Matt Wong + Sheila Murphy

Dec 13th 2011

AKT MINI EXAM NICE – COPD GUIDELINES BTS ASTHMA GUIDELINES INHALER TECHNIQUE QOF SPIROMETRY CSA EXERCISE

Which of the following are used in assessing the severity of COPD? A. Body mass index (BMI)B. AgeC. Medical Research Council (MRC)

dyspnoea score D. Smoking pack year historyE. Lung function

Which of the following statements apply to COPD?A. It is more common in those from upper

social classesB. It is often seen as a co-morbidity in

patients with ischaemic heart disease and lung cancer

C. Mortality from COPD is evenly spread across the UK as a whole

D. The estimated prevalence of COPD in patients over 40 years of age is 9-10%

What percentage of patients will die within 3 months of admission for a COPD-related condition?A. 33%B. 50%C. 5%D. 20%

Pulmonary rehabilitation should be offered to:A. All patients with moderate or severe

COPDB. All patients with COPD irrespective of

their MRC scoreC. Patients who are poorly motivatedD. All patients who meet the referral criteria

regardless of their inhaled drug therapyE. Patients with an MRC dyspnoea score of 3

or more unless they are on long-term oxygen therapy (LTOT)

Which of the following statements about the role of inhaled corticosteroids in COPD are true? A. In patients with moderate/ severe COPD

(FEV1 <50% predicted), treatment of the lung inflammation with inhaled corticosteroids has not shown to be of benefit in reducing exacerbations

B. There is no evidence to suggest that early use of inhaled steroids in patients with COPD will reduce the decline in FEV1 seen over years

C. The use of inhaled corticosteroids has been shown to be of some benefit in reducing the decline in health status seen in patients with moderate/ severe COPD (FEV1 <50% predicted)

D. Osteoporosis is commonly seen in patients taking high dose inhaled corticosteroids

Which of the following features suggest a patient should be admitted to hospital for management of their COPD exacerbation?A. CyanosisB. Mild peripheral oedemaC. Low oxygen saturation (<90%)D. Good level of activityE. Significant co-morbidities

Which of the following statements about oxygen therapy in COPD exacerbations are true?A. It should be given to all patientsB. It should be started at 100% until the

oxygen saturation is >95%C. It should be monitored by pulse oximetry

until access to full arterial or capillary blood gases are available

D. In patients on LTOT it should be given at the same rate as they receive at home

1. A, C, E 2. B, D 3. E 4. B 5. C, D 6. A, C, E 7. C, D 8. 3 9. D

Consider COPD in smokers >35 and with exertional SOB, chronic cough, regular sputum production, winter bronchitis, wheeze

No features of asthma – unproductive cough, diurnal variation, night-time waking with wheeze/breathlessness

Ask about: weight loss, fatigue, exercise tolerance, chest pain, night waking, haemoptysis, ankle swelling, occupational hazards

Post-bronchodilator spirometry CXR FBC – anaemia/polycythaemia BMI

FEV1/FVC < 0.7 = COPDStage 1-5 mild to very severe based on

FEV1 % >80% is mild 30% - 50% severe People must be symptomatic to make

diagnosis!

Grade 1 – not troubled by SOB except on exercise

Grade 2 – SOB when hurrying/walking up hill

Grade 3 – walks slower on level ground due to SOB, or has to stop when walking at own pace

Grade 4 – stops for breath after 100m or a few mins on ground level

Grade 5 – too breathless to leave the house or breathless when dressing

Smoking cessation for all Start treatment once diagnosis

confirmed Pulmonary rehab

For those with disability/recent admission

SABA : short acting B agonist salbutamol

LABA : long acting B agonist salmeterol

SAMA : short acting muscarinic antagonist ipratropium

LAMA : long acting muscarinic antagonist Tiotropium

ICS : inhaled corticosteroids Beclometasone, fluticasone, budesonide

Theophylline If inhaled therapy ineffective/can’t be used

Oral steroids Maintenance steroids not recommended, but if

severe COPD may be necessary, aim for low dose and monitor for osteoporosis 30mg for 7-14 days in exacerbations

LTOT used for 15 hours/day Assess need for LTOT if FEV1<30%, cyanosis,

polycythaemia, peripheral oedema, raised JVP, sats < 92% on air

2 x ABGs 2 occasions, 3 weeks apart LTOT if PaO2 < 7.3kPa or 7.3 – 8 with complications

Increase frequency of broncholdilator use/consider use of nebuliser

Prescribe oral abx if sputum purulent/clinical signs of peumonia

Steroid 30mg 7-14 days

Self-ManagementStart abx/steroid if SOB increases/interferes

with ADLsAbx if sputum purulentAdjust bronchodilator to control symptoms

not able to cope at home severe beathlessness, Sats <90% general condition is poor/ deteriorating cyanosis is present worsening peripheral oedema impaired level of consciousness patients on LTOT acute confusion exacerbation has had a rapid rate of onset significant comorbidity - cardiac disease

and IDDM changes on CXR arterial pH level < 7.35 arterial PaO2 < 7 kPa

Salbutamol CFC Free 100mcg/dose 3£ / 200 doses

Ipratropium 20 mcg5£ / 200 doses

Salmeterol 50 mcg29£ / 60doses/ 1 month

Salmeterol 50 mcg and fluticasone35£ / 60 doses/ 1 month

Tiotropium32£ / 30 doses/ 1 month

Contains a pressurised inactive gas that propels a dose of drug in each 'puff'

ADV most widely used

inhaler quick to use, small, and

convenient to carry

DISADV needs good co-

ordination to press the canister, and breathe in fully at the same time

Used with pressurised MDIs

The spacer between the inhaler and the mouth holds the drug like a reservoir when the inhaler is pressed

Valve at the mouth end ensures that the drug is kept within the spacer until you breathe in. When you breathe out, the valve closes.

Adv – No need to have good co-ordination to use a spacer device.

A facemask can be fitted on to some types of spacers, instead of a mouthpiece. This is sometimes done for young children and babies who can then use the inhaler simply by breathing in and out normally through the mask.

Alternatives to the standard MDI Don't require you to press a

canister on top

Bottom 3 are dry powder inhalers. Dose is triggered by breathing in at the

mouthpiece. You need to breathe in fairly hard to get the powder into your lungs. Accuhalers

Clickhalers

Easyhalers

Novolizers

Turbohalers

diskhalers

Twisthalers

ADV - Require less co-ordination than the standard MDI.

DISADV - They tend to be slightly bigger than the standard MDI.

Autohaler

Practice register of patients with COPD % with COPD in whom diagnosis has been confirmed by

spirometry with reversibility testing % with COPD with record of smoking status in the previous

15m % with COPD who smoke, who have been offered smoking

cessation advice or referral to a specialist service, where available in last 15 months

% with COPD with a record of FEV1 in the previous 27m % with COPD with record that inhaler technique has been

checked in the preceding 27m % with COPD who have had influenza immunisation in the

preceding 1 September to 31 March

PROMPTS: MRC Dysponea Score, FEV1, REVIEW EVERY 15m

OUR PRACTICE: Inhaler technique, sats, smoking, exacerbations,

immunisations, depression