Zusammenfassung der Ressource
COPD
- WHAT IS IT?
- COPD IS A TERM USED FOR A GROUP OF LUNG/AIRWAY DISEASES
THAT ARE NOT FULLY REVERSIBLE
- OBSTRUCTED DUE TO CHRONIC BRONCHITIS,
EMPHYSEMA OR BOTH
- ACCOUNTS FOR LARGE RATES OF MORBIDITY AND
MORTALITY: EXPECTED TO BE LEADING CAUSE OF DEALTH
BY 2030
- SYMPTOMS
- DYSPNOEA
- CHRONIC
COUGH
- REGULAR SPUTUM
PRODUCTION
- RISK FACTORS
- SMOKING
- HAS MANY ADVERSE EFFECTS: PRODUCTION OF DESTRUCTIVE PROTEOLYTIC ENZYMES RELEASED FROM
INFLAMMATORY CELLS IN THE LUNGS, OXIDATIVE STRESS AND THE INACTIVATION OF ALPHA-1 ANTI-TRYPSIN
- ESTIMATED THAT 15-20% SMOKERS DEVELOP COPD
- SERINE PROTEASE INHIBITOR THAT BALANCES
THE ACTION OF NEUTROPHIL-PROTEASE
ENZYMES IN THE LUNGS
- CHEMICALS
- ORGANIC AND INORGANIC DUSTS, CHEMICALS AND FUMES
- EXPOSURE CAN CAUSE COPD DEPENDING ON LUNG
IMPAIRMENT, INTENSITY AND DURATION OF EXPOSURE
- ACCOUNTS FOR 10-20% OF COPD CASES
- INDOOR AIR
POLLUTION
- OPEN FIRES OF WOOD, ANIMAL DUNG, COAL AND AGRICULTURAL RESIDUES CAN LEAD TO HIGH LEVELS OF
INDOOR AIR POLLUTION ESP IN POORLY ENTILATED AREAS
- ACCOUNTS FOR 10-20% OF COPD CASES
- GENETICS
- GENE THAT IS RECESSIVE AND HEREDITARY: DEFICIENCY OF THE ALPHA 1 ANTI-TRYPSIN GENE
- PATHOPHYSIOLOGY
- EMPHYSEMA
- PROGRESSIVE AND DESTRUCTIVE ENLARGEMENT OF THE BRONCHIOLES AND ALVEOLAR
SACS
- LEADS TO LOSS OF SURFACE AREA FOR GAS EXCHANGE & LOSS OF ELASTIC RECOIL FOR
EXPIRATION- CAN RESULT IN AIRWAY COLLAPSE ESP DURING EXPIRATION & HYPERVENTILATION
- PANACINAR
- LESS COMMON & OCCURS AS A RESULT OF AN ALPHA-1 ANTI-TRYPSIN GENE
DEFICIENCY
- STUDIES SHOW THIS TYPE IS LESS COMMON IN FEMALES AS OESTROGEN
INCREASES THE EXPRESSION OF PROTEASE INHIBITORS INCLUDING ALPHA-1
TRYPSIN
- CENTRILOBULAR
- DESTRUCTION OF BRONCHIOLES,
ALVEOLAR DUCTS AND ALVEOLI,
COMMON IN
SMOKERS/WORKING IN
POLLUTED AREAS
- CHRONIC BRONCHITIS
- PRESENCE OF A COUGH AND SPUTUM PRODUCTION FOR ATLEAST 3 MONTHS IN 2 CONSECUTIVE YEARS
- AN INFLAMMATORY RESPONSE TO INHALED IRRITANTS (USUALLY DUE TO CIGARETTE SMOKING)
- RESULTS IN THE ACCUMULATION AND HYPER-SECRETION OF MUCUS-SECRETING GLANDS IN THE BRONCHIAL TREE
- CAN INCREASE RISK OF BACKTERIAL OR VIRAL INFECTIONS AND THUS WORSEN SYMPTOMS
- OTHER CHANGES
- IMPAIRMENT OF GAS
EXHANGE RESUKTING IN
HYPOXAEMIA AND
HYPERCAPNIA, PULMONARY
HYPERTENSION AND
VASCULAR REMODELLING
- VR INCREASES RIGHT VENTRICULAR PRESSURE AND CAN LEAD TO VENTRICULAR HEART FAILURE KNOWN AS COR PULMONALE
- PHARMACOLOGY
- BRONCHODILATORS
