COPD

Definition

• Chronic obstructive pulmonary disease = chronic obstructive airway disease where the obstruction if not fully reversible.
• Includes chronic bronchitis, emphysema, and asthma with incomplete reversibility of airway obstruction.

Risk factors

• Current or past tobacco smoking smoking by far the biggest risk factor followed by passive smoking
• Environmental exposures (e.g., tobacco smoke, occupational dust, air pollution)
• Childhood respiratory history (e.g., premature birth, asthma)
• Genetic predispositions (e.g., alpha-1 antitrypsin deficiency)

Symptoms and Signs

• Symptoms: dyspnoea on exertion; chronic cough (esp productive); decreased exercise tolerance. Always consider other comorbidities (eg coronary).
• Signs: chest hyperinflation; wheeze; prolonged expiratory phase; Barrel shaped chest; Hoover’s sign; features of right HF / pulm HTN
• 

Investigations

(https://www.safetyandquality.gov.au/standards/clinical-care-standards/chronic-obstructive-pulmonary-disease-clinical-care-standard/information-clinicians)

• A diagnosis of COPD must rely on spirometry, as clinical features and imaging alone are insufficient.
• Spirometry Indications:
  • For individuals over 35 with recurrent respiratory symptoms and at least one risk factor.
  • For patients with suspected COPD exacerbations where spirometry confirmation is lacking.
  • Spirometry should be delayed in those with an active respiratory infection.
• High-Quality Spirometry:
  • Performed before and after administering a bronchodilator.
  • Executed by trained and competent clinicians.
  • Requires regular calibration and quality control of spirometers following ATS and ERS standards.
  • If unavailable, referral to specialized centers is recommended.
• Spirometry Results:
  • A post-bronchodilator FEV1/FVC ratio of less than 0.7 is diagnostic of COPD, with insignificant improvement post bronchodilator = COPD
  • FEV1 (% predicted) can be used to gauge disease severity.
  • Trap:
    • significant air trapping can cause reduction in FVC.
    • Plethysmographic studies useful to differentiate between gas trapping and mixed obstructive-restrictive lung diseases.
  • Near-threshold results warrant a repeat test for confirmation.
• CXR:
  • may show hyperinflation, flattened diaphragm, bullae.
  • ABG: useful during acute exacerbations if concerned about respiratory acidosis; also require for home O2 therapy (if <55mmHg, or <60mmHg with RVF).
• 6 min walk test:
  • functional capacity
  • Can be used to monitor treatment.
• If concerns about cor pulmonale, TTE and DLCO useful. 
• Investigations for comorbidities:
  • eg ischaemic heart disease (cigarette common risk factor for both conditions).

Pharmacological Management

Step 1: Initial Management with Short-Acting Bronchodilators

• Purpose: Relief of acute breathlessness and occasional symptoms.
• Medications:
  • Short-Acting Beta2-Agonists (SABA): Examples include salbutamol or terbutaline.
  • Short-Acting Muscarinic Antagonists (SAMA): Example includes ipratropium bromide.
• Usage: As-needed basis for short-term symptom control.

Step 2: Persistent Symptoms – Long-Acting Bronchodilator

• Indication: For patients experiencing persistent troublesome dyspnea despite using SABA/SAMA.
• Medications:
  • Long-Acting Beta2-Agonists (LABA): Examples include formoterol, salmeterol, or indacaterol.
  • Long-Acting Muscarinic Antagonists (LAMA): Examples include tiotropium, glycopyrronium, or umeclidinium.
  • Note: Do not combine a LAMA with a SAMA. Combining a LAMA with a SABA is permissible.
• Usage: Regular daily administration for maintenance therapy.

Step 3: Dual Long-Acting Bronchodilator Therapy

• Indication: Patients who continue to experience symptoms after using either a LABA or LAMA alone.
• Medications: Combination of LABA + LAMA.
  • Examples include indacaterol/glycopyrronium, vilanterol/umeclidinium, or formoterol/aclidinium.
• Action: Assess adherence and correct inhaler technique before advancing therapy.

Step 4: Addition of Inhaled Corticosteroids (ICS)

• Indication: For patients who have:
  1. A history of severe exacerbations (requiring hospitalization) or at least two moderate exacerbations in the past year.
  2. Severe symptoms persisting despite optimal LABA + LAMA therapy.
• Medications:
  • Examples include budesonide/formoterol, fluticasone/salmeterol, or fluticasone/vilanterol.
  • Note: Use with caution due to the risk of pneumonia, particularly in older adults. Should be reserved for patients with frequent exacerbations.
• Action: Regularly review the necessity of ICS to minimize long-term side effects.

