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COPD

Jul 25, 2019

COPD is chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. It was previously known as chronic bronchitis or emphysema. Check patients for Forced Expiratory Volume at 1 second (FEV1) and Forced Vital Capacity (FVC). Treatments are based on stage of COPD as per FEV1:FVC ratio and FVC.

Medications:

As per the staging of COPD based on spirometry results:

Stage 0 – Post bronchodilator FEV1:FVC > 0.7 and FEV1 > 80% of predicted normalised value

  • Inhaler Asthalin (Salbutamol 100 mcg per dose) – 2 puffs six hourly (maximum dose – 800 mcg per day)

Stage 1 – Post bronchodilator FEV1:FVC < 0.7 and FEV1 > 80% of predicted normalised value

  • Inhaler Tiova (Tiotropium 9 mcg) once a day (avoid in patients with narrow angle glaucoma or enlarged prostate) 
  • Inhaler Asthalin (Salbutamol 100 mcg per dose) – 2 puffs six hourly (maximum dose – 800 mcg per day) as needed.

Stage 2 – Post bronchodilator FEV1:FVC < 0.7 and FEV1 < 80% of predicted normalised value

  • Rotacap Serobid (Salmeterol 50 mcg) – 1 puff twice a day OR inhaler Duova 12/9 (Formoterol 12 mcg, Tiotropium 9 mcg) – 1 puff twice a day (avoid in patients with narrow angle glaucoma or enlarged prostate) 
  • Inhaler Asthalin (Salbutamol 100 mcg per dose) – 2 puffs six hourly (maximum dose – 800 mcg per day) as needed.

Stage 3 – Post bronchodilator FEV1:FVC < 0.7 and FEV1 < 50% of predicted normalised value.

  • Rotacap Serobid (Salmeterol 50 mcg) – 1 puff twice a day OR inhaler Duova 12/9 (Formoterol 12 mcg, Tiotropium 9 mcg) – 1 puff twice a day (avoid in patients with narrow angle glaucoma or enlarged prostate).
  • Tab. Montifresh (Montelukast 10 mg) 1 tablet once a day.
  • Add inhaler Budecort (Budesonide 200 mcg) – 1 puff twice a day.
  • Inhaler Asthalin (Salbutamol 100 mcg per dose) – 2 puffs six hourly (maximum dose – 800 mcg per day) as needed.

Stage 4 – Post bronchodilator FEV1:FVC < 0.7 and FEV1 < 30% of predicted normalised value.

  • Rotacap Serobid (Salmeterol 50 mcg) – 1 puff twice a day OR inhaler Duova 12/9 (Formoterol 12 mcg, Tiotropium 9 mcg) – 1 puff twice a day (avoid in patients with narrow angle glaucoma or enlarged prostate) AND
  • Add inhaler Budecort (Budesonide 200 mcg) – 2 puffs twice a day.
  • Tab. Montifresh (Montelukast 10 mg) 1 tablet once a day.
  • Tab. Rufus (Roflumilast 500 mcg) – 1 tablet once a day.
  • Low-flow oxygen to maintain oxygen saturation above 88%.
  • Inhaler Asthalin (Salbutamol 100 mcg per dose) – 2 puffs six hourly (maximum dose – 800 mcg per day).

Supportive treatments:

  • Inj. Influvac adult (inactivated Influenza vaccine) i.m. every year as soon as it becomes available. Inj. Influvac kids (inactivated Influenza vaccine) i.m. for children.
  • Inj. Pulmovax23 (Pnemococcal polysaccharide vaccine PPV 25 mcg) i.m. every 5 years.
  • Cap. Mox 500 (Amoxicillin 500 mg) 1 capsule thrice a day for 10 days (for super added infections).

General advice:

  • Stop smoking
  • Avoid passive smoking, polluted environments and irritant fumes.
  • Advice correct inhaler technique to patients.
  • Review patients for infection if sputum turns purulent.
  • Advice incentive spirometry, deep breathing exercises and regular gentle activities.

Investigations:

  • Arterial blood gas – to evaluate acidosis, hypoxia, CO2 wash out.
  • Complete blood count – for rule out underlying infection.
  • Blood culture – for culture and antibiotic sensitivity.
  • Sputum and sputum culture – for optimising antibiotic treatments.
  • Chest X ray – to rule out pneumonia or pneumothorax.
  • ECG – for cardiac evaluation and to rule out other differential diagnoses.

Referral:

Consider referral to respiratory physician if patient fails to respond to treatment or in case of COPD exacerbation (severe breathlessness, cyanosis, oxygen saturation less than 90%, ABG – pH less than 7.35, PaO2 less than 7 kPa).