COPD (Chronic Obstructive Pulmonary Disease)

Exam Cram

• COPD: stands for chronic obstructive pulmonary disease, encompassing chronic bronchitis and emphysema

• Presentation: progressive reduced exercise tolerance due to shortness of breath in smoker with 40 pack year, examination: polyphonic wheeze; investigations: hyperinflated chest XR and spirometry obstructive pattern

• Diagnosis: clinical- sob, smoker & obstructive pattern

• Management: 

  • Acute: steroids, antibiotics, nebulisers and NIV (if required)

  • Chronic: LABA/ LAMA then LABA/ LAMA/ ICS

Acute COPD Exacerbation Outline

Background

• Common cause for admission to hospital, c.10% admissions

Assessment

History

• Symptoms: shortness of breath, reduced exercise tolerance, fatigue, cough +/- productive, fevers

• Timescale: 1-5d, progressive

• Background: known COPD with multiple exacerabations previously

Examination

• Tachypnoeic +/- hypoxia

• Polyponic wheeze, coarse crackles if consolidation

• Frail, cachexic

Investigations

• CXR: can be commonly normal in a viral excerbation, can show consolidation/ pneumothorax or differential of heart failure

• Blood gas: ABG usually not required, VBG useful to look at CO2 and bicarb

  • • If severely acidotic from hypercapnia consider NIV

    • Raised bicarbonate suggests chronic C02 retainer, hence aim sats 88-92%

• ECG: sinus tachycardia with right axis deviation/ RBBB

• Pulmonary function tests: obstructive pattern

Diagnosis

• Diagnostic criteria: clinical

• Differentials: PE, CAP, CHF / core pulmonale; IPF, asthma

• Classification

  • Aetiology: primary, secondary (alpha-trypsin 1 deficiency)

  • Severity: FEV1

Management

Acute

1. Prednisolone 50mg OD 5 days

2. If bacterial infection suspected or unwell: amoxicillin/ benzyl penicillin & doxycycline / clarithromycin

3. Aim sats 88-92% if chronic CO2 retainer

4. Nasal prongs, nasal high flow or NIV

COPD Exacerbation Admission Cycle

Acute Exacerbation Admission 

Optimising ward base medical management

1. Oxygen

   • 88-92% sats if chronic C02 retainer

   • Nasal prongs -> venturi -> Non rebreathe

   • NIV for T2RF, very rarely intubated

2. Steroids: 

   • 50mg prednisolone 5d PO

   • IV Hydrocortisone 200mg stat + 100mg QID if nil by mouth

3. Antibiotics

   • If signs of consolidation on chest XR or unwell

   • If pneumonia, antigens: streph, legionella, mycoplasma

4. Inhalers

   • Salbutamol burst 2.5mg x3 every 20 mins then stretch to 3-4hrly

   • Ipratropium 500mcg stat + QID

   • Saline nebulisers if struggling to bring up sputum

   • Continue home inhalers

5. Investigations

   • Baseline: ECG, FBC, U&Es, LFTs +- CRP

   • CXR: ?pneumonia ?pneumothorax

   • VBG: ?worsening pC02; consider ABG

6. Disposition: 

   • Discharge  to community if mild work of breathing

   • Admit to medical (respiratory) ward for observation/ oxygen

   • HDU admission for NIV (new T2RF or acidosis)

7. Symptom control

   • Morphine 2mg QID prn

8. Housekeeping

   • Escalation status : majority with severe COPD would be DNR but for NIV

   • Morphine 2mg QID prn for symptomatic relief

   • VTE prophylaxis as normal

9. Some believe in Magnesium! (MgSO4 10mmol)

Ward Patient Decline

Differentials

• COPD ward management not optimised (common)

• Requires escalation of care to HDU for NIV

• Differential: Pulmonary Embolus , Congestive Heart Failure (CHF) , infection not covered

• End of life scenario

Investigations

• VBG: ?T2RF/ acidosis, > ABG 

• CTPA

• ECG/ troponin if cardiac cause suspected

• Baseline bloods: FBC, EUC, LFTs +- CRP/ PCT

Management

• BiPAP- if tachypnoea, tiring, acidotic

• Escalate antibiotics to Tazocin

• Furosemide if APO suspected; enoxaparin if PE suspected

• Discussions

  • Call HDU/ ICU ? biPAP

  • Escalation status update

  • Inform family

  • Senior registrar/ consultant

HDU Criteria

• Requiring NIV

  • MCQ answer: worsening T2RF

  • Real life answer pC02, hypoxia relevant; as is RR/ work of breathing

Daily Review

• Review respiratory rate, oxygen requirement, work of breathing and exercise tolerance 

