Chronic Obstructive Pulmonary Disease (COPD)
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 COPD.
When the diagnosis of COPD is suspected, seek confirmation with PFTs (e.g. FEV1).
In patients with COPD, use pulmonary function tests periodically to document disease progression.
Encourage smoking cessation in all patients diagnosed with COPD.
Offer appropriate vaccinations to patients diagnosed with COPD (e.g. influenza/pneumococcal vaccination).
In an apparently stable patient with COPD, offer appropriate inhaled medication for treatment (eg. anticholinergics/bronchodilators if condition is reversible, steroid trial).
Refer appropriate patients with COPD to other health professionals (e.g. a respiratory technician or pulmonary rehabilitation personnel) to enhance quality of life.
When treating patients with acute exacerbations of COPD, rule out co-morbidities (e.g. MI, CHF, systemic infections, anemia).
In patients with end-stage COPD, especially those who are currently stable, discuss, document, and periodically re-evaluate wishes about aggressive treatment interventions.
Persistent respiratory symptoms and airflow limitation due to airway/alveolar abnormalities usually caused by exposure to noxious particles/gases
Spirometry FEV1/FVC <0.70 post-bronchodilator
Mild = FEV1>80% predicted
Moderate = 50-80%
Severe = 30 to <50%
Very Severe <30%
Use for follow-up and prognosis
Dyspnea, cough, wheeze, sputum production
Smoking, air pollution, occupational exposures (dusts, chemical agents), genetic factors (alpha-1 antitrypsin), age and female, abnormal lung development, chronic bronchitis, childhood infections
Grade 0 = Symptoms on strenuous exercise
Grade 1 = Symptoms on hurrying on level or walking up slight hill
Grade 2 = Walk slower than people same age because of breathlessness, or stop to breathe when walking at regular pace on level
Grade 3 = Stop after 100m or after a few minutes on level
Grade 4 = Unable to leave house or breathless when dressing/undressing
Cough, Phlegm, Chest tightness, Breathlessness, Activities, Confidence, Sleep, Energy
Assessment of exacerbation risk
Earlier treated events (best predictor), hospitalization
Deteriorating airflow limitation
High blood eosinophil count
Assessment of comorbidities
Heart failure, ischemic heart disease, malignancy
Alpha-1 antitrypsin deficiency (AATD)
WHO recommends all patients with COPD should be screened once, especially if high prevalence area
Consider if early onset COPD, family history of AATD, <20py smoker, asthma poorly responsive to therapy
Classic <45yo with panlobular basal emphysema
Smoking cessation, exercise
Yearly influenza vaccine and pneumococcal vaccine (>65yo or risk)
Short-acting bronchodilator (beta-agonist and/or anticholinergic)
Salbutamol (Ventolin) 100 mcg/actuation 1 to 2 puffs inhaled PO q4h PRN, Levalbuterol
SAMA (if not on long-acting anticholinergic)
Ipratropium (Atrovent HDA) MDI 17mcg/actuation 2 inh QID, then additional actuations PRN
Ipratropium/Salbutamol (Combivent Respimat) 20/100mcg 2inh q4-6h PRN
Indacaterol (Onbrez Breezhaler) 1 capsule (75mcg) inhaled once daily using Breezhaler inhalation device
Olodaterol (Striverdi Respimat) 2.5mcg/actuation two inhalations once daily
LAMA (anticholinergic- muscarinic)
Tiotropium (Spiriva Respimat) 2.5mcg/actuation two inhalations once daily
Umeclidinium (Incruse Ellipta) 1 inhalation (62.5mcg) once daily
Combination if symptomatic
ICS/LABA: Fluticasone furoate/vilanterol trifenalate (Breo Ellipta) 100/25 mcg/dose one inhalation once daily
LAMA/LABA: Umeclidinium-vilanterol (Anoro Ellipta) 62.5mcg/25mcg one inhalation once daily
Inhaled glucocorticoid if repeat exacerbations/symptoms despite combination long-acting bronchodilators
Combination LABA and ICS
Formoterol/budesonide (Symbicort Turbuhaler) 12/400mcg inhaled BID
Salmeterol/fluticasone (Advair Diskus) 50/250mcg inhaled BID
Vilanterol/fluticasone (Breo Ellipta) 1puff inhaled once daily
Pulmonary rehabilitation for exercise-limited patients or FEV1<50%
Oxygen therapy for severe resting chronic hypoxemia (PaO2 <55mmHg, SaO2<88%)
Non-invasive ventilation (CPAP) for OSA or chronic hypercapnia with history hospitalization
Bronchoscopic and surgical treatments for advanced COPD
Treatment of exacerbation
Most commonly triggered by respiratory viral infection (rhinovirus) and environment (pollution, temperature)
Non-invasive ventilation for respiratory failure
SABA (eg. 4-8 puffs inhaled q20mins up to 4h then q1-4h PRN) +/- LAMA
Antibiotics and corticosteroids (Pred 40mg PO daily x5d) indicated if increased sputum purulence with one of: sputum volume or dyspnea (or if requires ventilation)
If simple COPDE, Amoxicillin 500mg TID x 7d, or clarithromycin 500 BID x 7d, or azithromycin, or cefuroxime, or doxycycline, or TMP-SMX
If complicated (FEV1<50%, >3 COPDE/y, comorbidity, oxygen needs, chronic inhaled steroid, recent antibiotic use)
Moxifloxacin 400mg PO daily x 5d, Levofloxacin 500mg PO daily x 7, or Clavulin
Sputum cultures if recurrent or severe, r/o pseudomonas
Teach inhaler technique
When to go to Emergency Department
Resp therapy/Respirology/Specialty clinic
Smoking cessation group
GOLD 2017. http://goldcopd.org
CFP 2016. http://www.cfp.ca/content/62/5/410.full