COPD

COPD

WHAT IS IT?
1. COPD IS A TERM USED FOR A GROUP OF LUNG/AIRWAY DISEASES THAT ARE NOT FULLY REVERSIBLE
  1. OBSTRUCTED DUE TO CHRONIC BRONCHITIS, EMPHYSEMA OR BOTH
2. ACCOUNTS FOR LARGE RATES OF MORBIDITY AND MORTALITY: EXPECTED TO BE LEADING CAUSE OF DEALTH BY 2030
SYMPTOMS
1. DYSPNOEA
2. CHRONIC COUGH
3. REGULAR SPUTUM PRODUCTION
RISK FACTORS
1. SMOKING
  1. HAS MANY ADVERSE EFFECTS: PRODUCTION OF DESTRUCTIVE PROTEOLYTIC ENZYMES RELEASED FROM INFLAMMATORY CELLS IN THE LUNGS, OXIDATIVE STRESS AND THE INACTIVATION OF ALPHA-1 ANTI-TRYPSIN
    1. ESTIMATED THAT 15-20% SMOKERS DEVELOP COPD
    2. SERINE PROTEASE INHIBITOR THAT BALANCES THE ACTION OF NEUTROPHIL-PROTEASE ENZYMES IN THE LUNGS
2. CHEMICALS
  1. ORGANIC AND INORGANIC DUSTS, CHEMICALS AND FUMES
    1. EXPOSURE CAN CAUSE COPD DEPENDING ON LUNG IMPAIRMENT, INTENSITY AND DURATION OF EXPOSURE
    2. ACCOUNTS FOR 10-20% OF COPD CASES
3. INDOOR AIR POLLUTION
  1. OPEN FIRES OF WOOD, ANIMAL DUNG, COAL AND AGRICULTURAL RESIDUES CAN LEAD TO HIGH LEVELS OF INDOOR AIR POLLUTION ESP IN POORLY ENTILATED AREAS
    1. ACCOUNTS FOR 10-20% OF COPD CASES
4. GENETICS
  1. GENE THAT IS RECESSIVE AND HEREDITARY: DEFICIENCY OF THE ALPHA 1 ANTI-TRYPSIN GENE
PATHOPHYSIOLOGY
1. EMPHYSEMA
  1. PROGRESSIVE AND DESTRUCTIVE ENLARGEMENT OF THE BRONCHIOLES AND ALVEOLAR SACS
    1. LEADS TO LOSS OF SURFACE AREA FOR GAS EXCHANGE & LOSS OF ELASTIC RECOIL FOR EXPIRATION- CAN RESULT IN AIRWAY COLLAPSE ESP DURING EXPIRATION & HYPERVENTILATION
  2. PANACINAR
    1. LESS COMMON & OCCURS AS A RESULT OF AN ALPHA-1 ANTI-TRYPSIN GENE DEFICIENCY
    2. STUDIES SHOW THIS TYPE IS LESS COMMON IN FEMALES AS OESTROGEN INCREASES THE EXPRESSION OF PROTEASE INHIBITORS INCLUDING ALPHA-1 TRYPSIN
  3. CENTRILOBULAR
    1. DESTRUCTION OF BRONCHIOLES, ALVEOLAR DUCTS AND ALVEOLI, COMMON IN SMOKERS/WORKING IN POLLUTED AREAS
2. CHRONIC BRONCHITIS
  1. PRESENCE OF A COUGH AND SPUTUM PRODUCTION FOR ATLEAST 3 MONTHS IN 2 CONSECUTIVE YEARS
    1. AN INFLAMMATORY RESPONSE TO INHALED IRRITANTS (USUALLY DUE TO CIGARETTE SMOKING)
      1. RESULTS IN THE ACCUMULATION AND HYPER-SECRETION OF MUCUS-SECRETING GLANDS IN THE BRONCHIAL TREE
        CAN INCREASE RISK OF BACKTERIAL OR VIRAL INFECTIONS AND THUS WORSEN SYMPTOMS
3. OTHER CHANGES
  1. IMPAIRMENT OF GAS EXHANGE RESUKTING IN HYPOXAEMIA AND HYPERCAPNIA, PULMONARY HYPERTENSION AND VASCULAR REMODELLING
    1. VR INCREASES RIGHT VENTRICULAR PRESSURE AND CAN LEAD TO VENTRICULAR HEART FAILURE KNOWN AS COR PULMONALE
PHARMACOLOGY
1. BRONCHODILATORS
  1. BETA-2-AGONISTS
    1. SHORT ACTING (SABA)
      1. SALBUTAMOL & TERBUTALINE
      2. ORAL, INHALATION
        TABS / CAPS, MDI / DPI
    2. LONG ACTING (LABA)
      1. SALMETEROL & FORMOTEROL
        INHALATION ONLY
        MDI / DPI
    3. STIMULATE BETA-2 ADRENORECEPTORS IN BRONCHIAL SMOOTH MUSCLE, INCREASE cAMP LEVELS AND PKA ACTIVITY, CAUSING BRONCHODILATION
      1. CAN ALSO INHIBIT MEDIATOR RELEASE FROM MAST CELLS AND TNF-ALPHA RELEASE FROM THE MONOCYTES AND INCREASES MUCUS CLEARANCE FROM CILIATED CELLS
  2. CORTICOSTEROID THERAPY
    1. INHALED CORTICOSTEROIDS
      1. BECLOMETASONE
        INHALATION
        MDI / DPI
    2. HIGH POTENCY INHALED CORTICOSTEROIDS
      1. BUDESOMIDE
        INHALATION
        MDI / DPI
    3. LIPOPHILIC THEREFORE CAN ENTER CELL EASILY, BIND TO INTRACELLULAR RECEPTORS WHICH DIMERISE AND MIGRATE TO THE NUCLEUS, COMPLEX AFFECTS TRANSCRIPTION OF mRNA OF SPECIFIC PROTEINS.
