CHRONIC CHRONIC OBSTRUCTIVEOBSTRUCTIVEPULMONARYPULMONARYDISEASEDISEASE

AIMS OF THIS SESSION

To Understand the definitionDiscuss causesDiscuss diagnosisDiscuss Management/MedicationDiscuss Oxygen Therapy

and enjoy!

DEFINITION

COPD is characterised by airflow obstruction.COPD is characterised by airflow obstruction.

air flow obstruction is usually progressiveair flow obstruction is usually progressive

It is not fully reversibleIt is not fully reversible

does not change markedly over several monthsdoes not change markedly over several months

. . The disease is pre-dominantly caused by smoking.The disease is pre-dominantly caused by smoking.

COPD is an umbrella term for

Emphysema

Chronic Bronchitis

Severe Chronic Asthma

NICE (2010)NICE (2010)

CHRONIC BRONCHITIS

Continuous inflammation of the cells lining the Continuous inflammation of the cells lining the bronchibronchi

Mucous hypersecretionMucous hypersecretion Destruction of the cilia, impairing mucous clearance Destruction of the cilia, impairing mucous clearance

leading to increased risk of infectionleading to increased risk of infection

Diagnosed by the production of sputum and cough on

most days for three months in two consecutive years

EMPHYSEMA

Destructive of the alveoli and terminal bronchioles Destructive of the alveoli and terminal bronchioles Loss of elasticity of smaller airwaysLoss of elasticity of smaller airways Loss of patency of bronchiolesLoss of patency of bronchioles

CAUSES OF COPDSMOKING: 90 % of cases,are caused by smoking90 % of cases,are caused by smoking15% are susceptible.15% are susceptible.Lung function decline is 3 times faster Lung function decline is 3 times faster If smoking stops, at one year FEV1 decline is age If smoking stops, at one year FEV1 decline is age related (Morgan & Britton 2003)related (Morgan & Britton 2003)

ALPHA 1 ANTITRIPSIN DEFICIENCY:GENETICFound in only 1% of cases.Found in only 1% of cases.

OCCUPATIONAL EXPOSURE TO RESPIRATORY POLLUTANTS:

Chemicals, dust, atmospheric pollutants, inherited Chemicals, dust, atmospheric pollutants, inherited tendencytendency

Nearly 30,000 deaths a year-accounting for 5% of all Nearly 30,000 deaths a year-accounting for 5% of all deaths, one death every 20 minsdeaths, one death every 20 mins

850,000 diagnosed – only 33%850,000 diagnosed – only 33%

Probably 2 million undiagnosedProbably 2 million undiagnosed

“ “Missing Millions”(BLF 2009)Missing Millions”(BLF 2009)

COPD is the fourth most common cause of death after COPD is the fourth most common cause of death after heart disease, lung disease and cerebrovascular heart disease, lung disease and cerebrovascular

diseasedisease

COPD is the only leading cause of death that is COPD is the only leading cause of death that is increasing in prevalence with a total cost £850 increasing in prevalence with a total cost £850 million/yr- 24 million working days lost-million/yr- 24 million working days lost-

Cigarette smoking is the major cause of COPD 90%Cigarette smoking is the major cause of COPD 90%

Mortality from COPD is increasing in women while Mortality from COPD is increasing in women while reaching a plateau in menreaching a plateau in men

Unless current trends are reversed, COPD may Unless current trends are reversed, COPD may become the biggest public health problem.become the biggest public health problem.

Death rate one of worst in EuropeDeath rate one of worst in Europe

DIAGNOSIS

Over 35

Smoker or ex smoker

no clinical features of asthma

Have any of these symptoms ?

exertional breathlessness

chronic cough

regular sputum production

frequent winter “bronchitis”

Wheeze (NICE 2010)

COPD OR ASTHMA ?COPD OR ASTHMA ?

COPDCOPD AsthmaAsthma

Smoker/ex smokerSmoker/ex smoker Nearly allNearly all PossiblyPossibly

Symptoms under age Symptoms under age of 35of 35

RareRare CommonCommon

Chronic productive Chronic productive coughcough

Progressive and persistentProgressive and persistent VariableVariable

BreathlessnessBreathlessness Progressive and persistentProgressive and persistent VariableVariable

Night time waking with Night time waking with breathlessness and/or breathlessness and/or

wheezewheeze

UncommonUncommon CommonCommon

Significant diurnal or Significant diurnal or day to day variationday to day variation

