Chronic obstructive pulmonary disease (COPD) and bronchiectasis in adults

• COPD, bronchiectasis and some persistent asthma can exist together in one person (overlap syndrome)
• Diagnosis — clinical history, physical examination, lung function tests (spirometry), x-ray, CT scan

First assessment

Ask

• Smoking — how many, how long, tried to stop, want to stop
• Petrol sniffing — past or present — causes lung damage
• Chronic cough, frequent chest infections
• Sputum — frequency, amount, colour, blood
• Shortness of breath — does it stop them doing usual physical activities or work
• Activities of daily living, quality of life
• Sleeping problems — snoring, stopping breathing, morning headaches, fatigue, daytime sleepiness

Check

Do

• Collect blood for FBC 
• Show person how to use puffer and spacer or other device as needed
• Spirometry — before and 15 minutes after salbutamol puffer with spacer — 100microgram/dose (4 puffs) 30 seconds apart
• Good response after reliever (FEV1 improves by more than 12% AND at least 200mL) usually means at least a component of asthma or reversibility
• If improvement of more than 400mL — asthma COPD overlap or asthma only likely
• In bronchiectasis — lung function may be normal, may show obstruction or restriction (FVC reduced, FEV1 normal or reduced, FEV1/FVC ratio 0.7 or more)
• If severe airflow obstruction OR shortness of breath worse than expected from spirometry — consider referral for echocardiogram to check for heart failure, pulmonary hypertension
• Medical consult
• If blood in sputum or diagnosis if not known
• For chest x-ray — look for bronchiectasis, emphysema, over-inflated lung, heart enlargement, heart failure, scarring from lung disease or old infection, malignancy
• If you suspect bronchiectasis — may need high resolution CT scan of chest
• If snoring, morning headache, daytime sleepiness, fatigue — see Breathing related sleep disorders 
• If O₂ sats less than 92% on room air when well or FEV1 less than 40% of predicted — consider home oxygen, may need extra oxygen for air travel

Management of all chronic lung diseases

Aim is to improve symptoms and slow worsening of lung function

• Do regular checks
• Consider referral for pulmonary rehabilitation 
• Make management/action plan with person and give them a copy
• Include — self-management, when to have regular checks, allied health and physician referrals, follow-up, what to do for acute episodes
• In severe chronic lung disease — talk with person and family about
• Treatment choices and going to hospital if they become unwell
• Developing an Advance Care Plan to reflect their wishes 

Regular checks

Every six months

Yearly

• Chronic disease check
• Blood for FBC, sputum MC&S and AFB/mycobacterial culture for atypical mycobacteria — to help with management of acute episodes 
• Spirometry — FEV1 and FVC
• Review and give person written copy of updated management/action plan

Do

• Give immunisations
• Encourage to QUIT smoking — proven to slow down lung damage and has many other advantages
• Strongly encourage physical activity — develop tailored exercise program with allied health support
• If bronchiectasis with productive cough or moderate-severe obstruction — consider referral to physiotherapy for techniques to help cough up sputum
• If unintended weight loss — medical consult

If planning to use oral corticosteroids/prednisolone for more than 2 weeks

• Treat for strongyloides every 3 months while on steroids
• Mantoux test to assess for previous or latent TB and risk of reactivation — talk with PHU about interpretation of results and management
• Hepatitis B serology — medical consult if HBsAg positive. If non-immune — immunise
• Consider baseline and annual assessment of bone mineral density especially if expected to use for more than 3 months — may need calcium and vitamin D supplements
• If Hb concentration increased and/or packed cell volume (PCV) on FBC consistently more than 0.56 (56%) — may need to reduce it by long term oxygen therapy or taking blood — specialist consult

COPD — chronic obstructive pulmonary disease

• Airway obstruction not fully reversible
• Consider COPD if over 35 years and current or ex-smoker, even if no symptoms
• Long history of smoking is the most common cause of COPD BUT can have COPD if never smoked, especially if long exposure to second-hand smoke or environmental/occupational dust

Diagnosis based on spirometry

• COPD (without asthma)
• Poor response (FEV1 improves by less than 12% or 200mL) to inhaled salbutamol
• FEV1/FVC ratio less than 0.7 or 70%
• COPD with some reversibility/asthma
• FEV1/FVC  ratio less than 0.7 or 70% when asthma (reversible airway obstruction) has been treated

Symptoms

• Cough with sputum most days for several months at a time, over 2 or more years
• Often worse cough in morning — amount of sputum can be small
• May have wheeze

Exacerbation (acute episode) of COPD

• Looks and feels worse than usual
• At least 2 of
• Increased shortness of breath
• Increased sputum production or cough
• Change in colour of sputum — clear/white to yellow OR yellow to green

Do first — severe exacerbation

• Sit person up — use wheelchair to move them
• Give salbutamol nebulised as needed — 5mg
• AND ipratropium nebulised as needed — 500microgram — can mix with salbutamol
• Nebulisers have high risk of transmitting infection and should only be used if absolutely necessary. Wear full PPE
  
• Continue oxygen 
• Monitor O₂ sats continuously by oximeter — aim to keep levels at 88–92% 
• Watch for drowsiness — may indicate CO₂ retention (slowing of breathing)
• Medical consult — consider hydrocortisone IV — 100mg, every 6 hours (qid)

Check

• ECG if chest pain or history of heart disease 
• Head-to-toe exam — with attention to level of respiratory distress 