- BETA-2-AGONISTS
- SHORT ACTING (SABA)
- SALBUTAMOL & TERBUTALINE
- ORAL,
INHALATION
- TABS / CAPS, MDI / DPI
- LONG ACTING (LABA)
- SALMETEROL & FORMOTEROL
- INHALATION
ONLY
- MDI / DPI
- STIMULATE BETA-2 ADRENORECEPTORS IN BRONCHIAL SMOOTH
MUSCLE, INCREASE cAMP LEVELS AND PKA ACTIVITY, CAUSING
BRONCHODILATION
- CAN ALSO INHIBIT MEDIATOR RELEASE FROM MAST CELLS AND
TNF-ALPHA RELEASE FROM THE MONOCYTES AND INCREASES
MUCUS CLEARANCE FROM CILIATED CELLS
- CORTICOSTEROID
THERAPY
- INHALED CORTICOSTEROIDS
- BECLOMETASONE
- INHALATION
- MDI / DPI
- HIGH POTENCY INHALED CORTICOSTEROIDS
- BUDESOMIDE
- INHALATION
- MDI /
DPI
- LIPOPHILIC THEREFORE CAN ENTER CELL EASILY, BIND TO INTRACELLULAR
RECEPTORS WHICH DIMERISE AND MIGRATE TO THE NUCLEUS, COMPLEX AFFECTS
TRANSCRIPTION OF mRNA OF SPECIFIC PROTEINS.
- INCREASE SYNTHESIS OF ANTI-INFLAMMATORY PROTEINS VIA
TRANSACTIVATION. REDUCE THE SYNTHESIS OF
PRE-INFLAMMATORY PROTEINS VIA TRANSREPRESSION
- INCREASE SYNTHESIS OF ANNEXIN-1 = A NATURAL
INHIBITOR OF PHOSPHOLIPIDASE 2
- THEREFORE LESS ARACHADONIC ACID
AVAILABLE TO BE METABOLISED BY COX-1 LOX
ENXYMES AND HENCE LESS PGs AND LTs
SYNTHESISED
- THEY ALSO DECREASE THE SYNTHESIS OF
PRO-INFLAMMATORY PROTEINS (COX-2 & NOS-2)
AND INHIBIT NUCLEAR FACTOR K (INVOLVED WITH
THE INFLAMMATORY CYTOKINE PRODUCTION)
- MUSURINIC
ANTAGONISTS
- SHORT ACTING (SAMA)
- IPRATROPIUM
- INHALATION
- DPI / MDI /
NEB
- BLOCK ACH RELEASE FROM
THE VAGUS NERVE
- LONG ACTING (LAMA)
- TIOTROPIUM
- INHALATION
- DPI /
pMDI
- BLOCK M3 RECEPTORS ON SMOOTH MUSCLE THUS ANTAGONISING THE
EFFECTS OF ACH ON THE SNOOTH MUSCLE, REDUCING INTRACELLULAR CONC
OF cGMP AND CAUSING BRONCHIAL SMOOTH MUCLE RELAXATION AND
BRONCHODILATION
- METHYLXANTHINES
- THEOPHYLLINE, AMINOPHYLLINE (PRODRUG)
- ORAL
- MR TABS / CAPS
- NON-SELECTIVE PHOSPHODIESTERASE INHIBITOR AND INCREASES cAMP OR cGMP
- RESULTS IN RELAXATION OF THE AIRWAY SMOOTH MUSCLE
- HIGHER DOSES OF THIS DRUG EXHIBITS BRONCHODILATORY EFFECTS & INCREASE
DIAPHRAGMATIC STRENGTH & AID MUCUS CLEARANCE BY CILIATED CELLS
- PHARMACEUTICS
- pMDIs
- PORTABLE,
CHEAP,
DISPOSABLE,
REPRODUCIBLE
DOSE
- COLD FREON EFFECT,
REQUIRES INHALER
TECHNIQUE,
PROPELLANT (CFCs),
HIGH ORAL DEPOSITION,
MAX DOSE 5mg
- USE OF SPACER:
OVERCOME
INHALATION/ACTUATION
COORDINATION ISSUES &
COLD FREON EFFECT
- DPIs
- COMPACT, PORTABLE,
UNOBTRUSIVE,
PROPELLANT FREE,
BREATH ACTUATED,
NO TECHNIQUE
REQUIRED, DELIVER
LARGER DOSES
COMPARED TO MDI,
NO COLD FREON
EFFECT
