Chronic Obstructive Pulmonary Disease (COPD)

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 COPD.

2. When the diagnosis of COPD is suspected, seek confirmation with PFTs (e.g. FEV1).

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

4. Encourage smoking cessation in all patients diagnosed with COPD.

5. Offer appropriate vaccinations to patients diagnosed with COPD (e.g. influenza/pneumococcal vaccination).

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

7. Refer appropriate patients with COPD to other health professionals (e.g. a respiratory technician or pulmonary rehabilitation personnel) to enhance quality of life.

8. When treating patients with acute exacerbations of COPD, rule out co-morbidities (e.g. MI, CHF, systemic infections, anemia).

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

General Overview

• Definition: 

  • Persistent respiratory symptoms and airflow limitation due to airway/alveolar abnormalities usually caused by exposure to noxious particles/gases

• Diagnosis: 

  • Spirometry FEV1/FVC <0.70 post-bronchodilator 

    • Grade

      • Mild = FEV1>80% predicted

      • Moderate = 50-80%

      • Severe = 30 to <50%

      • Very Severe <30%

    • Use for follow-up and prognosis

• Symptoms: 

  • Dyspnea, cough, wheeze, sputum production

• Risk: 

  • Smoking, air pollution, occupational exposures (dusts, chemical agents), genetic factors (alpha-1 antitrypsin), age and female, abnormal lung development, chronic bronchitis, childhood infections

Assess symptoms

• mMRC

  • 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

• COPD Assessment Test

  • 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

Treatment

• Smoking cessation, exercise

• Yearly influenza vaccine and pneumococcal vaccine (>65yo or risk)

• Bronchodilators

  • Short-acting bronchodilator (beta-agonist and/or anticholinergic)

    • SABA

      • 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

    • Combination SAMA/SABA

      • Ipratropium/Salbutamol (Combivent Respimat) 20/100mcg 2inh q4-6h PRN

  • Long-acting

    • LABA

      • 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

• Mild

  • SABA (eg. 4-8 puffs inhaled q20mins up to 4h then q1-4h PRN) +/- LAMA

• Moderate

  • 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

    • Consider 

      • Procalcitonin

      • Sputum cultures if recurrent or severe, r/o pseudomonas

• Severe

  • Magnesium sulfate 2g IV over 20 minutes may reduce hospitalizations (NNTB = 7)

  • Hospitalization/ER visit

Prevention 

• Lifestyle

  • Stop smoking

  • Exercise

• Vaccine

  • Influenza

  • Pneumococcal 23-valent

• Meds

  • LA bronchodilators/anticholinergics

  • Teach inhaler technique

  • Action plan

• When to go to Emergency Department

• Refer

  • Pulmonary Rehab

  • Resp therapy/Respirology/Specialty clinic

  • Smoking cessation group