Comprehensive Management of COPD: a Guide to Diagnosis, Treatment, and Care

1. Management of COPD

2. Setting the scene • Predicted Bolton has 11,167 patients with COPD but only 6045 diagnosed • Bolton PCT total spend on inhalers is £1,948,763 • Bolton patients lose around 16.2 years of life due to mortality from respiratory conditions • Nationally 70% of COPD patients die in hospital

4. Diagnosis • History!!!!! • Increased breathlessness • Cough productive of sputum • No significant variation • ‘winter’ infections • Smoking history >20pack years • Occupation • Spirometry + reversibility

5. Pack year calculator

8. Reversibility • Patient should not have had usual medication • Spirometry • Salbutamol 2.5-5mgs nebulised OR • Salbutamol 200-400mcgs via LVS • Spirometry 20mins post bronchodilator • If FEV1/FVC ratio ≤ 70% obstructive • Post bronchodilation FEV1 is grade severity

10. MRC score

12. Other Therapies • Mucolytics • Methylxanthines • Pneumonia & Influenza vaccines • Oxygen • Pulmonary rehabilitation

13. Oxygen therapy Types of domicillary oxygen Assessment Are they hypoxic? Which disease Objective assessment How and when is it to be used Which modalities • LTOT • Ambulatory • Short Burst

14. Domiciliary Oxygen Therapy

15. Smoking cessation

18. Pulmonary Rehabilitation What does it consist of ? • Improves • Quality of life • Exercise tolerance • Muscle strength • Symptoms • Education and self management

19. Managing an exacerbation • Sustained worsening of symptoms • Increased breathlessness • Increased sputum production change in colour/consistency • Consider hospital or home • Oral Prednisolone • +/- antibiotics • Increase bronchodilators • Controlled oxygen therapy • At review consider self management plan

21. Pulse Oxymetry • Measures amount of saturated haemoglobin • Problems - poor peripheral circulation, carbon monoxide poisoning, skin pigmentation, nail varnish • Doesn’t measure CO2!

22. High Concentration Reservoir Mask • Non re-breathing Reservoir Mask. • Critical illness / Trauma patients. • Post-cardiac or respiratory arrest. • Delivers O2 concentrations between 60 & 80% or above • Effective for short term treatment.

23. Nasal Cannulae • Recommended in the Guideline as suitable for most patients with both type I and II respiratory failure. • 2-6L/min gives approx 24-50% FIO2 • FIO2 depends on oxygen flow rate and patient’s minute volume and inspiratory flow and pattern of breathing. • Comfortable and easily tolerated • No re-breathing • Low cost product • Preferred by patients (Vs simple mask)

24. Simple face mask(Medium concentration, variable performance) • Used for patients with type I respiratory failure. • Delivers variable O2 concentration between 35% & 60%. • Low cost product. • Flow 5-10 L/min Flow must be at least 5 L/min to avoid CO2 build up and resistance to breathing (although packaging may say 2-10L)

25. Venturi or Fixed Performance Masks Aim to deliver constant oxygen concentration within and between breaths. 24-40% Venturi Masks operate accurately 60% Venturi mask gives ~50% FIO2 With TACHYPNOEA (RR >30/min) the oxygen supply should be increased by 50% Increasing flow does not increase oxygen concentration

27. Palliation

28. Patient journey diagnosis death Communication, planning, multi-disciplinary team working Preventative treatment, surgery, vaccine, smoking cessation Pharmacotherapy, quality of life, social support, end of life plans

29. Managing breathlessness • Non- pharmacotherapy • Devices • Aids • Pacing • Psychological support • Pharmacotherapy • Bronchodilators • Oxygen • Opiates • Benzodiazepines

30. Opiates & Benzodiazepines • 2nd or 3rd line • Diazepam or Lorazepam • Used when no response to other therapies • Morphine • Low dose • Oral • Consider side effects • IV or SC Diamorphine in extreme distress

31. COPD treatment circa 2010