- DEPENDS ON PT INSPIRATION FLOW
RATE, HUMIDITY MAY CAUSE
PARTICLES TO AGGREGATE AND
CAPSULES TO SOFTEN, DOSE IS
LOST IF PT EXPIRES INTO DPI,
LACTOSE
- LIMITING FOR COPD PT
- NEBULISER
- NON-SPECIFIC
INHALATION
TECHNIQUE, DELIVERS
LARGE DOSES, SIMPLE
FORMULATION
- INHALATION IS TIME
CONSUMING, BULKY
DEVICE, CONTENTS
EASILY
CONTAMINATED,
EXPENSIVE, POOR
DELIVERY EFFICACY &
VARYING
PERFORMANCE
- PATIENT AND CLINICAL MONITORING
- SPIROMETRY
- MRC
DYSPOEA
SCALE
- GRADE 1
- GRADE 2
- GRADE 3
- GRADE 4
- GRADE 5
- TOO BREATHLESS TO LEAVE THE HOUSE/ BREATHLESS WHEN DRESSING/ UNDRESSING
- STOPS FOR BREATH AFTER WALKING ~100M OF AFTER A FEW MINS ON LEVEL GROUND
- WALKS SLOWER THAN CONTEMPORARIES ON LEVEL GROUND B/C OF
BRETHLESSNESS/ HAS TO STOP FOR BREATH WHEN WALKING AT OWN PACE
- SOB WHEN HURRYING OR WALKING UP A HILL
- NOT TROUBLED BY BREATHLESSNESS EXCEPT ON STRENUOUS EXERCISE
- PERFORMED
AT TIME OF
DIAGNOSIS
- TO RECONSIDER
DIAGNOSIS IF PTS
SHOW EXCEPTIONAL
RESPONSE TO
TREATMENT
- MEASURE
POST-BRONCHODILATOR
SPIROMETRY
TO
CONFIRM
COPD
DSIAGNOSIS
- CONSIDER ALTERNATIVE DIAGNOSIS OR INVESTIGATIONS IN:
- OLDER PEOPLE
WITHOUT TYPICAL
SYMPTOMS OF
COPD WHERE
FEV1/FVC RATIO:
>0.7
- YOUNGER PEOPLE
WITH SYMPTOMS
OF COPD WHERE
FEV1/FVC RATIO:
=>0.7
- FEV1 VALUE
(PREDICTED)
- >80% = STAGE 1
(MILD)
- COPD SHOULD ONLY
BE DIAGNOSED IF
RESP SYMPTOMS
PRESENT
- 50 - 79% = STAGE 2
(MODERATE)
- POST-BROCHODILATOR FEV1 / FVC = <0.7
- 30 - 49% = STAGE 3
(SEVERE)
- <30% = STAGE 4
(VERY SEVERE)
- AIRFLOW OBSTRUCTION DEFINED AS REDUCED FEV1/FVC RATIO (<0.7)
- SPIROMETRY SHOULD BE PERFORMED IN PTS >35, CURRENT OR EX-SMOKERS, AND HAVE A CHRONIC COUGH
- SPIROMETRY SHOULD BE CONSIDERED IN PTS WITH CHRONIC BRONCHITIS
- A SIG. NO. OF THESE
WILL GO ON TO
DEVELOP AIRFLOW
LIMITATION
- FURTHER
INVESTIGATIONS
- AT THE TIME OF THEIR INITIAL DIAGNOSIS, PRECAUTIONS MUST BE TAKEN
- CHEST RADIOGRAPH
- TO EXCLUDE OTHER PATHOLOGIES
- FULL BLOOD COUNT
- TO IDENTIFY ANAEMIA OR POLYCYTHAEMIA
- BODY MASS INDEX (BMI)
- ADDITIONAL INVESTIGATIONS SHOULD BE PERFORMED TO AID MANAGEMENT IN SOME CASES
- SERIAL DOMICILLIARY PEAK
FLOW MEASUREMENTS
- TO EXCLUDE ASTHMA IF DIAGNOSTIC DOUBT REMAINS
- CT SCAN OF
THORAX
- TO INVESTIGATE SYMPTOMS THAT SEEM DISPROPORTIONATE TO SPIROMETRIC IMPAIRMENT,
TO INVESTIGATE ABNORMALITIES SEEN ON CHEST RADIOGRAPH, TO ASSESS SUITABILITY FOR
SURGERY
- ALPHA-1
ANTITRYPSIN
- IF EARLY ONSET, MINIMAL SMOKING OR FAMILY HISTORY
- TRANSFER FACTOR FOR
CO (TLCO)
