COPD + ASTHMA

1. COPD + ASTHMA Matt Wong + Sheila Murphy Dec 13th 2011

2. CONTENTS • AKT MINI EXAM • NICE – COPD GUIDELINES • BTS ASTHMA GUIDELINES • INHALER TECHNIQUE • QOF • SPIROMETRY • CSA EXERCISE

3. AKT • Which of the following are used in assessing the severity of COPD? • A. Body mass index (BMI) • B. Age • C. Medical Research Council (MRC) dyspnoea score • D. Smoking pack year history • E. Lung function

4. AKT • Which of the following statements apply to COPD? • A. It is more common in those from upper social classes • B. It is often seen as a co-morbidity in patients with ischaemic heart disease and lung cancer • C. Mortality from COPD is evenly spread across the UK as a whole • D. The estimated prevalence of COPD in patients over 40 years of age is 9-10%

5. AKT • What percentage of patients will die within 3 months of admission for a COPD-related condition? • A. 33% • B. 50% • C. 5% • D. 20%

6. AKT • Pulmonary rehabilitation should be offered to: • A. All patients with moderate or severe COPD • B. All patients with COPD irrespective of their MRC score • C. Patients who are poorly motivated • D. All patients who meet the referral criteria regardless of their inhaled drug therapy • E. Patients with an MRC dyspnoea score of 3 or more unless they are on long-term oxygen therapy (LTOT)

7. AKT • Which of the following statements about the role of inhaled corticosteroids in COPD are true? • A. In patients with moderate/ severe COPD (FEV1 <50% predicted), treatment of the lung inflammation with inhaled corticosteroids has not shown to be of benefit in reducing exacerbations • B. There is no evidence to suggest that early use of inhaled steroids in patients with COPD will reduce the decline in FEV1 seen over years • C. The use of inhaled corticosteroids has been shown to be of some benefit in reducing the decline in health status seen in patients with moderate/ severe COPD (FEV1 <50% predicted) • D. Osteoporosis is commonly seen in patients taking high dose inhaled corticosteroids

8. AKT • Which of the following features suggest a patient should be admitted to hospital for management of their COPD exacerbation? • A. Cyanosis • B. Mild peripheral oedema • C. Low oxygen saturation (<90%) • D. Good level of activity • E. Significant co-morbidities

9. AKT • Which of the following statements about oxygen therapy in COPD exacerbations are true? • A. It should be given to all patients • B. It should be started at 100% until the oxygen saturation is >95% • C. It should be monitored by pulse oximetry until access to full arterial or capillary blood gases are available • D. In patients on LTOT it should be given at the same rate as they receive at home

10. AKT

11. AKT

12. ANSWERS to AKT • 1. A, C, E • 2. B, D • 3. E • 4. B • 5. C, D • 6. A, C, E • 7. C, D • 8. 3 • 9. D

13. AKT

14. AKT

15. NICE + COPD • Consider COPD in smokers >35 and with exertional SOB, chronic cough, regular sputum production, winter bronchitis, wheeze • No features of asthma – unproductive cough, diurnal variation, night-time waking with wheeze/breathlessness • Ask about: weight loss, fatigue, exercise tolerance, chest pain, night waking, haemoptysis, ankle swelling, occupational hazards

16. InVESTIGATIONS • Post-bronchodilator spirometry • CXR • FBC – anaemia/polycythaemia • BMI • FEV1/FVC < 0.7 = COPD • Stage 1-5  mild to very severe based on FEV1 % • >80% is mild • 30% - 50% severe • People must be symptomatic to make diagnosis!

17. MRC Dyspnoea Scale • Grade 1 – not troubled by SOB except on exercise • Grade 2 – SOB when hurrying/walking up hill • Grade 3 – walks slower on level ground due to SOB, or has to stop when walking at own pace • Grade 4 – stops for breath after 100m or a few mins on ground level • Grade 5 – too breathless to leave the house or breathless when dressing

18. MANAGEMENT • Smoking cessation for all • Start treatment once diagnosis confirmed • Pulmonary rehab • For those with disability/recent admission

19. Drug ThERAPY • SABA : short acting B agonist • salbutamol • LABA : long acting B agonist • salmeterol • SAMA : short acting muscarinic antagonist • ipratropium • LAMA : long acting muscarinic antagonist • Tiotropium • ICS : inhaled corticosteroids • Beclometasone, fluticasone, budesonide

