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CPD 18: CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) Biography - Eamonn Brady MPSI is the owner of Whelehans Pharmacy in Mullingar. He graduated from the Robert Gordon University in Aberdeen in 2000 with a Masters in Pharmacy. He worked for Boots in the UK before moving back to Ireland in 2002. He bought Whelehans Pharmacy in Mullingar in 2005. He undertakes clinical training for nurses in the midlands.

1. REFLECT - Before reading this module, consider the following: Will this clinical area be relevant to my practice. 2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area. 3. PLAN - If I have identified a knowledge gap

- will this article satisfy those needs - or will more reading be required? 4. EVALUATE - Did this article meet my learning needs - and how has my practise changed as a result? Have I identified further learning needs? 5. WHAT NEXT - At this time you may like to record your learning for future use or assessment. Follow the 4 previous steps, log and record your findings.

Chronic obstructive pulmonary disease (COPD) Chronic obstructive pulmonary disease (COPD) is the name for a group of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. The main symptom of COPD is an inability to breathe in and out properly, otherwise known as airflow obstruction. After pneumonia, COPD is the leading cause of respiratory death in Ireland.1 Airflow obstruction is caused by long-term damage to the lungs, usually as a result of smoking. According to the Irish Thoracic Society, 440,000 people in Ireland suffer from COPD. It usually affects people who are over 40 years of age. It is more common in men than women but according to the British Thoracic society, the rate of COPD in women is increasing. Smoking is the cause of 90% of COPD cases in developed countries. The Global Burden of Disease Studies have predicted that by 2020 it will be the fifth commonest cause of disease morbidity, and the third commonest cause of death worldwide, causing more deaths than lung cancer, heart disease and stroke.2,3,4. This is due to two reasons; firstly there is an increase in tobacco consumption in underdeveloped countries. Secondly, even though tobacco consumption is falling in developed countries, the ageing population is

leading to more cases of COPD.5,6 Because of the prevalence of smoking in young people in Ireland, it is predicted that Ireland will continue to have one of the highest prevalence of COPD in the world.7 TYPES Chronic bronchitis: bronchitis means 'inflammation of the bronchi'. These are the tubes or airways which carry oxygen from the air through the lungs. This inflammation increases mucus production in the airways, producing phlegm which causes a cough. Emphysema: this is where the alveoli (air sacs) in the lungs lose their elasticity. This reduces the support of the airways, causing them to narrow. It also means the lungs are not as good at getting oxygen into the body, so the patient has to breathe harder. This can result in shortness of breath. THE EFFECTS OF COPD The condition builds up over a number of years, causing the airways of the lungs (bronchioles) to narrow, permanently damaging the air sacs (alveoli). COPD is the result of a chronic inflammatory response in the large airways (chronic bronchitis), the small airways (bronchiolitis which may progress to fibrosis) and the lung parenchyma (emphysema). Pathological changes that occur include mucus hyper

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Published by IPN and supported with an unrestricted educational grant from Pfizer Healthcare Ireland. Copies can be downloaded from Disclaimer: All material published in CPD and the Pharmacy is copyright and no part of this can be used within any other publication without the permission of the publishers and author.

60 Second Summary Chronic obstructive pulmonary disease (COPD) is the name for a group of lung diseases which include chronic bronchitis, emphysema and chronic obstructive airways disease. The main symptom of COPD is an inability to breathe in and out properly, otherwise known as airflow obstruction. After pneumonia, COPD is the leading cause of respiratory death in Ireland.1 According to the Irish Thoracic Society, 440,000 people in Ireland suffer from COPD. It usually affects people who are over 40 years of age. It is more common in men than women but according to the British Thoracic society, the rate of COPD in women is on the rise. Smoking is the cause of 90% of COPD cases in developed countries. It is estimated that by 2020 COPD will be the fifth most common cause of disease morbidity, and the third most common cause of death worldwide, causing more deaths than lung cancer, heart disease and stroke.2,3,4

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CPD 18: CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) • difficulty breathing, • shortness of breath, and • repeated lung and chest infections. The symptoms are often worse in winter. It is common for sufferers of COPD to have two or more chest infections a year when the symptoms are worse than normal. Because the amount of oxygen reaching the heart and muscles is diminished, COPD can make patients feel tired. This can affect the ability to work and exercise and with severe COPD even simple tasks can become difficult.

secretion, ciliary dysfunction, airflow limitation, pulmonary hyperinflation and gas exchange abnormalities. Unlike other chronic diseases such as rheumatoid arthritis and interstitial lung disease, where the inflammatory response seem to slow down as the disease progresses, the inflammatory response in COPD appears to increase with the severity of the disease.8 As the condition progresses, breathing in and out will becomes difficult. This is called airway limitation. The patient finds it hard to do normal activities, such as walking up the stairs. If not enough oxygen is getting through the narrowed airways to the heart, the patient may also be at risk of heart failure. The World Health Organisation’s GOLD definition for airflow limitation is an FEV1/ FVC ratio of ≤ 70%.12 The FEV1/FVC ratio is a calculated ratio used in the diagnosis of lung diseases such as COPD. It represents the proportion of the forced vital capacity exhaled in the first second. Normal values are approximately 80%. The symptoms of COPD can seem similar to those of asthma. Asthma can be controlled with treatment but COPD causes permanent damage to the lungs. Treatment for COPD usually involves relieving the symptoms; for example, by using an inhaler to make breathing easier.