Step 5: Macrolide Antibiotics (for Selected Patients)

• Indication: For severe COPD with frequent exacerbations despite maximal therapy.
• Medications:
  • Low-dose macrolides (e.g., azithromycin 250 mg 3 times per week).
  • Consider only after evaluation by a respiratory specialist.
• Risks: Cardiac toxicity, ototoxicity, and antibiotic resistance.
• Monitoring: Review after 6 months and post-exacerbation. Regular ECGs may be needed to monitor for QT prolongation.

Inhaler and Spacer Technique

1. Clinician Preparation:
   • Ensure all healthcare providers have a solid understanding of the correct inhaler techniques.
   • Misuse is common; up to 90% of patients may not use inhalers correctly, leading to suboptimal drug delivery.
2. Education and Demonstration:
   • Demonstrate proper inhaler use, including:
     • Breath-Actuated Inhalers: Ensure slow, steady inhalation.
     • Pressurized Metered-Dose Inhalers (pMDIs): Use a spacer device for optimal drug delivery.
     • Dry Powder Inhalers (DPIs): Ensure fast and deep inhalation.
   • Educate on cleaning, maintenance, and storage.
3. Regular Technique Checks:
   • Evaluate technique:
     • Before escalating treatment.
     • After any change in therapy.
     • Following an exacerbation.
   • Consider a
     • Home Medicines Review (HMR) or
     • Residential Medication Management Review (RMMR) to assess adherence and technique.
4. Simplification Strategies:
   • Use familiar devices or combination inhalers when possible.
   • Educate on the environmental impact of inhalers and recommend greener alternatives if suitable.

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Acute Exacerbations

Recognizing Exacerbations:

• Key Symptoms:
  • Increased breathlessness beyond normal day-to-day variation.
  • Reduced exercise tolerance and increased fatigue.
  • Tachypnea, increased cough, and sputum production (especially if purulent).
  • Fever may indicate an infectious trigger.
• Differential Diagnoses: Consider heart failure, pulmonary embolism, pneumonia, and sepsis.

General Treatment Approach:

• An exacerbation of COPD can involve increased airflow limitation, excess sputum production, airway inflammation, infection, hypoxia, hypercarbia, and acidosis.
• Treatment is directed at addressing each of these problems.

Confirm Exacerbation and Categorize Severity:

• Medical History & Examination: Essential to gather a detailed history and conduct a thorough physical examination.
• Spirometry: Used to confirm COPD diagnosis, especially useful prior to discharge.
• Oxygenation Assessment:
  • Pulse Oximetry: Routine measurement alongside other vital signs.
  • Arterial Blood Gases (ABGs): Indicated if:
    • FEV1 < 1.0 L or < 40% predicted.
    • SpO2 < 92% with adequate perfusion.
    • Falling SpO2 and increased FiO2 needed.
    • Risk of hypercapnia.

Spirometry:

• Purpose: Confirms diagnosis of COPD by demonstrating airflow limitation.
• Timing: Can be performed prior to discharge to verify diagnosis.

Assess Oxygenation:

• Pulse Oximetry: Should be recorded routinely.
• Arterial Blood Gases: Crucial for:
  • FEV1 < 1.0 L or < 40% predicted.
  • SpO2 < 92%.
  • Declining SpO2 with increased FiO2.
  • Risk of hypercapnia.
  • Hypoxaemic respiratory failure: PaO2 < 60 mmHg.
  • Ventilatory failure: PaCO2 > 45 mmHg.
  • Respiratory acidosis: Indicates need for assisted ventilation.

Venous Blood Gases (VBG):

• Study by McKeever et al (2016):
  • VBG pH ≤7.34 had high sensitivity (88.9%) and specificity (95.6%) for ABG pH ≤7.35.
  • VBGs suggested for initial assessment, ABGs for further assessment if VBG pH ≤7.34.
  • Caution due to lesser precision with VBGs.

Chest X-ray and ECG:

• Purpose: Identify alternative diagnoses and complications (e.g., pulmonary oedema, pneumothorax, pneumonia, empyema, arrhythmias, myocardial ischaemia).

Clinical Prediction Score – BAP-65:

• Parameters: Age, basal urea nitrogen, acute mental status change, pulse.
• Utility: Predicts in-hospital mortality.
  • Mortality increases with higher score classification (from 1 to 5).
  • Highest class mortality: 14.1% to >25%.

