Transcript COPD + ASTHMA

Matt Wong + Sheila Murphy
Dec 13th 2011
 AKT
MINI EXAM
 NICE – COPD GUIDELINES
 BTS ASTHMA GUIDELINES
 INHALER TECHNIQUE
 QOF
 SPIROMETRY
 CSA EXERCISE
 Which
of the following are used in
assessing the severity of COPD?
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A. Body mass index (BMI)
B. Age
C. Medical Research Council (MRC) dyspnoea
score
D. Smoking pack year history
E. Lung function
 Which
of the following statements apply to
COPD?
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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%
 What
percentage of patients will die within
3 months of admission for a COPD-related
condition?
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A. 33%
B. 50%
C. 5%
D. 20%
 Pulmonary
rehabilitation should be offered
to:
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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)

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
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 Which
of the following features suggest a
patient should be admitted to hospital for
management of their COPD exacerbation?
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A. Cyanosis
B. Mild peripheral oedema
C. Low oxygen saturation (<90%)
D. Good level of activity
E. Significant co-morbidities
 Which
of the following statements about
oxygen therapy in COPD exacerbations are
true?
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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
 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
 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
 Post-bronchodilator
spirometry
 CXR
 FBC
– anaemia/polycythaemia
 BMI
 FEV1/FVC
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< 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!
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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
 Smoking
cessation for all
 Start treatment once diagnosis confirmed
 Pulmonary rehab
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For those with disability/recent admission
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SABA : short acting B agonist
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LABA : long acting B agonist
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
ipratropium
LAMA : long acting muscarinic antagonist
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salmeterol
SAMA : short acting muscarinic antagonist
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salbutamol
Tiotropium
ICS : inhaled corticosteroids
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Beclometasone, fluticasone, budesonide
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Theophylline
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If inhaled therapy ineffective/can’t be used
Oral steroids
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Maintenance steroids not recommended, but if severe
COPD may be necessary, aim for low dose and monitor
for osteoporosis

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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
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LTOT if PaO2 < 7.3kPa or 7.3 – 8 with complications
 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
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Start abx/steroid if SOB increases/interferes with
ADLs
Abx if sputum purulent
Adjust bronchodilator to control symptoms
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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
 Salbutamol
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CFC Free 100mcg/dose
3£ / 200 doses
 Ipratropium
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5£ / 200 doses
 Salmeterol
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50 mcg
29£ / 60doses/ 1 month
 Salmeterol
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20 mcg
50 mcg and fluticasone
35£ / 60 doses/ 1 month
 Tiotropium
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32£ / 30 doses/ 1 month

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
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DISADV
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needs good co-ordination
to press the canister, and
breathe in fully at the
same time
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Used with pressurised MDIs
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The spacer between the inhaler and the
mouth holds the drug like a reservoir
when the inhaler is pressed
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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.
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Adv – No need to have good coordination to use a spacer device.
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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.
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Alternatives to the standard MDI
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Don't require you to press a
canister on top
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Bottom 3 are dry powder inhalers.
Autohaler
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Dose is triggered by breathing in at the
mouthpiece. You need to breathe in fairly
hard to get the powder into your lungs.
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Accuhalers
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Clickhalers
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Easyhalers
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Novolizers
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Turbohalers
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diskhalers
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Twisthalers
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ADV - Require less co-ordination
than the standard MDI.
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DISADV - They tend to be slightly
bigger than the standard MDI.
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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:
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MRC Dysponea Score, FEV1, REVIEW EVERY 15m
OUR PRACTICE:
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Inhaler technique, sats, smoking, exacerbations, immunisations,
depression