COPD Management Guide for MSRA & NICE NG115 Revision

COPD Management: MSRA High Yield

Key Revision Points for FY2/GPST | Based on NICE NG115

Diagnosis & Severity Staging

Spirometry: Post-bronchodilator FEV1/FVC < 0.7 confirm diagnosis

GOLD 1 (Mild): FEV1 ≥ 80%

GOLD 2 (Moderate): FEV1 50–79%

GOLD 3 (Severe): FEV1 30–49%

GOLD 4 (Very Severe): FEV1 < 30%

Non-Pharmacological Management

Single most important intervention. Offer NRT, Varenicline (if avail), or Bupropion. Combine with behavioural support.

Annual Influenza; One-off Pneumococcal; COVID-19 boosters as per guidance.

Pulmonary Rehab (PR). Indicated if MRC Grade 3+ (functionally limited by breathlessness). Available to any symptomatic patient, including recent hospitalisation.

Pharma Step 1: Asthmatic Features?

Starting Point: SABA or SAMA PRN

Does the patient have Asthmatic Features?

• Previous diagnosis of Asthma/Atopy<br>• High blood eosinophils<br>• Substantial diurnal variation in PEF or FEV1

NO Asthmatic Features

LABA + LAMA

YES Asthmatic Features

LABA + ICS

Pharma Step 2: Escalation to Triple Therapy

Patient remains breathless or exacerbating despite LABA+LAMA or LABA+ICS

LAMA + LABA + ICS

Already on LABA+LAMA: Add ICS if severe exacerbations (requiring hospitalisation) or ≥2 moderate exacerbations/year.

Already on LABA+ICS: Add LAMA if symptoms persist or exacerbations continue (very common step-up).

3 Month Trial: If no benefit from ICS, withdraw it (back to LAMA+LABA) to reduce pneumonia risk.

Acute Exacerbation: Community Management

Anthonisen Criteria for Antibiotics (Need 2/3)

1. Increased Dyspnoea<br>2. Increased Sputum Volume<br>3. Increased Sputum Purulence (Key sign)

STEROIDS: Prednisolone 30 mg for 5 days

ANTIBIOTICS (5 Day Course): Amoxicillin 500mg TDS<br>OR Clarithromycin 500mg BD<br>OR Doxycycline 200mg loading -> 100mg OD

Refer if: Cyanosis, peripheral oedema, confusion, O2 sat <90% or rapid decline.

Acute Exacerbation: Hospital Management

Target Sats: 88–92% (Titrate via Venturi)

Avoid hyperoxygenation (risk of hypercapnic respiratory failure). Check ABG within 1hr.

• Nebulised Salbutamol (2.5-5mg) + Ipratropium (500mcg)<br>• Steroids: Hydrocortisone IV or Prednisolone PO<br>• Antibiotics if infective cause suspected

DECAF Score for prognosis: Dyspnoea, Eosinopenia, Consolidation, Acidemia, Fibrillation.

Non-Invasive Ventilation (NIV) Criteria

Patient with Acute Exacerbation of COPD failing maximal medical therapy (Nebs + Steroids + Controlled O2 for 1 hour).

Respiratory Acidosis: pH < 7.35<br>AND<br>Hypercapnia: pCO2 > 6.0 kPa

If pH < 7.25: Rises ITU priority (Invasive ventilation may be needed if NIV fails).

Contraindications: Facial burns/trauma, vomiting, fixed upper airway obstruction, undrained pneumothorax.

Long-Term Oxygen Therapy (LTOT)

Prerequisites: Non-smoker, stable COPD, optimal medical management. Measured via 2 ABGs at least 3 weeks apart.

Group 1: Hypoxaemia

pO2 < 7.3 kPa

Group 2: Hypoxaemia + Complications

pO2 7.3 – 8.0 kPa

PLUS one of:<br>• Secondary Polycythaemia<br>• Peripheral Oedema<br>• Pulmonary Hypertension

Must use for minimum 15 hours/day for mortality benefit.

High Yield Exam Pearls

Azithromycin Prophylaxis: Consider in non-smokers, optimised inhalers, freq exacerbations. Need CT thorax + ECG (QT interval) before starting.

Cor Pulmonale: Right heart failure due to lung disease. Signs: Raised JVP, parasternal heave, loud P2. Treat with LTOT and diuretics.

Lung Cancer Risk: Any COPD patient with haemoptysis or weight loss needs urgent 2WW referral (CXR first in primary care usually, but low threshold for CT).

Theophylline: Narrow therapeutic index. Interacts with Macrolides & Ciprofloxacin (P450 inhibitors) -> Toxicity (vomiting, seizures, arrhythmias).