CXR and Pneumonia:

• Study (2012): 920 patients with COPD exacerbation.
  • Higher mortality with CXR-confirmed pneumonia (20.1% vs. 5.8%, p<0.001).
• Dyspnoea Severity: Associated with in-hospital mortality and early readmission.

Medications

1. Bronchodilators:

• Inhaled Beta-Agonists:
  • Salbutamol: 400–800 mcg
  • Terbutaline: 500–1000 mcg
• Antimuscarinic Agents:
  • Ipratropium: 80 mcg
• Administration Methods:
  • Pressurised metered dose inhaler (pMDI) with spacer
  • Jet nebulisation:
    • Salbutamol: 2.5–5 mg
    • Terbutaline: 5 mg
    • Ipratropium: 500 mcg
• Dosing Interval: Titrate based on response, ranging from hourly to six-hourly.
• Delivery Method Efficacy: No significant difference between nebulisers and pMDI with spacer regarding FEV1 at one hour and serious adverse events (van Geffen 2016) [evidence level I].

3. Corticosteroids:

• Oral Corticosteroids: Hastens resolution and reduces relapse likelihood.
• Typical Regimen: Prednisolone 40–50 mg daily for up to two weeks.
• Longer Courses: Do not add benefit and increase risk of side effects.
• Recommended Regimen as per COPDx:
  • 5-day course of oral prednisolone at 30mg to 50mg.
  • Tapering may be necessary for patients on corticosteroids for longer than 14 days.
  • Long-term corticosteroid therapy (>7.5 mg prednisolone daily for more than 6 months) increases the risk of osteoporosis.
  • Prevention and treatment of corticosteroid-induced osteoporosis should be considered.
  • Longer courses of prednisolone may increase mortality and pneumonia risk (Sivapalan 2019).

4. Antibiotics:

• Indication: Clinical Features of Infection: Increased sputum volume, change in sputum color, and/or fever warrant antibiotic therapy (evidence level II, strong recommendation).
• Common Pathogens:
  • Haemophilus influenzae
  • Streptococcus pneumoniae
  • Moraxella catarrhalis
• First-Line Antibiotics:
  • Amoxicillin 500 mg three times daily.
  • Doxycycline 100 mg daily.
  • Avoid Broad-Spectrum Antibiotics unless specific indications exist; they do not offer superior outcomes and may increase harm.
  • Intravenous Antibiotics: Reserved for patients unable to take oral medications.

5. Controlled Oxygen Therapy:

• Indication: For patients with hypoxia, aiming to improve oxygen saturation to 88-92%.
• Delivery Methods:
  • Nasal prongs: 0.5–2.0 L/min
  • Venturi mask: 24% or 28%
• Caution: Minimize excessive oxygen to avoid worsening hypercapnia.

6. Ventilatory Assistance:

• Indication: For increasing hypercapnia and acidosis.
• Preferred Method: Non-invasive ventilation (NIV) via mask.

Summary

• Antibiotics are beneficial in COPD exacerbations with signs of bacterial infection.
• Diagnostic indicators like sputum purulence, CRP, and procalcitonin levels can guide antibiotic use.
• Short courses of antibiotics are generally as effective as longer courses and have fewer adverse effects.
• Combination therapy with corticosteroids and antibiotics is effective, particularly in the early stages of treatment.

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Chronic Management

1. Smoking Cessation

• Cease Smoking:
  • Smoking cessation is the most critical intervention for all COPD patients.
  • Use a combination of behavioral support and pharmacotherapy as recommended by Australian guidelines:
    • Nicotine Replacement Therapy (NRT): patches, gum, lozenges, sprays.
    • Prescription Medications: Varenicline (Champix) or bupropion (Zyban).
  • Access local Quitline services and utilize the ‘Ask, Advise, Help’ approach for smoking cessation.

2. Inhaler Therapy – Regularly assess and educate on correct inhaler technique and spacer use.

3. Vaccination Recommendations

• Annual Influenza Vaccine: Recommended for all COPD patients to prevent flu-related complications.
• Pneumococcal Vaccine:
  • 13-valent Pneumococcal Conjugate Vaccine (Prevenar 13) and 23-valent Pneumococcal Polysaccharide Vaccine (Pneumovax 23) based on age and risk factors.
• COVID-19 Vaccine: Ensure COPD patients are up to date with COVID-19 vaccinations.

4. Pulmonary Rehabilitation

• Multidisciplinary Pulmonary Rehabilitation Programs:
  • Strongly recommended for all symptomatic COPD patients.
  • Includes exercise training, education, and behavior change support.
  • Refer to local programs using resources like the Lung Foundation Australia’s Pulmonary Rehabilitation Finder.
  • Benefits include reduced breathlessness, improved quality of life, and fewer hospitalizations.

