COPD – Canadian Thoracic Society 2007

COPD

  • A respiratory disorder characterized by progressive airway obstruction, lung hyperinflation, and systemic manifestations.
  • Exacerbations gradually increase in frequency & severity
  • Early Dx & smoking cessation can slow progression of COPD
  • 2 types
    1. Chronic bronchitis – chronic productive cough x 3 months for 2 successive years with other causes (bronchiectasis) excluded
    2. Emphysema – abnormal and permanent enlargement of the airspaces distal to the terminal bronchioles that is accompanied by destruction of the airspace walls

Risk Factors:
  • Smoking – Primary risk factor
  • Environmental – air pollution & Occupational exposure
  • Less common: a-1 antitrypsin deficiency (1%)

1 In all patients presenting with symptoms of prolonged or recurrent cough, dyspnea, or decreased exercise tolerance, especially those who also have a significant smoking history, suspect the diagnosis of chronic obstructive pulmonary disease (COPD).
2 When the diagnosis of COPD is suspected, seek confirmation with pulmonary function studies (e.g.,FEV1).

Assessment
Spirometry for current or ex-smoker >40yo who answer yes to any of the following Q:
  1. Chronic Cough – Do you cough regularly?
  2. Sputum production – Do yo cough up phlegm regularly?
  3. Dyspnea – Do even simple chores make you SOB?
  4. Wheeze – Do you wheeze when you exert yourself, or at night?
  5. Frequent Respiratory infections – Do you get frequent colds that persist longer than those of other people you know?
  6. Nonsmokers with occupational exposure / air pollutants, or a-1 antitrypsin deficiency. 

Hx:
  1. Tobacco consumption in total pack years +/- environmental exposure
  2. Severity of dyspnea
  3. Frequency / severity of exacerbations
  4. Symptoms that could point to complications: ankle swelling (R HF), progressive Wt gain
  5. Symptoms that suggest comorbidities: CV dz, lung Ca, osteoporosis, MSK disorder, anxiety, depression
  6. Current med Tx
DDx:
  • Asthma, CHF, bronchiectasis, TB
O/E:
  • Signs of lung hyperinflation, R HF, muscle wasting (advanced dz)
Ix:
  1. Dx requires postbronchodilator spirometry  FEV1/FVC < 0.7
  2. CXR useful to r/o comorbidities
  3. Exercise tests & echocardiography & regular PFT
  4. B/w & biomarker & sputum cytology
  5. Nutrition / skeletal muscle function & Radiology

3 In patients with COPD, use pulmonary function tests periodically to document disease progression.

Dz severity

Spirometry + MRC dyspnea scale for dz stratification

MRC (Medical Research Council) dyspnea scale – Grade 1-5

  1. Not troubled by breathlessness, except with strenous exercise
  2. Trouble by SOB when hurrying on the level or walking up a light hill.
  3. Walker slower than people of the same age on the level because SOB or has to stop for breath when walking at own pace on the level
  4. Stops for breath after walking about 100yards (90m) or after a few min on the level
  5. Too breathless to leave the house, or breathless when dressing or undressing

Inaccuracy due to non-COPD conditions (cardiac dysfunction, anemia, muscle weakness, metabolic disorders).
Classfication of COPD severity with care in pt with comorbid dz or other contributors to SOB.

Classification by symptoms and disability

  • Mild – MRC 2
  • Moderate – MRC 3-4
  • Severe – MRC 5 or the presence of chronic respiratory failure or clinical signs of R HF

Classification by impairment of PFTPost bronchodilator Spirometry: FEV1/FVC < 0.7 (req for COPD dx) plus FVE1

  • Mild – FEV1 >=80% predicted
  • Moderate – 50% >= FEV1 <80% predicted
  • Severe – 30% <= FEV1 < 50% predicted
  • Very severe FEV1 <30% predicted

4 Encourage smoking cessation in all patients diagnosed with COPD.*
5 Offer appropriate vaccinations to patients diagnosed with COPD (e.g., influenza/pneumococcal vaccination).
7 Refer appropriate patients with COPD to other health professionals (e.g., a respiratory technician or pulmonary rehabilitation personnel) to enhance quality of life.

Rx:

The goals are to prevent dz progression (smoking cessation only), reduce the frequency and severity of exacerbations, alleviate symptoms, improve exercise tolerance, treat exacerbation and complications, improve overall health, and reduce mortality (smoking cessation only).

