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CHRONIC OBSTRUCTIVE PULMONARY DISEASE - Coggle Diagram
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Chronic obstructive pulmonary disease (COPD) is a common, treatable (but not curable) and largely preventable lung condition. It is characterised by persistent respiratory symptoms (such as breathlessness, cough, and sputum) and airflow obstruction (usually progressive and not fully reversible).
DIFFERENTIAL DIAGNOSIS
Asthma
Bronchiectasis
Heart Failure
Lung Cancer
Interstitial lung disease
Anaemia
Tuberculosis (TB)
Cystic fibrosis.
Upper airway obstruction
DIAGNOSIS
Diagnosis of COPD is based on typical clinical features supported by spirometry.
Suspect COPD in people aged over 35 years with a risk factor (such as smoking, occupational or environmental exposure) and one or more of the following symptoms:
SYMPTOMS
Breathlessness — typically persistent, progressive over time, and worse on exertion.
Chronic/recurrent cough.
Regular sputum production.
Frequent lower respiratory tract infections.
Wheeze.
OTHER SYMPTOMS
Weight loss, anorexia and fatigue — common in severe COPD but other causes must be considered.
Waking at night with breathlessness.
Ankle swelling – consider cor pulmonale.
Chest pain – uncommon in COPD, consider other causes.
Haemoptysis – uncommon in COPD, consider other causes.
Reduced exercise tolerance.
EXAMINATION
Examination may be normal. Where present, signs may include:
Cyanosis.
Raised jugular venous pressure and/or peripheral oedema (may indicate cor pulmonale).
Cachexia.
Hyperinflation of the chest.
Use of accessory muscles and/or pursed lip breathing.
Wheeze and/or crackles on auscultation of the chest.
Consider COPD in younger people who have symptoms of COPD, even when their FEV1/FVC ratio is above 0.7.
Consider other causes in older people without typical symptoms of COPD who have an FEV1/FVC ratio less than 0.7.
A post bronchodilator FEV1/FVC less than 0.7 confirms persistent airflow obstruction.
Spirometry is required for confirmation of diagnosis:
Spirometry & investigations
Arrange investigations including:
Chest X-ray — to help exclude other causes (such as lung cancer, bronchiectasis, tuberculosis, and heart failure).
Full blood count — to identify anaemia or polycythaemia.
Spirometry.
Measure post-bronchodilator spirometry to confirm the diagnosis of COPD — do not routinely perform reversibility testing as part of diagnostic work up.
ECG and serum natriuretic peptides – if cardiac disease or pulmonary hypertension are suspected.
Echocardiogram may also be indicated.
Serial home peak flow measurements – to exclude asthma if diagnosis is in doubt.
CT thorax – if symptoms seem disproportionate to spirometry measurements; another diagnosis (such as fibrosis or bronchiectasis) is suspected, or an abnormality on chest x-ray requires further investigation.
Sputum culture – if sputum is purulent and persistent (to identify organisms).
Serum alpha-1-antitrypsin.
Consider alpha-1-antitrypsin deficiency in people with early onset of symptoms, minimal smoking history or a positive family history.
Referral to a specialist for management and screening of family members is required if alpha-1-antitrypsin deficiency is identified.
Post-bronchodilator spirometry should be performed and interpreted by an appropriately trained health professional to confirm the diagnosis of chronic obstructive pulmonary disease (COPD).
Spirometry should be carried out 15–20 minutes after the person has inhaled a short-acting bronchodilator (for example 400 micrograms salbutamol delivered via a spacer device — local protocols may vary).
Airflow obstruction is defined as a post bronchodilator ratio of forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) of less than 0.7.
Other causes should be considered in older people who have a FEV1/FVC ratio below 0.7 but do not have typical symptoms of COPD.
COPD should be considered in younger people with typical symptoms even if FEV1/FVC ratio is above 0.7.
Where post-bronchodilator FEV1/FVC ratio is less than 0.7, severity of airflow obstruction is graded according to reduction in FEV1 compared to appropriate reference values (based on age, sex, height and ethnicity):
Stage 1, mild — FEV1 80% of predicted value or higher.
Stage 2, moderate — FEV1 50–79% of predicted value.
Stage 3, severe — FEV1 30–49% of predicted value.
Stage 4, very severe — FEV1 less than 30% of predicted value or FEV1 less than 50% with respiratory failure.
outine spirometry reversibility testing is not recommended.
Spirometry should be performed at diagnosis, when diagnosis is reconsidered and for monitoring of disease severity and progression.
Cor pulmonale
Cor pulmonale is right heart failure secondary to lung disease, and is caused by pulmonary hypertension as a consequence of hypoxia.
Suspect cor pulmonale in people with:
Peripheral oedema.
Raised jugular venous pressure.
Systolic parasternal heave.
A loud pulmonary second heart sound (over the second left intercostal space).
Hepatomegaly.
Other causes of peripheral oedema should be considered.
HISTORY TAKING
Onset, variability and progression of symptoms such as:
Breathlessness — assess severity using the Medical Research Council (MRC) dyspnoea scale.
Cough and sputum production — ask about haemoptysis and consider other causes.
Peripheral oedema — consider cor pulmonale.
Weight loss – consider other causes.
