FEV1 <50% predicted OR < 1.5l • Signs of corpulmonalae • Sats <92% • PO2 <7.3 (8kPa) • Drying of nasal passages, oxygen toxicity, • Palliative care – target saturations not indicated

27. Ambulatory Oxygen • O2 use during exercise /ADL • LTOT patients • Objective evidence of desaturation on exercise

28. Short burst oxygen • Or Palliative O2 • To relieve SOB • Excludes LTOT & ambulatory oxygen users

30. HOOF

31. HOOF

32. Non invasive ventilation • Home NIV • Recurrent acute type 2 respiratory failures • Intolerance LTOT • Increased co2 with symptoms • Overlap OSA / Obesity hypoventialtion • End of life care

33. Chronic disease management • Stop smoking • Prn Bronchodilator • Annual flu jab • Pneumococcal vaccine (5yrs) • Regular exercise • Maintain weight normal range

34. Nutrition • Underweight usually • BMI <20 • Assess co morbidities • Social factors • Encourage snacking, Higher fat foods • Supplements after 1 month of above • Dietician advise

35. Pulmonary rehab

36. Pulmonary rehab • SOB waking on level ground at normal pace • 2hr sessions, 6 weeks • Motivated patients

37. Patient views about COPD

38. Key Messages • Consider Azithromycin in recurrent exacerbations • Prescribe short burst O2 with caution – expensive and little evidence • Pulmonary rehabilitation important multidisciplinary management • Finally remember how breathing through a straw felt!

39. Any Questions?