      1. INCREASE SYNTHESIS OF ANTI-INFLAMMATORY PROTEINS VIA TRANSACTIVATION. REDUCE THE SYNTHESIS OF PRE-INFLAMMATORY PROTEINS VIA TRANSREPRESSION
        INCREASE SYNTHESIS OF ANNEXIN-1 = A NATURAL INHIBITOR OF PHOSPHOLIPIDASE 2
        THEREFORE LESS ARACHADONIC ACID AVAILABLE TO BE METABOLISED BY COX-1 LOX ENXYMES AND HENCE LESS PGs AND LTs SYNTHESISED
    4. THEY ALSO DECREASE THE SYNTHESIS OF PRO-INFLAMMATORY PROTEINS (COX-2 & NOS-2) AND INHIBIT NUCLEAR FACTOR K (INVOLVED WITH THE INFLAMMATORY CYTOKINE PRODUCTION)
2. MUSURINIC ANTAGONISTS
  1. SHORT ACTING (SAMA)
    1. IPRATROPIUM
      1. INHALATION
        DPI / MDI / NEB
    2. BLOCK ACH RELEASE FROM THE VAGUS NERVE
  2. LONG ACTING (LAMA)
    1. TIOTROPIUM
      1. INHALATION
        DPI / pMDI
    2. BLOCK M3 RECEPTORS ON SMOOTH MUSCLE THUS ANTAGONISING THE EFFECTS OF ACH ON THE SNOOTH MUSCLE, REDUCING INTRACELLULAR CONC OF cGMP AND CAUSING BRONCHIAL SMOOTH MUCLE RELAXATION AND BRONCHODILATION
3. METHYLXANTHINES
  1. THEOPHYLLINE, AMINOPHYLLINE (PRODRUG)
    1. ORAL
      1. MR TABS / CAPS
  2. NON-SELECTIVE PHOSPHODIESTERASE INHIBITOR AND INCREASES cAMP OR cGMP
    1. RESULTS IN RELAXATION OF THE AIRWAY SMOOTH MUSCLE
  3. HIGHER DOSES OF THIS DRUG EXHIBITS BRONCHODILATORY EFFECTS & INCREASE DIAPHRAGMATIC STRENGTH & AID MUCUS CLEARANCE BY CILIATED CELLS
PHARMACEUTICS
1. pMDIs
  1. PORTABLE, CHEAP, DISPOSABLE, REPRODUCIBLE DOSE
  2. COLD FREON EFFECT, REQUIRES INHALER TECHNIQUE, PROPELLANT (CFCs), HIGH ORAL DEPOSITION, MAX DOSE 5mg
    1. USE OF SPACER: OVERCOME INHALATION/ACTUATION COORDINATION ISSUES & COLD FREON EFFECT
2. DPIs
  1. COMPACT, PORTABLE, UNOBTRUSIVE, PROPELLANT FREE, BREATH ACTUATED, NO TECHNIQUE REQUIRED, DELIVER LARGER DOSES COMPARED TO MDI, NO COLD FREON EFFECT
  2. DEPENDS ON PT INSPIRATION FLOW RATE, HUMIDITY MAY CAUSE PARTICLES TO AGGREGATE AND CAPSULES TO SOFTEN, DOSE IS LOST IF PT EXPIRES INTO DPI, LACTOSE
    1. LIMITING FOR COPD PT
3. NEBULISER
  1. NON-SPECIFIC INHALATION TECHNIQUE, DELIVERS LARGE DOSES, SIMPLE FORMULATION
  2. INHALATION IS TIME CONSUMING, BULKY DEVICE, CONTENTS EASILY CONTAMINATED, EXPENSIVE, POOR DELIVERY EFFICACY & VARYING PERFORMANCE
PATIENT AND CLINICAL MONITORING
1. SPIROMETRY
  1. MRC DYSPOEA SCALE
    1. GRADE 1
      1. GRADE 2
        GRADE 3
        GRADE 4
        GRADE 5
        TOO BREATHLESS TO LEAVE THE HOUSE/ BREATHLESS WHEN DRESSING/ UNDRESSING
        STOPS FOR BREATH AFTER WALKING ~100M OF AFTER A FEW MINS ON LEVEL GROUND