- TO INVESTIGATE SYMPTOMS THAT SEEM
DISPROPORTIONATE TO THE SPIROMETRIC IMPAIRMENT
- ECG
- TO ASSESS CARDIAC STATE IF FEATURES OF COR PULMONALE
- SPUTUM
CULTURE
- TO IDENTIFY ORGANISMS IF SPUTUM IS PERSISTENTLY PRESENT AND PURULENT
- PULSE
OXIMETRY
- TO ASSESS NEED FOR OXYGEN THERAPY, IF CYANOSIS OR COR
PULMONALE PRESENT OR IF FEV1 <50% PREDICTED
- ASSESSMENT OF
SEVERITY AND
PROGNOSTIC
FACTORS
- COPD IS HETEROGENEOUS SO
NO SINGLY MEASUREMENT
CAN GIVE ,ADEQUATE
ASSESSMENT OF SEVERITY,
SEVERITY IS IMPORTANT TO
MEASURE AS IT GIVES A
PROGNOSTIC OUTLOOK
- FEV1 IS A POOR
REFLECTION OF
DISABILITY,
- FEV, BMI, TLCO, MRC
SCALE, paO2 AND
COR PULMONAE
MUST BE ASSESSED
- CLINICAL
FEATURE
- SMOKER/EX-SMOKER
- NEARLY ALL
- POSSIBLY
- COPD
- ASTHMA
- SYMPTOMS <35 YEARS
- RARE
- OFTEN
- CHRONIC PRODUCTIVE COUGH
- COMMON
- UNCOMMON
- BREATHLESSNESS
- VARIABLE
- PERSISTENT &
PROGRESSIVE
- NIGHT TIME WAKING W/
BREATHLESSNESS / WHEEZING
- COMMON
- UNCOMMON
- SIGNIFICANT DIURNAL / DAY-TO-DAY
VARIABILITY OF SYMPTOMS
- COMMON
- UNCOMMON
- MANAGEMENT
- SMOKING CESSATION
- UP TO DATE SMOKING HISTORY
INCLUDING PACK YEARS SMOKED
SHOULD BE DOCUMENTED FOR
EVERYONE WITH COPD
- ALL COPD PTS, REGARDLESS OF AGE,
SHOULD BE ENCOURAGED TO STOP
SMOKING, AND OFFERED HELP AT
EVERY OPPORTUNITY TO DO SO
- UNLESS CONTRAINDICATED,
OFFER NRT, VARENICLINE OR
BUPROPION WITH APPROPRIATE
SUPPORT PROGRAM TO OPTIMISE
RESULTS
- TREATMENT
- INFECTION CAN COMPLICATE COPD AND CAN BE PREVENTED BY VACCINATION
- PNEUMOCOCCAL POLYSACCHARIDE CONJUGATE (ABSORBED) VACCINE & INFLUENZA VACCINE
- PERSISTENT DYPNOEA /
EXACERBATIONS DESPITE
SABA/SAMA USE
- FEV1 ≥ 50% PREDICTED: OFFER OD LAMA (INSTEAD OF QDS SAMA) OR LABA
- FEV1 < 50% PREDICTED: EITHER ICS WITH LABA IN COMBINATION INHALER, OR LAMA
- FEV1 ≥ 50% PTS WITH
PERSISTING DYSPNOEA /
EXACERBATIONS DESPITE LABA
MAINTENANCE THERAPY
- CONSIDER LAMA + ICS IN COMBINATION INHALER
- CONSIDER LAMA IN ADDITION TO LABA WHERE ICS IS NOT TOLERATED OR DECLINED
- INITIAL COURSE FOR
ALLEVIATION OF DYSPNOEA AND
EXERCISE LIMITATION
- SABA OR SAMA INHALERS TO BE PRESCRIBED
- PTS WITH PERSISTENT DYSPNOEA AND
EXACERBATIONS DESPITE LABA + ICS
COMBINATION MAINTENANCE THERAPY
- OFFER LAMA IN ADDITION, IRRESPECTIVE OF FEV1
- VICE VERSA
- MAINTENANCE USE OF
ORAL CS THERAPY IS
NOT NORMALLY
RECOMMENDED
- SO,ME PTS WITH ADVANCED
COPD MAY REQUIRE
MAINTENANCE ORAL CS WHEN
THEY CANNOT BE WITHDRAWN
FOLLOWING AN EXACERBATION
- IN SUCH CASES,
KEEP DOSE AS LOW
AS POSSIBLE
