Neobook — clinical reference

J43.0-2/J43.8-9/J44.0-1/J44.8-9

DESCRIPTION

COPD is characterised by persistent respiratory symptoms (dyspnoea, chronic cough and sputum production), and airflow limitation. Spirometry is required to diagnose COPD, where the post bronchodilator FEV1/FVC ratio is <0.7. COPD is likely to worsen over time, even with optimal care.
Regular follow-up is necessary to monitor lung function, symptoms, exacerbations, co-morbidities, and the need for treatment regimen changes.
COPD can be graded on severity of symptoms and frequency of exacerbations to assist in treatment selection and to monitor treatment success:

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GOLD group	mMRC breathlessness score	Exacerbations/hospitalisations in past year
A	0-1	<2 exacerbations (and no hospitalisations)
B	>2	<2 exacerbations (and no hospitalisations)
E	N/A	≥2 exacerbations (or ≥1 leading to hospitalisation)

Assess breathlessness using the mMRC dyspnoea scale:

Grade	Exacerbations in past year
0	Dyspnoea with strenuous exercise
1	Dyspnoea when hurrying on level ground or walking up a slight hill
2	Walks slower than people of the same age group, due to dyspnoea
3	Stops for breath after walking 91m, or after a few minutes on level ground
4	Too breathless to leave the house, or dyspnoea when dressing/undressing

URL to the modified Medical Research Council (mMRC) dyspnoea scale calculator: https://www.mdcalc.com/mmrc-modified-medical-research-council-dyspnea-scale

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GENERAL MEASURES

Patients with clinical COPD must undergo spirometry to confirm and grade the severity of obstruction.
Patients should be screened for ongoing smoking and advised to stop at each visit.
Smoking cessation and avoidance of noxious respiratory particles should form the mainstay of management.

MEDICINE TREATMENT

Note:

Correct inhaler technique should be demonstrated and checked regularly. Appendix VI: Devices for Respiratory Conditions for guidance on inhaler, spacer and nebuliser device techniques.

Management of acute exacerbations

Progression of disease (measured by symptoms and deterioration in lung function) in COPD is variable, but is greater in patients who experience COPD exacerbations which are defined as:
- worsening of dyspnoea,
- increased cough,
- increased sputum production or purulence or,
- greater than usual day to day variability of symptoms.
Severe exacerbations are defined as being sufficiently severe to prompt use of an oral corticosteroid course and/or an antibiotic.
COPD exacerbations are not always associated with significant decreases in PEF or FEV₁, and are defined by symptoms and, when severe, measures of respiratory failure. Most are precipitated by viral and/or bacterial infection, and are more common in winter.
Patients should be admitted if there is a marked increase in dyspnoea, symptoms disturb eating or sleeping, change in mental status or poor social circumstances. Causes of worsening symptoms other than an acute exacerbation of COPD such as cardiac failure, pulmonary embolus, or pneumonia must be considered.
If available, check blood gases for the presence of hypoxaemia and hypercapnia. In some patients with long-standing lung disease the drive to respiration switches from hypercapnia (increases in PaCO₂) to hypoxaemia (level of respiratory failure). In such patients, relief of hypoxaemia with uncontrolled oxygen therapy may result in hypoventilation, with consequent rise in PaCO₂ to dangerous levels and associated respiratory acidosis leading to coma and death. For this reason, hypoxaemia should be corrected using controlled use of supplemental oxygen, preferably starting with a nasal cannula 1-2 litres/minute.
If the patient’s arterial PaCO₂ does not rise, the FiO₂ may be increased until a PaO₂ of 8kPa (60 mmHg), or oxygen saturation of 90%, is reached. The FiO₂ must be reduced, or oxygen removed, if worsening hypercapnia occurs; these patients might require non-invasive ventilation or intubation for mechanical ventilation.
Where blood gas facilities are not readily available, the patient’s clinical status should be reviewed regularly to check for increasing drowsiness, headache, or confusion, which may precede coma.
Where resources for mechanical ventilation are scarce, oxygen saturation targets for patients with long-standing COPD and limited effort tolerance may be relaxed if the patient is improving clinically.
Salbutamol, 0.5% (5 mg/mL) nebuliser solution.
- 1 mL (5 mg) salbutamol 0.5% solution, made up to 4 mL with sodium chloride 0.9%, preferably delivered at a flow rate of 6-8 L/min with oxygen.
- Nebulise continuously (refill the nebuliser reservoir every 20 minutes).

If a poor response to nebulised salbutamol:

ADD

Ipratropium bromide 0.5 mg (UDV) with the first refill of the nebuliser reservoir.
- Patients who fail to respond within 1 hour must be discussed with a specialist. (Patients with COPD have fixed airway disease. Unlike asthmatics, PEF is not a reliable measure of disease).