Do — mild to moderate exacerbation

• Sputum for MC&S
• Give oxygen to target O₂ sats 88–92% — monitor every 15 minutes
• Give salbutamol puffer with spacer — 100microgram/dose (8–10 puffs), every 1–4 hours until responding
• If symptoms not well controlled or severe — add ipratropium puffer with spacer — 21microgram/dose (4–6 puffs) as needed
• Give prednisolone oral — adult 50mg, once a day for 5 days then review — do not give for more than 2 weeks
  
• If person also has diabetes — may need extra blood glucose control medicine when taking prednisolone
• If signs of infection — fever, change in colour of sputum
• Regardless of sputum results — give amoxicillin oral — adult 1g, twice a day (bd) for 5 days
• If allergy to penicillin — give doxycycline oral — adult 100mg, twice a day (bd) for 5 days (do not give if pregnant)
  

Medical consult if

• Person needs more oxygen than by 28% venturi (air-entrainment) mask or 4L/min by nasal cannula or becoming sleepy — often needs to go to hospital
• RR less than 12/min or more than 26/min after first dose of salbutamol
• Not improving with treatment
• Other medical problems — diabetes, heart disease, kidney disease
• COPD is moderate or severe based on earlier spirometry
• Using home oxygen
• History of being in ICU for acute episodes especially if non-invasive ventilation or intubation needed

Ongoing management of COPD

May also have heart failure, ischaemic heart disease, RHD, asthma — consider these when person with chronic lung disease is very short of breath

• Stepwise progression of medicines — Table 7.24
• Adherence and inhaler technique should be checked regularly — after each acute episode and when considering progressing medicines

Severe disease

• If O₂ sats less than 92% on room air when well, clinical signs of pulmonary hypertension OR polycythaemia (haemoglobin level more than 170g/L)
  
• Refer to specialist for blood gases, echocardiogram, assessment for home oxygen
• May need oxygen if flying in plane or being transported in ambulance — include in management plan
• If on home oxygen — increase flow rate by 2L/min when flying
• Refer to allied health and palliative care for home assessment and support — bedding, wheelchair, respiratory education, advice on Advance Health Directive

*See next page for information about inhaled steroids

Improved inhaled steroids

• Improve lung function, quality of life and decrease the rate of moderate and severe exacerbations
• ALSO increase the incidence of pneumonia, especially in patients with severe COPD and do not improve survival
• Carefully weigh risks and benefits before adding an inhaled steroid
• Stable patients with rare exacerbations should not be on an inhaled steroid — consider stopping
• If no benefit after 6 months — consider stopping inhaled steroid
• Patients with asthma/COPD overlap have to be treated with an inhaled steroid

Bronchiectasis

• Widening of airways caused by severe or repeated infections that fail to clear away secretions
• Specialist consult to check for underlying treatable cause
• Diagnosis confirmed by HRCT scan
• Consider bronchiectasis if
• Chronic productive cough for longer than 8 weeks (despite treatment) in person under 35 years
• Chest x-ray showing changes caused by infection persisting for more than 6 weeks
• Spirometry may be normal or have reduced FEV1 and FVC together (restriction)
• Chronic cough with daily sputum not responding to standard treatment
• May have shortness of breath, wheeze, chest pain
• May have haemoptysis (cough up blood)

Exacerbation (acute episode) of bronchiectasis

• Increased cough, amount and darker yellow or green coloured sputum
• Often wheezing, more short of breath, fever
• May have haemoptysis (cough up blood) or chest pain

Check

• ECG if chest pain or history of heart disease 
• Head-to-toe exam — with attention to level of respiratory distress, eg talking in single words or sentences
• Past sputum results for sensitivities

Do 

• Sputum for MC&S, check for blood
• Give amoxicillin oral — adult 1g, twice a day (bd) for 14 days

• OR doxycycline oral — adult 100mg, twice a day (bd) for 14 days
• If allergy to penicillin — give doxycycline oral — adult 200mg, single dose
• THEN doxycycline oral — adult 100mg, once a day for 13 days
  
• If pregnant do not give doxycycline — medical consult
• If rapid improvement and no resistant bacteria in sputum — can reduce antibiotics to 10 days
• If no improvement — give antibiotics according to most recent sputum results
• Chest physiotherapy — if history or symptoms of reflux. Avoid head down postural drainage
• Reliever (eg salbutamol) may be helpful if person is wheezy

Medical consult if

• Haemoptysis (coughing up blood)
• Can't look after themselves at home — washing, toileting, dressing, eating
• Very wheezy or previous diagnosis of co-existing asthma — may need prednisolone
• Very unwell — may need to send to hospital. Treat according to most recent available sputum results
• If no results available give ceftriaxone IV/IM — adult 2g, once a day
• If positive Pseudomonas — give ciprofloxacin oral — adult 750mg, twice a day (bd) for 14 days
• If allergy — medical consult

Ongoing management of bronchiectasis

• Refer to physio for coughing techniques and aids to help removal of sputum, eg Accapella device,  PEP valve, flutter valve
• Inhaled corticosteroids may help if a component of asthma OR COPD OR very wheezy
• Medical/respiratory physician follow-up
• To exclude secondary causes of bronchiectasis and develop management plan
• If 3 or more acute episodes or 2 or more needing hospitalisation in last year 
• If Pseudomonas aeruginosa isolated in sputum for first time 
• For pulmonary rehabilitation