UncommonUncommon CommonCommon

SPIROMETRY

Spirometry measures the volume of air expired from the Spirometry measures the volume of air expired from the lungs during a single maximal forced expiration. The lungs during a single maximal forced expiration. The key measurements are:-key measurements are:-

Forced Vital capacity (FVC)Forced Vital capacity (FVC)

Forced Expiratory Volume in one second (FEV1)Forced Expiratory Volume in one second (FEV1)

FVC/FEV1 RatioFVC/FEV1 Ratio

CLASSIFICATION OF COPD

MILDMILD FEV1 >80%FEV1 >80%

MODERATEMODERATE FEV1 50-80%FEV1 50-80%

SEVERESEVERE FEV1 30-50%FEV1 30-50%

VERY SEVERE FEV1,30%VERY SEVERE FEV1,30%

NICE GUIDELINE (2010))NICE GUIDELINE (2010))

SYMPTOMS ASSOCIATED WITH AN EXACERBATION

DYSPNOEA More breathless than normal Reduced exercise tolerance

SPUTUM PRODUCTION Increase in purulence

SPUTUM VOLUME Increase in normal amount

COUGH

INVESTIGATIONSINVESTIGATIONS

Chest X rayChest X ray

Arterial blood gas – can aid medical diagnosisArterial blood gas – can aid medical diagnosis

ECGECG

FBC, Urea and ElectrolytesFBC, Urea and Electrolytes

Theophylline levels if appropriateTheophylline levels if appropriate

Sputum microscopy/culture if purulentSputum microscopy/culture if purulent

OBSERVATIONS/MONITORINGOBSERVATIONS/MONITORING

RESPIRATORY RESPIRATORY rate/rhythm/workload/equalrate/rhythm/workload/equal O2 Sats – 90-92%O2 Sats – 90-92% Colour skin, lips, nails(clubbing)Colour skin, lips, nails(clubbing) Patient able to speak in sentences/words or not at allPatient able to speak in sentences/words or not at all Temp/Pulse/BPTemp/Pulse/BP ConfusionConfusion urine outputurine output Peripheral oedemaPeripheral oedema Depression/lethargyDepression/lethargy Assess need for NIV/IVAssess need for NIV/IV Not needed- PEFRNot needed- PEFR

TREATMENTTREATMENT Regular bronchodilator therapy Regular bronchodilator therapy

(consider IV aminophylline if poor response to nebs)(consider IV aminophylline if poor response to nebs)

Continue/start Oral antibioticsContinue/start Oral antibiotics

Continue/start oral Prednisolone Continue/start oral Prednisolone

(continue inhaled steroids also as takes 7 – 10 days to (continue inhaled steroids also as takes 7 – 10 days to kick in)kick in)

Oxygen therapy asOxygen therapy as prescribedprescribed

(dependant on blood gas result and Sats O2)(dependant on blood gas result and Sats O2)

Non invasive Ventilation Non invasive Ventilation

NURSING MANAGEMENTNURSING MANAGEMENT

Liase with multi disciplinary team members to provide Liase with multi disciplinary team members to provide specialised care. specialised care.

Disease process/progressionDisease process/progression

Inhalers/medicationInhalers/medication

Smoking cessationSmoking cessation

NutritionNutrition

Pulmonary rehab/Community Matron/Breathlessness Pulmonary rehab/Community Matron/Breathlessness clinic/Support groupclinic/Support group

VaccinationsVaccinations

Physiotherapist-Breathing exercises, expectoration, Physiotherapist-Breathing exercises, expectoration, coping mechanisms, energy conservationcoping mechanisms, energy conservation

BenefitsBenefits

Further exacerbations- Exacerbation self Further exacerbations- Exacerbation self management plan and standby antibiotics and steroidsmanagement plan and standby antibiotics and steroids

PRE DISCHARGE MANAGEMENTPRE DISCHARGE MANAGEMENT SpirometrySpirometry

Blood gasBlood gas

Full knowledge of treatment – correct inhaler techniqueFull knowledge of treatment – correct inhaler technique

Self management plan re antibiotics and steroids at Self management plan re antibiotics and steroids at homehome

FU appt-with Respiratory Nurses if O2 indicatedFU appt-with Respiratory Nurses if O2 indicated

Refer to Pulmonary rehabRefer to Pulmonary rehab

Check smoking statusCheck smoking status

END of LIFE?

Palliative care register

Advanced directives/PPC/Assessment of concerns

Hospice/day hospital

COMPLICATIONS OF COPDCOMPLICATIONS OF COPD..

