copd
Chronic Obstructive Pulmonary Disease (COPD)
Definition
A group of diseases characterised by airflow blockage and breathing problemsChronic obstructive pulmonary disease (COPD) - generally is a smoker but should be thought of in anyone who presents with breathlessness.
Causes
- smoking or Hx of smoking
- exposure to other particulate matter
- α1-antitrypsin deficiency
Symptoms
- exertional breathlessness
- chronic cough
- regular sputum production
- frequent winter 'bronchitis'
- wheeze
Medical Research Council (MRC) dyspnoea scale |
|
|---|---|
| Grade | Level of activity |
| 1 | Not troubled by breathlessness except during strenuous exercise |
| 2 | Short of breath when hurrying or walking up a slight hill |
| 3 | Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace |
| 4 | Stops for breath after walking about 100 m or after a few minutes on the level |
| 5 | Too breathless to leave the house, or breathless when dressing or undressing |
Signs
- Cyanosis
- Raised JVP, peripheral oedema (suggestive of cor pulmonale)
- Cachexia
- Hyperinflation of the chest
- Accessory muscles use, 'pursed lip' breathing
- Wheeze and/or crackles on auscultation of the chest.
Tests
- routine bloods including FBC (raised eosinophils suggests steroid responsiveness), CRP, proBNP (if suspicion of PHT)
- CXR and CT thorax when considering other pathology or symptoms are disproportionate
- ECG, proBNP and ECHO when cardiac causes of SOB need excluding or pulmonary hypertension suspected
- Spirometry is required but not definitive for diagnosis: A post bronchodilator FEV1/FVC < 0.7 confirms persistent airflow obstruction.
- sputum MCS and α1-antitrypsin levels
- transfer factor for CO - if symptoms disproportionate to spirometry
Management
- long acting β agonist (LABA) and may be in combination with,
- long acting muscarinic agonists (LAMA) and may be in combination with,
- steroids - inhaled (ICS) and/or oral
- slow release theophylline if can't tolerate inhalers or which fail
- oral mucolytics for chronic cough with sputum
- Oral phosphodiesterase-4 inhibitors (eg roflumilast)
- Long-term oxygen therapy (LTOT) and ambulatory oxygen are sometimes required. (Weaning and support)
- prophylactic antiotics - azithromycin may be appropriate if non-smoker and optimised therapies and vaccinations
Acute infective exacerbation:
- Prednisolone 30mg OD for 5/7
- Antibiotics: NICE and check local guidelines
- amoxycillin 500mg tds for 5/7
- Doxycycline 200mg OD (not if pregnant)
- clarythromycin 500mg bd for 5/7
Escalation if fails:
- change of antibiotic class
- seek sputum MCS
- consider CXR, bloods looking for alternative reason for deterioration
When to admit
- Rapid onset of symptoms
- severe SOB or inability to cope
- Acute confusion or impaired consciousness
- Cyanosis
- O2 saturation deterioration from usual best
CURB65 Score
Confusion?
Urea ›7mmol/L?
Respiratory Rate ≥30?
sBP<90 or dBP≤60mmHg?
Age ≥65yrs?
| Score | Risk | Plan |
|---|---|---|
| 0 or 1 | 1.5% mortality | Routine care Monitoring not usually required |
| 2 | 9.2% mortality | Consider need for admission – if remaining at home should be admitted to remote monitoring virtual ward |
| ≥3 | 22% mortality | Admission recommended (be guided by any existing Urgent Care Plan / treatment escalation plan) |
Author: Dr Dylan Jenkins Oct 2023. refs