Once clinically stabilised, nebulise with:

Salbutamol, 0.5% (5 mg/mL) nebuliser solution
- 1 mL (5 mg) salbutamol 0.5% solution, made up to 4 mL with sodium chloride 0.9%, preferably delivered at a flow rate of 6-8 L/min with oxygen.
- Repeat 4–6 hourly.

AND

Corticosteroids (intermediate-acting) e.g:
- Prednisone, oral, 40 mg immediately.

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Follow with:

Prednisone, oral, 40 mg daily to complete 5 days.

In patients who cannot use oral therapy:

Hydrocortisone, IV, 100 mg 6 hourly until patient can take oral medication.

Once oral medication can be taken, follow with:

Corticosteroids (intermediate-acting) e.g.:
Prednisone, oral, 40 mg daily to complete 5 days of corticosteroids in total.
- Monitor response and clinical signs.

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Antibiotic therapy for acute exacerbations

Indications:

Patients with increased sputum purulence AND either increased sputum volume or increased dyspnoea

Patients with a severe exacerbation (respiratory acidosis, severe dyspnoea, or persistent hypoxaemia despite supplemental oxygen).
- Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 5 days.

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Severe penicillin allergy: (Z88.0)

Azithromycin, oral, 500 mg daily for 3 days.

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Chronic therapy

FOR ALL STAGES:

Short acting β2-agonists, e.g.:
- Salbutamol, MDI, 200 mcg 6 hourly as needed (educate on correct inhaler use - use a large volume spacer if inhaler technique remains poor).

GROUP B:

ADD

Long acting β2-agonist (LABA), e.g.:
- Formoterol, inhalation, 12 mcg 12 hourly.

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GROUP E (frequent exacerbations (≥2 per year)):

If blood eosinophils <0.1 cellsx10⁹/L:

ADD

Long acting β2-agonist (LABA), e.g.:
- Formoterol, inhalation, 12 mcg 12 hourly.

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If blood eosinophils ≥0.1 cellsx10⁹/L:

ADD

LABA/ICS combination, e.g.:
- Salmeterol/fluticasone, inhalation, 50/250 mcg 12 hourly.

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Note:

Do not measure blood eosinophils while taking oral corticosteroids, as this may temporarily lower the eosinophil count.

Patients on protease inhibitors:

Replace LABA/ICS combination with:

Beclomethasone, inhalation, 400 mcg 12 hourly.

AND

Formoterol, inhalation, 12 mcg 12 hourly.

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If inadequate control with above therapy:

Theophylline, slow release, oral, 200 mg at night (Specialist consultation).
- Ongoing use of theophylline should be re-evaluated periodically. If there is no benefit after 12 months, discontinue theophylline.

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AND

Refer patients for additional assessment and management.

Corticosteroids

Oral corticosteroids are not recommended for stable COPD.

Pre-operative assessment for surgical procedures:

Patients with chronic lung disease are at an increased risk of post-operative pulmonary complications. Risk is increased with increasing severity of pulmonary disease, and with upper abdominal or thoracic surgery.
Patients undergoing elective surgery must be optimised pre-operatively by following the recommended treatment for their disease. Clinical assessment is generally sufficient, as further investigations such as spirometry, CXR and ABGs are reserved for patients with clinically severe disease/ unstable disease, or where the diagnosis is uncertain.
COPD patients should be wheeze free and without dyspnoea on moderate exertion (carrying shopping walking up a flight of stairs), or a history of frequent exacerbations. As COPD is a disease characterised by fixed airway obstruction, some patients may have continuous wheezing and will require further pre-operative assessment.

Peri-operative oral corticosteroids may be used to gain optimal control but are not advocated for routine use:

Corticosteroids (intermediate-acting), e.g.:
- Prednisone, oral, 30 mg daily for not longer than 5 days.

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AND

Inhaled therapy must be continued and may be administered via nebulisation peri-operatively:

Short acting β2-agonists, e.g.:
- Salbutamol MDI, 200 mcg, 30 minutes pre-intubation.

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Prophylaxis (Z25.1)

Annual influenza vaccination. See Adult vaccination.

REFERRAL

Assessment for long-term home-based oxygen therapy, if COPD with PaO2 <7.3 kPa (55 mmHg) and non-smoker for at least 3 months.
Recent onset of respiratory failure or signs of cor pulmonale.
Symptoms that appear disproportionate to the level of airflow obstruction, as judged by spirometry or clinical evaluation (absence of hyperinflation or unusual pattern of symptoms).
Onset <40 years of age.
COPD with a history of little or no smoking.
Recurrent exacerbations, i.e. ≥2 per year.
Failure to respond to treatment.

Click here to access the pdf.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.1_16 September 2024

Chapter 16: Respiratory Disorders _16.4 Chronic Obstructive Pulmonary Disease (COPD)

Chronic Obstructive Pulmonary Disease (COPD)

Drugs mentioned

ICD-10 codes