        WALKS SLOWER THAN CONTEMPORARIES ON LEVEL GROUND B/C OF BRETHLESSNESS/ HAS TO STOP FOR BREATH WHEN WALKING AT OWN PACE
        SOB WHEN HURRYING OR WALKING UP A HILL
      2. NOT TROUBLED BY BREATHLESSNESS EXCEPT ON STRENUOUS EXERCISE
  2. PERFORMED AT TIME OF DIAGNOSIS
  3. TO RECONSIDER DIAGNOSIS IF PTS SHOW EXCEPTIONAL RESPONSE TO TREATMENT
  4. MEASURE POST-BRONCHODILATOR SPIROMETRY TO CONFIRM COPD DSIAGNOSIS
  5. CONSIDER ALTERNATIVE DIAGNOSIS OR INVESTIGATIONS IN:
    1. OLDER PEOPLE WITHOUT TYPICAL SYMPTOMS OF COPD WHERE FEV1/FVC RATIO: >0.7
    2. YOUNGER PEOPLE WITH SYMPTOMS OF COPD WHERE FEV1/FVC RATIO: =>0.7
  6. FEV1 VALUE (PREDICTED)
    1. >80% = STAGE 1 (MILD)
      1. COPD SHOULD ONLY BE DIAGNOSED IF RESP SYMPTOMS PRESENT
    2. 50 - 79% = STAGE 2 (MODERATE)
      1. POST-BROCHODILATOR FEV1 / FVC = <0.7
    3. 30 - 49% = STAGE 3 (SEVERE)
    4. <30% = STAGE 4 (VERY SEVERE)
  7. AIRFLOW OBSTRUCTION DEFINED AS REDUCED FEV1/FVC RATIO (<0.7)
  8. SPIROMETRY SHOULD BE PERFORMED IN PTS >35, CURRENT OR EX-SMOKERS, AND HAVE A CHRONIC COUGH
    1. SPIROMETRY SHOULD BE CONSIDERED IN PTS WITH CHRONIC BRONCHITIS
      1. A SIG. NO. OF THESE WILL GO ON TO DEVELOP AIRFLOW LIMITATION
2. FURTHER INVESTIGATIONS
  1. AT THE TIME OF THEIR INITIAL DIAGNOSIS, PRECAUTIONS MUST BE TAKEN
    1. CHEST RADIOGRAPH
      1. TO EXCLUDE OTHER PATHOLOGIES
    2. FULL BLOOD COUNT
      1. TO IDENTIFY ANAEMIA OR POLYCYTHAEMIA
    3. BODY MASS INDEX (BMI)
  2. ADDITIONAL INVESTIGATIONS SHOULD BE PERFORMED TO AID MANAGEMENT IN SOME CASES
    1. SERIAL DOMICILLIARY PEAK FLOW MEASUREMENTS
      1. TO EXCLUDE ASTHMA IF DIAGNOSTIC DOUBT REMAINS
      2. CT SCAN OF THORAX
        TO INVESTIGATE SYMPTOMS THAT SEEM DISPROPORTIONATE TO SPIROMETRIC IMPAIRMENT, TO INVESTIGATE ABNORMALITIES SEEN ON CHEST RADIOGRAPH, TO ASSESS SUITABILITY FOR SURGERY
    2. ALPHA-1 ANTITRYPSIN
      1. IF EARLY ONSET, MINIMAL SMOKING OR FAMILY HISTORY
    3. TRANSFER FACTOR FOR CO (TLCO)
      1. TO INVESTIGATE SYMPTOMS THAT SEEM DISPROPORTIONATE TO THE SPIROMETRIC IMPAIRMENT
    4. ECG
      1. TO ASSESS CARDIAC STATE IF FEATURES OF COR PULMONALE
    5. SPUTUM CULTURE
      1. TO IDENTIFY ORGANISMS IF SPUTUM IS PERSISTENTLY PRESENT AND PURULENT
    6. PULSE OXIMETRY
      1. TO ASSESS NEED FOR OXYGEN THERAPY, IF CYANOSIS OR COR PULMONALE PRESENT OR IF FEV1 <50% PREDICTED
ASSESSMENT OF SEVERITY AND PROGNOSTIC FACTORS