5. Long-Term Oxygen Therapy (LTOT)

• Indications for LTOT:
  • Resting PaO₂ < 55 mmHg, or 55–60 mmHg with evidence of right heart failure or polycythemia.
  • Must be non-smoker due to fire hazard.
  • Requires specialist referral for assessment and initiation.
• Duration: Minimum of 15 hours/day to improve survival in hypoxaemic patients.
• Intermittent Oxygen:
  • Consider for use during exertion if oxygen saturation falls below 88%.

6. Fitness to Fly

• Pre-Flight Assessment:
  • Assess the need for supplemental oxygen during air travel if SpO₂ < 92% at rest or during exertion.
  • Refer to the Lung Foundation Australia’s resources on fitness to fly for further guidelines.

7. Management of Comorbidities

• Cardiovascular Disease: Screen for and manage comorbidities like hypertension, ischemic heart disease, and heart failure.
• Diabetes: Monitor blood glucose regularly in COPD patients with comorbid diabetes.
• Osteoporosis: Consider bone density testing for patients on long-term corticosteroids.
• Mental Health:
  • Regularly assess for anxiety and depression. Refer to mental health professionals if needed.
  • Address social isolation with referrals to community programs or support groups.

8. Surgical and Advanced Interventions

• Lung Volume Reduction Surgery (LVRS):
  • Consider for select patients with upper-lobe predominant emphysema and low exercise capacity after rehabilitation.
• Bronchoscopic Interventions:
  • Endobronchial Valves for lung volume reduction in emphysema patients not suitable for surgery.
  • Requires specialist evaluation in tertiary centers.
• Lung Transplant:
  • Consider for end-stage COPD patients under 65 with severe disease not responsive to maximal medical therapy.

9. Multidisciplinary Team (MDT) Involvement

• (multidisciplinary team approach; see http://lungfoundation.com.au/wp-content/uploads/2014/02/Pulmonary-Rehab-Fact-Sheet-Feb-2015.pdf)
• Collaborate with a multidisciplinary team including:
  • Respiratory specialists
  • general practitioners
  • pharmacists
  • physiotherapists
  • dietitians
  • social workers
  • mental health professionals.
  • Ensure coordination between hospital and primary care for seamless follow-up post-hospitalization.

10. Regular Monitoring and Self-Management Education

• Patient Education:
  • Educate on COPD self-management, including recognizing symptoms of exacerbation and proper use of inhalers.
  • Encourage adherence to medications and inhaler technique.
  • Utilize tools like the COPD Action Plan to guide early management of exacerbations.
• Exacerbation Management:
  • Create a personalized action plan, including when to seek medical help.
  • Teach patients breathing techniques, energy conservation methods, and airway clearance techniques.

11. Telehealth and Remote Support

• Telehealth:
  • Utilize telehealth for regular follow-up, particularly for patients in rural and remote areas.
  • Leverage online education tools and apps endorsed by Lung Foundation Australia for self-management support.

(Controversial)

• Long term prophylactic antibiotics (usually macrolide): shown to decrease exacerbations, but promotes resistance. Specialist initiated only.
• Theophylline: reduced exacerbations, but multiple side effects.

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Symptom Support and Palliative Care for COPD

Early Palliative Care Consideration:

• Start a palliative approach from diagnosis, especially for those with significant comorbidities.
• Address the misconception that palliative care is only for end-of-life patients

Factors Indicating Palliative Care Need:

• Poor respiratory function (e.g., FEV1 < 25% predicted, hypoxaemia).
• Need for advanced respiratory therapy (e.g., home oxygen).
• Severe comorbidities (e.g., heart failure).
• Unintended weight loss or cachexia.
• Functional decline or increasing dependence.
• Difficult physical or emotional symptoms.
• Disease progression or frequent hospitalisations.

Holistic Approach:

• Address all aspects of patient well-being.
• Offer referrals to specialists (e.g., physiotherapists, psychologists) based on patient needs.

Advance Care Planning:

• Discuss and establish an advance care plan if not already done.
• Document and upload to the patient’s My Health Record if applicable.