  • • ?safe for discharge, stable or declining for NIV

• Review inhaler and opioid requirement/ usage

Discharge Planning

• Off oxygen for 24hrs (i.e. overnight)

• Safe to function at home, depending upon care receiving

• Expected discharge 2-5 days

• Pulmonary rehab, smoking cessation, inhaler technique, vaccines: pneumococcal once & yearly influenza / covid

• Respiratory follow up

Chronic COPD 

Diagnosis

Clinical diagnosis, key factors:

• Reduced exercise tolerance

• Smoking history

• CXR: hyperinflation, CT-Thorax: emphysematous changes

• Spirometry: obstructive picture

Management

1. Pulmonary rehab, smoking cessation, vaccines (pneumococcal & influenza)

2. LABA/ LAMA or LABA/ ICS (high dose)

3. Add ICS

4. Add Roflumilast (PDE-4)

5. LTOT: Pa02 < 55

6. EoL/ palliative care input: morphine

Indications for Roflumilast

1. FEV1 < 50% after bronchodilator

2. Exacerbations x2 in last year, despite triple therapy

Deeper Dive

Oxygen Saturations

Target Sats

The aim is to match the oxygen saturations between when they are well vs unwell. For example, most individuals saturate 98-100% whereas individuals with lung disease live with reduce saturations. As the lung disease progresses the saturations drop further to at worst 88% (rarely 86-88%). 88-92% is commonly the COPD target range. 

• 100% Normal saturations

• 94-98% Sats aim in individuals who aren't C02 retainers

• > 92% Commonly accepted threshold in generally very unwell patients, often used in ICU

• 88-92% Target sats in COPD 

• < 85% Not compatible with life

Why do COPD patients require a lower target range?

Our respiratory rate is dictated from CO2 levels rather than hypoxia. In COPD patients, their lungs are sub-optimal therefore poor at elimating CO2. Therefore severe COPD patients will live with degree of CO2 retention and hypoxia (around 90% sats). These patients' breathing is stimulated by hypoxia and they have 'turned down' their sensitivity to CO2, through exposure. If we give these patients oxygen during an acute exacerbation, their breathing will slow and they will become hypercapnic. Hypercapnia causes drowsiness, called narcosis. 

Which COPD patients are target 94-98% and which are 88-92%?

COPD patients who are 'chronic CO2 retainers' require lower sats. In short if their usualy sats are 98%, this should be the aim during an acute illness. Similarly if their usual sats are 90%, this should be used instead. Old venous blood gasses can be useful to see if their CO2 is normally raised, suggesting they are a CO2 retainer. Other signs include a raised bicarbonate. This compensatory mechanism takes time to occur, therefore if raised in the acute setting suggests chronic CO2 retention. 

Associations

Alpha Trypsin 1 Deficiency: consider in COPD presentation if under 50 & non smoker

Asthma: significant number of COPD presentations meet the criteria of reversibility on spirometry (FEV1 > 15% with bronchodilator), therefore ICS is an important first step. 

Acute Management

Benzodiazepines & morphine  in COPD

There is little evidence that benzodiazepines relieve the symptom of shortness of breath in COPD [1]. I was surprised because I've seen many COPD patients prescribed both morphine & lorazepam. There is evidence morphine relieves breathlessness, therefore I will only prescribe this now [2]. 

Magnesium in COPD

Seen variance in practice and sometimes given- unlikely to cause harm but lack of solid evidence it is helpful. 

Long Term Management

Eosinophils

Raised eosinophils can suggest steroid responsiveness, here NICE recommends LABA/ ICS as first line, then triple therapy. ICS may increase the risk of pneumonia. 

LTOT Indications

Resting PO2 < 7.3kPA or < 55 mmHg

If signs of pulmonary HTN: PO2 < 8kPA or < 60mmHg

ICS

Inhaled corticosteroids do not affect disease progression but reduce exacerbations, whilst increasing the risk of pneumonia. If there is evidence of reversibility (i.e. asthma), can start with an ICS / LABA rather than LABA/ LAMA. 

References & Resources

1. https://pmc.ncbi.nlm.nih.gov/articles/PMC6344455/#:~:text=Although%20convincing%20evidence%20linking%20benzodiazepines,severe%20COPD%20symptoms%20(21).

2. Smallwood N, Le B, Currow D, Irving L, Philip J. Management of refractory breathlessness with morphine in patients with chronic obstructive pulmonary disease. Intern Med J. 2015 Sep;45(9):898-904. doi: 10.1111/imj.12857. PMID: 26332621.

3. Ni H, Aye SZ, Naing C. Magnesium sulfate for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2022 May 26;5(5):CD013506. doi: 10.1002/14651858.CD013506.pub2. PMID: 35616126; PMCID: PMC9134202.

Written in 2025