  • Smoking cessation – offer pharmacotherapy, exercise, education, self-management
  • pulmonary rehabilitation for pt who are
    • clinically stable
    • with reduced activity levels and increased dyspnea despite Tx
    • No evidence of active ischemic, MSK, psych or other dz
    • sufficient motivation
  • Annual influenza vaccine
  • Pneumococcal vaccine once per lifetime (repeat in 5-10 yr if high risk)

6 In an apparently stable patient with COPD, offer appropriate inhaled medication for treatment (e.g., anticholinergics/ bronchodilators if condition is reversible, steroid trial).

  1. Mild s/sx:
    • Short-acting bronchodilator prn
  2. Moderate – Severe s/sx:
    • Long-acting bronchodilator – Tiotropium + SABA prn
  3. Moderate – Severe s/sx w/ infrequent exacerbations (<1/yr):
    • Tiotropium + LABA + SABA prn
  4. Moderate – Severe s/sx w/ Hx of exacerbations:
    • Tiotropium + LABA/ICS (only w/ LABA) + SABA prn
  5. Severe s/sx despite tiotropium + LABA/ICS:
    • long-acting theophylline (monitor blood level, s/e, drug interactions)
Long term O2 therapy
  • Stable COPD and severe hypoxemia (PaO2 <=55mmHg)
  • PaO2 bilateral ankle edema, cor pulmonale, or hematocrit >56% (polycythemia)
  • NPPV – pt with a severe exacerbation pH
  • Not indicated in
    • respiratory arrest, hemodynamic instability
    • high risk of aspiration, impaired mental status, inability to cooperate
Surgery
  • FEV1 <25% predicted without reversibility
  • Partial pressure of arterial CO2 >55mmHg
  • Elevated pulmonary artery pressure with progressive deterioration
Alpha-antitrypsin deficiency
  • Alpha antitrypsin (AAT) Replacement for patients with 65% > FEV1 >35% + quit smoking + optimal pharmacotherapy but continue to show a rapid decline in FEV1

Prevention of acute exacerbations
  1. Smoking cessation
  2. Annual influenza vaccination if no c/i
  3. Pneumococcal vaccination – repeat in 5-10yr prn
  4. Consider tiotropium +/- LABA if FEV1 <60%
  5. Consider Tiotropium + LABA/ICS if FEV1<60% & frequent exacerbation (>=1/yr)

8 When treating patients with acute exacerbations of COPD, rule out co-morbidities (e.g., myocardial infarction, congestive heart failure, systemic infections, anemia).

Rx of acute exacerbation (>48hr of worsening dyspnea, cough ± sputum)
  1. Hx & PE to rule out other causes, ABG – if low O2 sat, and CXR
  2. Gram stain + Culture if ++ purulent sputum, poor lung function, frequent exacerbations, Abx in prev 3/12
  3. PFT if no previous spirometry
  4. Inhaled bronchodilator to relieve dyspnea
  5. O2 to improve O2 Sat to 88-92%
  6. Oral or parenteral corticosteroids: Prednisone 50mg/d for 10-14 days in moderate to severe COPD
  7. Abx if + purulent exacerbations (2/3: ↑ dyspnea/cough, sputum, sputum purulence)
    1. Low risk: Doxycycline 100mg daily or Biaxin 1g-extended daily x 7 d
    2. High risk (pt with CAD/CHF, >3 exacerbations / yr): Clavulin 875mg bid x 7d or Moxifloxacin 400mg daily x 5d
  8. Admit if
    1. Marked increase in intensity of symptoms or new physical signs
    2. Severe COPD with failure of an exacerbation to respond to Tx
    3. Presence of serious comorbidities
    4. Frequency exacerbations 
    5. Older age with insufficient home support
Common triggers:
  • URTI – most common
  • Irritants, PE, MI, anemia, CHF, systemic infections

9 In patients with end-stage COPD, especially those who are currently stable, discuss, document, and periodically re-evaluate wishes about aggressive treatment interventions. 

Referral:
  • Uncertain Dx
  • Severe/ disproportionate symptoms to spirometry
  • Accelerated decline of lung function
  • Onset <40yo
  • Failure to respond to Tx
  • Severe/Recurrent exacerbations
  • Complex comorbidities
  • Assessment for pulmonary rehab, Home O2, surgical Tx
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Posted in 15 COPD, 99 Priority Topics, FM 99 priority topics, Resp

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