- PTS TREATED WITH
LONG-TERM ORAL CS
SHOULD BE MONITORED FOR
DEVELOPMENT OF
OSTEOPEROSIS & GIVEN
APPROPRIATE PROPHYLAXIS
- PTS OVER 65 SHOULD BE
GIVEN PROPHYLAXIS
WITHOUT MONITORING
- THEOPHYLLINE
- SHOULD ONLY BE GIVEN AFTER
TRIAL OF SHORT-ACTING AND
LONG-ACTING
BRONCHODILATORS, OR IN PTS
UNABLE TO USE INHALERS
- REQUIRES (TDM)
MONITORING DUE TO
INTERACTIONS/TOXICITY
- EXTRA CAUTION WITH ELDERLY
DUE TO ALTERED
PHARMACOKINETICS & LIKELY
CO-MORBIDITIES/POLYPHARMACY
- EFFECTIVENESS TO BE
ASSESSED BY SYMPTOM
IMPROVEMENT, DAILY
ACTIVITY, EXERCISE CAPACITY
& LUNG FUNCTION
- DOSE TO BE REDUCED AT
TIME OF EXACERBATION IF
MACROLIDE OR
FLUROQUINOLONE IS
PRESCRIBED
- MUCOLYTIC THERAPY: ONLY TO BE USED WHEN
PTS HAVE A CHRONIC COUGH WITH SPUTUM
PRODUCTION & CONTINUED IF SYMPTOMATIC
RELIEF IS OBSERVED UPON USE
- KEEP IT
SIMPLE
- SMOKING
- INHALER TECHNIQUE
- MONITORING
- PREVENT DISEASE PROGRESSION
- SYMPTOM CONTROL
- MEDICINES REVIEW
- COPD PATIENTS
ARE ELIGIBLE
FOR
TARGETTEDMUR
AND NMS
- PHARMACOTHERAPY
- LIFESTYLE
- AEROBIC EXERCISE TOLERANCE
- DIET
- BREATHING EXERCISES
- PSYCHOLOGICAL SUPPORT
- SHARED DECISION MAKING
- PATIENT BELIEFS & EXPERIENCES
- EDUCATION
- PURPOSE OF DRUG
- S/E OF INHALED CS
- SIGNS OF TOXICITY
- COUNSELLING
- SIGNS OF TOXICITY
- ENCOURAGE CONCORDANCE
TO ENSURE ADHERENCE
- INTEGRATED
APPROACH TO CARE
- MULTIDISCIPLINARY TEAM
- RESPIRATORY
NURSE
SPECIALIST
- GP
- PHYSIOTHERAPIST
- DIETICIANS
- OCCUPATIONAL
THERAPISTS
- SOCIAL
WORKER
- MULTIDISCIPLINARY
PALLIATIVE CARE
TEAM
- HOSPITAL AT
HOME SCHEMES
- CLINICAL &
COMMUNITY
PHARMACISTS
- THE NHS
- COPD OBJECTIVES
- 1
- 2
- 3
- 4
- TO ENHANCE QUALITY OF LIFE FOR PEOPLE WITH COPD ACROSS ALL
GROUPS, WITH A POSITIVE, ENABLING EXPERIENCE OF CARE AND SUPPORT
UNTIL THE END OF LIFE
- TO REDUCE THE NO. OF PEOPLE WITH COPD WHO DIE PREMATURELY THROUGH
EARLY IDENTIFICATION, DIAGNOSIS & INTERVENTION, WITH PROACTIVE CARE AND
MANAGEMENT OF ALL STAGES OF COPD, WITH PARTICULAR FOCUS ON
DISADVANTAGED GROUPS AND AREAS OF HIGH PREVALENCE
- TO REDUCE THE NO. OF PEOPLE WHO DEVELOP COPD BY ENSURING
THE PUBLIC IS EDUCATED ABOUT THE IMPORTANCE OF LUNG HEALTH, WITH
RISK FACTORS ADDRESSED, REDUCED OR AVOIDED & PROACTIVELY
ADDRESS HEALTH INEQUALITIES
- TO IMPROVE RESPIRATORY HEALTH AND WELL-BEING OF
ALL COMMUNITIES AND REDUCE INEQUALITIES
- 5
- TO ENSURE PEOPLE WITH COPD ACROSS ALL SOCIAL GROUPS RECEIVE SAFE
AND EFFECTIVE CARE WHICH MINIMIZES PROGRESSION, ENHANCES RECOVERY
AND PROMOTES INDEPENDENCE