20. NICE Management

21. Oral THERAPIES • Theophylline • If inhaled therapy ineffective/can’t be used • Oral steroids • Maintenance steroids not recommended, but if severe COPD may be necessary, aim for low dose and monitor for osteoporosis • 30mg for 7-14 days in exacerbations • LTOT used for 15 hours/day • Assess need for LTOT if FEV1<30%, cyanosis, polycythaemia, peripheral oedema, raised JVP, sats < 92% on air • 2 x ABGs 2 occasions, 3 weeks apart • LTOT if PaO2 < 7.3kPa or 7.3 – 8 with complications

22. MANAGEMENT OF EXACERBATIONS • Increase frequency of broncholdilator use/consider use of nebuliser • Prescribe oral abx if sputum purulent/clinical signs of peumonia • Steroid 30mg 7-14 days • Self-Management • Start abx/steroid if SOB increases/interferes with ADLs • Abx if sputum purulent • Adjust bronchodilator to control symptoms

23. CONSIDER ADMISSION • not able to cope at home • severe beathlessness, Sats <90% • general condition is poor/ deteriorating • cyanosis is present • worsening peripheral oedema • impaired level of consciousness • patients on LTOT • acute confusion • exacerbation has had a rapid rate of onset • significant comorbidity - cardiac disease and IDDM • changes on CXR • arterial pH level < 7.35 • arterial PaO2 < 7 kPa

24. BTS ASTHMA GUIDELINES – DIAGNOSIS in CHILDREN

25. BTS ASTHMA GUIDELINES – DIAGNOSIS in CHILDREN

26. BTS ASTHMA GUIDELINES – DIAGNOSIS in ADULTS

27. BTS ASTHMA GUIDELINES – DIAGNOSIS in ADULTS

28. BTS ASTHMA GUIDELINES – TREATMENT in ADULTS

29. BTS ASTHMA GUIDELINES – DIAGNOSIS in CHILDREN AGED 5-12

30. BTS ASTHMA GUIDELINES – DIAGNOSIS in CHILDREN AGED <5

31. COSTS • Salbutamol CFC Free 100mcg/dose • 3£ / 200 doses • Ipratropium 20 mcg • 5£ / 200 doses • Salmeterol 50 mcg • 29£ / 60doses/ 1 month • Salmeterol 50 mcg and fluticasone • 35£ / 60 doses/ 1 month • Tiotropium • 32£ / 30 doses/ 1 month

32. meTered dose inhaler • Contains a pressurised inactive gas that propels a dose of drug in each 'puff' • ADV • most widely used inhaler • quick to use, small, and convenient to carry • DISADV • needs good co-ordination to press the canister, and breathe in fully at the same time

33. SPACER DEVICES • Used with pressurised MDIs • The spacer between the inhaler and the mouth holds the drug like a reservoirwhen the inhaler is pressed • Valve at the mouth end ensures that the drug is kept within the spacer until you breathe in. When you breathe out, the valve closes. • Adv – No need to have good co-ordination to use a spacer device. • A facemask can be fitted on to some types of spacers, instead of a mouthpiece. This is sometimes done for young children and babies who can then use the inhaler simply by breathing in and out normally through the mask.

34. Breath-activated inhalers • Alternatives to the standard MDI • Don't require you to press a canister on top • Bottom 3 are dry powder inhalers. • Dose is triggered by breathing in at the mouthpiece. You need to breathe in fairly hard to get the powder into your lungs. • Accuhalers • Clickhalers • Easyhalers • Novolizers • Turbohalers • diskhalers • Twisthalers • ADV - Require less co-ordination than the standard MDI. • DISADV - They tend to be slightly bigger than the standard MDI. Autohaler

35. QOF • Practice register of patients with COPD • % with COPD in whom diagnosis has been confirmed by spirometry with reversibility testing • % with COPD with record of smoking status in the previous 15m • % with COPD who smoke, who have been offered smoking cessation advice or referral to a specialist service, where available in last 15 months • % with COPD with a record of FEV1 in the previous 27m • % with COPD with record that inhaler technique has been checked in the preceding 27m • % with COPD who have had influenza immunisation in the preceding 1 September to 31 March • PROMPTS: • MRC Dysponea Score, FEV1, REVIEW EVERY 15m • OUR PRACTICE: • Inhaler technique, sats, smoking, exacerbations, immunisations, depression

36. QOF - ASTHMA

37. SPIROMETERY EXERCISE

38. CSA EXERCISE