1. COPD IS HETEROGENEOUS SO NO SINGLY MEASUREMENT CAN GIVE ,ADEQUATE ASSESSMENT OF SEVERITY, SEVERITY IS IMPORTANT TO MEASURE AS IT GIVES A PROGNOSTIC OUTLOOK
  1. FEV1 IS A POOR REFLECTION OF DISABILITY,
  2. FEV, BMI, TLCO, MRC SCALE, paO2 AND COR PULMONAE MUST BE ASSESSED
CLINICAL FEATURE
1. SMOKER/EX-SMOKER
  1. NEARLY ALL
  2. POSSIBLY
2. COPD
3. ASTHMA
4. SYMPTOMS <35 YEARS
  1. RARE
  2. OFTEN
5. CHRONIC PRODUCTIVE COUGH
  1. COMMON
    1. UNCOMMON
6. BREATHLESSNESS
  1. VARIABLE
  2. PERSISTENT & PROGRESSIVE
7. NIGHT TIME WAKING W/ BREATHLESSNESS / WHEEZING
  1. COMMON
  2. UNCOMMON
8. SIGNIFICANT DIURNAL / DAY-TO-DAY VARIABILITY OF SYMPTOMS
  1. COMMON
  2. UNCOMMON
MANAGEMENT
1. SMOKING CESSATION
  1. UP TO DATE SMOKING HISTORY INCLUDING PACK YEARS SMOKED SHOULD BE DOCUMENTED FOR EVERYONE WITH COPD
  2. ALL COPD PTS, REGARDLESS OF AGE, SHOULD BE ENCOURAGED TO STOP SMOKING, AND OFFERED HELP AT EVERY OPPORTUNITY TO DO SO
  3. UNLESS CONTRAINDICATED, OFFER NRT, VARENICLINE OR BUPROPION WITH APPROPRIATE SUPPORT PROGRAM TO OPTIMISE RESULTS
2. TREATMENT
  1. INFECTION CAN COMPLICATE COPD AND CAN BE PREVENTED BY VACCINATION
    1. PNEUMOCOCCAL POLYSACCHARIDE CONJUGATE (ABSORBED) VACCINE & INFLUENZA VACCINE
  2. PERSISTENT DYPNOEA / EXACERBATIONS DESPITE SABA/SAMA USE
    1. FEV1 ≥ 50% PREDICTED: OFFER OD LAMA (INSTEAD OF QDS SAMA) OR LABA
    2. FEV1 < 50% PREDICTED: EITHER ICS WITH LABA IN COMBINATION INHALER, OR LAMA
  3. FEV1 ≥ 50% PTS WITH PERSISTING DYSPNOEA / EXACERBATIONS DESPITE LABA MAINTENANCE THERAPY
    1. CONSIDER LAMA + ICS IN COMBINATION INHALER
    2. CONSIDER LAMA IN ADDITION TO LABA WHERE ICS IS NOT TOLERATED OR DECLINED
  4. INITIAL COURSE FOR ALLEVIATION OF DYSPNOEA AND EXERCISE LIMITATION
    1. SABA OR SAMA INHALERS TO BE PRESCRIBED
  5. PTS WITH PERSISTENT DYSPNOEA AND EXACERBATIONS DESPITE LABA + ICS COMBINATION MAINTENANCE THERAPY
    1. OFFER LAMA IN ADDITION, IRRESPECTIVE OF FEV1
    2. VICE VERSA
  6. MAINTENANCE USE OF ORAL CS THERAPY IS NOT NORMALLY RECOMMENDED
    1. SO,ME PTS WITH ADVANCED COPD MAY REQUIRE MAINTENANCE ORAL CS WHEN THEY CANNOT BE WITHDRAWN FOLLOWING AN EXACERBATION
      1. IN SUCH CASES, KEEP DOSE AS LOW AS POSSIBLE
    2. PTS TREATED WITH LONG-TERM ORAL CS SHOULD BE MONITORED FOR DEVELOPMENT OF OSTEOPEROSIS & GIVEN APPROPRIATE PROPHYLAXIS
      1. PTS OVER 65 SHOULD BE GIVEN PROPHYLAXIS WITHOUT MONITORING
  7. THEOPHYLLINE
    1. SHOULD ONLY BE GIVEN AFTER TRIAL OF SHORT-ACTING AND LONG-ACTING BRONCHODILATORS, OR IN PTS UNABLE TO USE INHALERS