Exposure to risk factors including:
Smoking — if the person is a current smoker document pack-years smoked (number of cigarette smoked per day divided by 20 multiplied by number of years smoked).
Occupational or environmental exposures.
Impact of COPD on wellbeing and daily life can be assessed using the COPD Assessment test (CAT) — available in the GOLD guidelines.
Previous exacerbations or hospitalization.
Past medical history and comorbidities including:
Anxiety and depression.
Cardiovascular disease and metabolic syndrome.
Lung or liver disease.
Osteoporosis.
Asthma.
Family history including:
Lung or liver disease – consider underlying causes such as alpha-1-antitrypsin deficiency.
RESPIRATORY REFERRAL PROCESS
There is diagnostic uncertainty, for example:
Difficulty distinguishing COPD from asthma or other conditions such as bronchiectasis or pulmonary fibrosis.
Symptoms are disproportionate to findings on spirometry.
Lung cancer is suspected (for example they have haemoptysis or suspicious features on chest X-ray).
COPD is very severe or rapidly worsening.
For example, forced expiratory volume in 1 second (FEV1) is less than 30% predicted or rapidly declining.
Cor pulmonale is suspected.
The person is less than 40 years of age and/or there is a family history of alpha-1-antitrypsin deficiency.
If alpha-1-antitrypsin deficiency is confirmed, screening is indicated for the person's family.
If they have frequent infections — to assess preventable factors and exclude bronchiectasis.
Referral to a respiratory specialist may also be required to assess the need for:
Oxygen therapy.
Long-term non-invasive ventilation.
Nebulizer therapy or long-term oral corticosteroids.
Lung surgery (for example, for a person with bullous lung disease who is still symptomatic on maximal treatment).
Refer the person for pulmonary rehabilitation if they are functionally disabled by chronic obstructive pulmonary disease (COPD) (usually Medical Research Council (MRC) dyspnoea scale grade 3 or above), or have had a recent hospitalization for an acute exacerbation.
Refer directly for pulmonary rehabilitation if possible, depending on local referral pathways.
Advise the person that commitment to pulmonary rehabilitation can improve quality of life, increase exercise capacity and reduce breathlessness.
Refer the person for LTOT assessment if they have:
Oxygen saturations of 92% or less breathing air.
Very severe (forced expiratory volume in 1 second [FEV1] less than 30% predicted) or severe (FEV1 30–49% predicted) airflow obstruction.
Cyanosis.
Polycythaemia.
Peripheral oedema.
Raised jugular venous pressure.
FURTHER REFERALS
onsider referral to a physiotherapist for a person with excessive sputum, to learn:
How to use positive expiratory pressure devices.
Active cycle of breathing techniques.
Consider referral to social services and occupational therapy if:
The person is experiencing difficulties with activities of daily living or functional disability.
Consider referral to psychological services if:
Anxiety or depression related to chronic obstructive pulmonary disease (COPD) are identified.
TREATMENTS
Non-pharmacological treatments and inhaled treatments
Offer pneumococcal and influenza vaccinations.
At every opportunity, offer treatment and support to stop smoking (where applicable).
Offer pulmonary rehabilitation if indicated.
Explain the diagnosis, risk factors for progression and the importance of a healthy diet and physical activity
Develop a personalised self-management plan in conjunction with the person.
If the person is breathless and has exercise limitation:
Offer a short-acting beta-2 agonist (SABA) or short-acting muscarinic antagonist (SAMA) to use as needed to relieve breathlessness and improve exercise tolerance.
Take into account individual factors such as age, dexterity, coordination, and inspiratory flow when choosing a delivery system for inhaled medication — ensure the person has appropriate training on use and can demonstrate satisfactory technique.
Regularly review medication, adherence and inhaler technique.
f the person continues to be limited by symptoms or has exacerbations despite use of short-acting bronchodilators:
Review to ensure that:
Non-pharmacological management is optimal and relevant vaccinations and smoking cessation support (if applicable) have been offered.
Symptoms are not due to another condition.
If they have no asthmatic features or features suggestive of steroid responsiveness:
Offer a long-acting beta-2 agonist (LABA) plus a long-acting muscarinic antagonist (LAMA).
If the person continues to have day-to-day symptoms adversely affecting quality of life:
Consider a 3 month trial of LABA plus LAMA plus inhaled corticosteroids (ICS).
If there is no improvement at 3 months change back to LABA plus LAMA.
If symptoms have improved, continue with LAMA plus LABA plus ICS and review at least annually.
n people taking ICS for COPD:
Be aware of, and discuss the increased risks (including pneumonia) of these.
If treatment with an ICS is continued, ensure reasons are clearly documented.
If the person is currently using LABAs outside of recommendations above (such as LAMA or LABA monotherapy) and symptoms are well controlled, no change in treatment is required until clinical needs change.
If the person is still limited by breathlessness or subject to frequent exacerbations consider the need for referral and/or add on treatments.
onsider referral for dietetic advice if:
Body Mass Index (BMI) is abnormal (high or low) or changing over time (3 kg or more in an older person).
Other causes of unintentional weight loss (including malignancy) should be considered.
Nutrition should form part of all pulmonary rehabilitation programmes.