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Cultural Safety and Equity for Aboriginal and Torres Strait Islander People in COPD Care

from: https://www.safetyandquality.gov.au/standards/clinical-care-standards/chronic-obstructive-pulmonary-disease-clinical-care-standard/information-clinicians

nts:

Domain	Key Strategies
1. Culturally Safe Communication and Care	– Build trust through long-term engagement – Encourage self-identification as ATSI – Use clear, jargon-free language – Engage interpreters when needed – Be mindful of body language and non-verbal cues
2. Collaborative Approach to Care	– Involve patients in shared decision-making – Use culturally appropriate visual aids – Include family, carers, and Elders in consultations – Recognise and accommodate extended family structures
3. Inclusion of ATSI Health Professionals	– Integrate Aboriginal Health Workers into care team – Involve in education, discharge, and follow-up – Provide staff cultural safety training to address bias
4. Flexibility in Service Delivery	– Offer flexible appointments and outreach services – Consider home visits and telehealth – Partner with Aboriginal Medical Services (AMS)
5. Tailored COPD Management	– Respect traditional beliefs and healing practices – Use holistic language (physical, emotional, spiritual) – Provide culturally relevant diet and activity advice
6. Social and Environmental Considerations	– Assess housing, crowding, dust/smoke/mould exposure – Address barriers to medication access in remote areas – Provide education on reducing traditional and second-hand smoke exposure – Address social determinants (e.g. income, education, housing)
7. Preventative Measures and Early Diagnosis	– Implement early COPD screening in high-risk groups – Promote influenza and pneumococcal vaccination – Discuss smoking cessation respectfully – Use culturally adapted Quitline and support programs
8. End-of-Life Cultural Practices	– Initiate culturally sensitive palliative care discussions – Involve family and community in end-of-life planning – Support traditional and spiritual needs – Provide mental health and grief support
9. Quality Monitoring and Improvement	– Record ATSI status in health records – Audit services for cultural safety – Engage ATSI community in service and policy development
10. Community Empowerment	– Deliver community COPD education – Support ATSI-led health initiatives – Encourage culturally congruent self-management strategies

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COPDX approach

• C – confirm diagnosis and grade severity
  • Suspect the diagnosis with a suggestive history of chronic cough, sputum production, exertional dyspnoea, wheeze and frequent exacerbations
  • Confirm with Spirometry demonstrating FEV1/FVC<70% obstructive pattern.
  • Classify the severity into mild, moderate and severe by symptom severity, functional impairment, frequency of exacerbation and spirometry values.
• O – optimise function
  • Education
    • Involves information on
      • disease management
      • its progression
      • treatment options
      • self-management strategies
      • proper inhaler technique
      • recognition of exacerbations
  • Lifestyle measures
    • Exercise Training: Improves exercise tolerance, reduces dyspnea, and enhances quality of life. Recommended activities include aerobic exercises (walking, cycling) and resistance training.
  • Nutritional Support
    • Malnutrition: High-calorie, high-protein diets to prevent muscle wasting.
    • Obesity: Weight management programs to reduce the work of breathing
  • Medication measures
    • Step-wise management as per guidelines with SABA, SAMA, LABA, LAMA and ICS
    • Long-term oxygen therapy for patients with chronic respiratory failure (PaO₂ ≤ 55 mmHg or SaO₂ ≤ 88%).
    • Ambulatory oxygen therapy for those with significant desaturation during exercis
    • Chest Physiotherapy
      • Includes postural drainage, chest percussion, and vibration.
• P – prevent deterioration
  • Pulmonary rehabilitation
    • Refer all COPD patients, including those hospitalized for exacerbations, to pulmonary rehabilitation.
    • Ensure rehabilitation starts within four weeks after hospital discharge to prevent readmission and improve outcomes.
    • If hospital-based rehab is unavailable, consider telerehabilitation, local exercise programs, or specialists in pulmonary care.
      • Exercise
      • education
      • breathlessness management
      • medication guidance
      • nutrition
      • psychological support
  • Immunisation (influenza, pneumococcal)
    • Influenza Vaccine: Annually to reduce the risk of respiratory infections.
    • Pneumococcal Vaccine: Both PPSV23 and PCV13 are recommended to prevent pneumococcal disease.
  • Smoking cessation
    • Behavioural counselling.
    • Pharmacotherapy (e.g., nicotine replacement therapy, varenicline, bupropion).
    • Support groups and smoking cessation programs.
  • Avoidance of Environmental Pollutants
    • Minimizing exposure to indoor and outdoor air pollutants, dust, and occupational irritants.
    • Use of air purifiers and proper ventilation at home.
  • Psychosocial Support
    • Counseling or therapy for patients experiencing anxiety, depression, or social isolation.
    • Support groups for patients and caregivers.
• D – develop a management plan
  • GP management plan
  • COPD action plan
  • Advanced care directive
• X – manage acute exacerbations
  • Oxygen, NIV 
  • Bronchodilator
  • Steroids
  • Antibiotics