    2. REQUIRES (TDM) MONITORING DUE TO INTERACTIONS/TOXICITY
    3. EXTRA CAUTION WITH ELDERLY DUE TO ALTERED PHARMACOKINETICS & LIKELY CO-MORBIDITIES/POLYPHARMACY
    4. EFFECTIVENESS TO BE ASSESSED BY SYMPTOM IMPROVEMENT, DAILY ACTIVITY, EXERCISE CAPACITY & LUNG FUNCTION
    5. DOSE TO BE REDUCED AT TIME OF EXACERBATION IF MACROLIDE OR FLUROQUINOLONE IS PRESCRIBED
  8. MUCOLYTIC THERAPY: ONLY TO BE USED WHEN PTS HAVE A CHRONIC COUGH WITH SPUTUM PRODUCTION & CONTINUED IF SYMPTOMATIC RELIEF IS OBSERVED UPON USE
3. KEEP IT SIMPLE
  1. SMOKING
  2. INHALER TECHNIQUE
  3. MONITORING
    1. PREVENT DISEASE PROGRESSION
    2. SYMPTOM CONTROL
    3. MEDICINES REVIEW
    4. COPD PATIENTS ARE ELIGIBLE FOR TARGETTEDMUR AND NMS
  4. PHARMACOTHERAPY
  5. LIFESTYLE
    1. AEROBIC EXERCISE TOLERANCE
    2. DIET
    3. BREATHING EXERCISES
    4. PSYCHOLOGICAL SUPPORT
    5. SHARED DECISION MAKING
      1. PATIENT BELIEFS & EXPERIENCES
  6. EDUCATION
    1. PURPOSE OF DRUG
    2. S/E OF INHALED CS
    3. SIGNS OF TOXICITY
    4. COUNSELLING
    5. SIGNS OF TOXICITY
  7. ENCOURAGE CONCORDANCE TO ENSURE ADHERENCE
4. INTEGRATED APPROACH TO CARE
  1. MULTIDISCIPLINARY TEAM
    1. RESPIRATORY NURSE SPECIALIST
    2. GP
    3. PHYSIOTHERAPIST
    4. DIETICIANS
    5. OCCUPATIONAL THERAPISTS
    6. SOCIAL WORKER
    7. MULTIDISCIPLINARY PALLIATIVE CARE TEAM
    8. HOSPITAL AT HOME SCHEMES
    9. CLINICAL & COMMUNITY PHARMACISTS
THE NHS
1. COPD OBJECTIVES
  1. 1
    1. 2
      1. 3
        4
        TO ENHANCE QUALITY OF LIFE FOR PEOPLE WITH COPD ACROSS ALL GROUPS, WITH A POSITIVE, ENABLING EXPERIENCE OF CARE AND SUPPORT UNTIL THE END OF LIFE
        TO REDUCE THE NO. OF PEOPLE WITH COPD WHO DIE PREMATURELY THROUGH EARLY IDENTIFICATION, DIAGNOSIS & INTERVENTION, WITH PROACTIVE CARE AND MANAGEMENT OF ALL STAGES OF COPD, WITH PARTICULAR FOCUS ON DISADVANTAGED GROUPS AND AREAS OF HIGH PREVALENCE
      2. TO REDUCE THE NO. OF PEOPLE WHO DEVELOP COPD BY ENSURING THE PUBLIC IS EDUCATED ABOUT THE IMPORTANCE OF LUNG HEALTH, WITH RISK FACTORS ADDRESSED, REDUCED OR AVOIDED & PROACTIVELY ADDRESS HEALTH INEQUALITIES
    2. TO IMPROVE RESPIRATORY HEALTH AND WELL-BEING OF ALL COMMUNITIES AND REDUCE INEQUALITIES
    3. 5
      1. TO ENSURE PEOPLE WITH COPD ACROSS ALL SOCIAL GROUPS RECEIVE SAFE AND EFFECTIVE CARE WHICH MINIMIZES PROGRESSION, ENHANCES RECOVERY AND PROMOTES INDEPENDENCE

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	Created by Zinab Keshk about 8 years ago