RESPIRATORY FAILURE

COR PULMONALE

POLYCYTHAEMIA

PULMONARY EMBOLI

DEPRESSION / ANXIETY

RESPIRATORY FAILURE

TYPE 1 TYPE 1 Respiratory FailureRespiratory Failure

PaO2 below 8Kpa(60.80mmHg) with normal/low PaCO2PaO2 below 8Kpa(60.80mmHg) with normal/low PaCO2

TYPE 2 Respiratory FailureTYPE 2 Respiratory Failure::

PaO2, below 8kpa(60.8mmHg) and increased PaCO2 PaO2, below 8kpa(60.8mmHg) and increased PaCO2 above 6.5kPa( 49.4mmHg)above 6.5kPa( 49.4mmHg)

AIMS OF THERAPYAIMS OF THERAPY

• Prevent further disease progressionPrevent further disease progression

• Relieve symptomsRelieve symptoms

• Improve exercise capacityImprove exercise capacity

• Maintain best quality of lifeMaintain best quality of life

• Prevent exacerbationsPrevent exacerbations

MEDICATIONSBronchodilators should be the initial treatmentAssess effectiveness by

improvement in symptoms

ADL

exercise capacity

rapidity of relief of symptoms

Note - FEV1 will not reflect any significant improvement

MEDICATIONS

If symptoms persist add

Long acting anticholinergic.Long acting anticholinergic.

Long-acting B2 agonistLong-acting B2 agonist

MEDICATIONS

Inhaled steroids - for all COPD pts?Inhaled steroids - for all COPD pts?

MethylxanthinesMethylxanthines

AntidepressantsAntidepressants

MucolyticsMucolytics

TREATMENT FACTORS AFFECTING CONCORDANCE OF INHALED MEDICATIONS

Drug regimeDrug regime

- Too complex- Too complex

- Frequency of dosing- Frequency of dosing

- Unsuitable inhaler ie rheumatic, elderly- Unsuitable inhaler ie rheumatic, elderly

Lack of noticeable immediate benefit eg inhaled Lack of noticeable immediate benefit eg inhaled steroids and long acting bronchodilatorssteroids and long acting bronchodilators

Multiple prescription chargesMultiple prescription charges

NON TREATMENT FACTORS Lack of understanding of treatment inc lack of clear Lack of understanding of treatment inc lack of clear

instructionsinstructions

Fear of side effectsFear of side effects

Dislike/distrust of health serviceDislike/distrust of health service

Reluctance to accept diagnosis Reluctance to accept diagnosis

Preference for alternative therapiesPreference for alternative therapies

Lack of social support/family circumstancesLack of social support/family circumstances

Language, reading or eyesight difficultiesLanguage, reading or eyesight difficulties

LONG TERM OXYGEN THERAPY

LTOT is considered in patients with PaO2 of 7.3kPa when stable or

PaO2 of 7.3 – 8kPa with one of the following : secondary polycytheamia

nocturnal hypoxaemia,

peripheral oedema or pulmonary hypertension

Severe airflow obstruction – FEV1<30%

Performed in secondary carePerformed in secondary care

Initial - 6 weeks post exacerbation, clinically stableInitial - 6 weeks post exacerbation, clinically stable

Second assessment – 3-4 weeks later with trial of Second assessment – 3-4 weeks later with trial of oxygenoxygen

LTOT should be used for at least 15hrs/day via a LTOT should be used for at least 15hrs/day via a concentrator installed by company concentrator installed by company

ASSESSMENTASSESSMENT

SHORT BURST OXYGENSHORT BURST OXYGEN

No evidence to support its use in COPD . Used more forNo evidence to support its use in COPD . Used more for symptom relief in fibrosis /palliative caresymptom relief in fibrosis /palliative care

for short bursts only for short bursts only by cylinder by cylinder Can be prescribed by GP Can be prescribed by GP

AMBULATORY OXYGENAMBULATORY OXYGEN

Evidence of desaturation on exerciseEvidence of desaturation on exercise

6 min walk test monitored by saturations.6 min walk test monitored by saturations.

Lightweight cylinders +/- conserver deviceLightweight cylinders +/- conserver device

CHRONIC CHRONIC OBSTRUCTIVEOBSTRUCTIVEPULMONARYPULMONARY

DISEASEDISEASEEndEnd

RESPIRATORY NURSES

ALISON CALVERT RLI/WGH EXT 3608/5611MOBILE 07917240710

SARAH JEWELL FGH PAGER VIA SWITCH EXT 1502

HELEN BOOTH RLI BLEEP 767 EXT 3608