Many COPD suffers experience weight loss as having difficulty breathing can lead to the patient using up a lot more energy. Also the breathlessness can make it difficult to eat as much as normal. Severe weight loss can lead to weakening of the heart and heart failure. Not everyone with COPD experiences weight loss and in fact obesity makes COPD worse. FIRST SIGNS OF COPD A patient should be referred to their GP when they experience the following symptoms which are the first signs of COPD: • an increasing breathlessness when exercising, or moving around. • a persistent cough with phlegm that never seems to go away, and • frequent chest infections, particularly in winter. There is currently no cure for COPD but early treatment can slow down the progression of the condition. CAUSES Smoking is the cause of over 80% of COPD cases. The risk of COPD increases the more the patient smokes and the longer they smoke. Between the ages of 35-45, everyone’s lung function begins to gradually decline. For smokers, this loss of lung function speeds up to around three times the normal rate.

• early morning smokers cough,

While not all smokers develop clinically significant COPD, studies show that most smokers, if they live long enough and smoke enough, will develop airflow limitation.9 It is estimated that less than 20% of smokers develop significant airway obstruction.17 This is likely to be down to the fact that many smokers stop smoking before significant lung damage occurs.

• persistent coughing,

Less common causes of COPD include:

• mucus and phlegm,

• passive smoking,

• wheezing,

• pollution,

• tight chest,

• fumes and dust, and

SYMPTOMS COPD does not usually become noticeable until after the age of 40. Symptoms include:

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• being born more susceptible to the condition (genetic link). Worldwide, up to 20% of COPD patients are lifelong non-smokers.10 PROGNOSIS Five-year survival for men with mild disease is 78% and with severe disease it is 32%, with corresponding figures for women being 72% and 24%.11 DIAGNOSIS The diagnosis of COPD is made on a combination of the presence of chronic progressive symptoms and signs on a background of exposure to potential risk factors, and spirometric evidence of airflow obstruction. Common symptoms include shortness of breath (persistent and progressive), cough, sputum, wheeze (particularly early morning) and exercise intolerance. Common signs are chest hyperinflation, quiet breath sounds or rhonchi (rattling sound when breathing) and peripheral oedema. Tests must be done to eliminate other conditions such as asthma. Tests include: •

Spirometry- this involves blowing into and out of a tube called a spirometer, this establishes lung function and determines if the airways have narrowed.

• Chest Radiography- a chest x-ray determines if there is an expansion of the lungs which can point to COPD • CT scan- a CT scan can give a more definitive diagnosis of different lung diseases than a chest x-ray •

Blood test- this can show if the patient is suffering from anaemia which can make COPD symptoms worse. A blood test may also be used to check for polycythaemia (an excess of red blood cells). Polycythaemia shows the body may not be getting enough oxygen as a result of the lungs being damaged.

COPD TREATMENT There is no cure for COPD, so treatment involves relieving the symptoms. For those still smoking, smoking cessation must be the first step of treatment. Short-acting bronchodilator inhalers Short-acting bronchodilator inhalers deliver a small dose of medicine directly to the lungs, causing the muscles in the airways to relax and open up (bronchodilate). They also prevent hyperinflation (over expansion) of the lungs. There are two types of short-acting bronchodilator inhalers: • beta-2 agonist inhalers, such as salbutamol and terbutaline, and

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CPD 18: CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) • anti-cholinergic inhalers, such as ipratropium and oxitropium . For people with mild COPD symptoms, one bronchodilator inhaler used as needed (as and when patient feels breathless) may be sufficient to relieve the symptoms. For other people, it may be necessary to use one of each type of bronchodilator, a beta-2 agonist and an anti-cholinergic inhaler, four times a day. Long-acting bronchodilator inhalers If a short-acting bronchodilator inhaler does not help to relieve symptoms, a long-acting bronchodilator inhaler may also be used. These work in a similar way to the shortacting bronchodilators, but each dose lasts for at least 12 hours. There are two types of long-acting bronchodilator inhalers: • beta-2 agonist inhalers, such as salmeterol (Serevent®) and formoterol (Oxis®), and • anti-cholinergic inhalers, such as tiotropium (Spiriva®). Corticosteroid inhalers Corticosteroids are similar to a natural hormone (cortisol) that is produced by the body. Corticosteroid inhalers reduce the inflammation in the airways. An inhaled corticosteroid used for four weeks can help distinguish asthma from COPD. Clear improvement over 3 to 4 weeks suggests asthma. If a patient with moderate or severe COPD is not getting adequate relief from bronchodilator inhaler, a four-week trial using a long-acting bronchodilator and a corticosteroid inhaler is warranted. The trial will only be continued if it helps to control the symptoms. However, they do not slow down the progression of the disease.11,12 With severe COPD, a corticosteroid inhaler may be prescribed without having a fourweek trial. This is because there is some evidence to suggest that corticosteroids prevent flare-ups in those with very severe COPD. Corticosteroids must be used regularly for maximum benefit and alleviation of symptoms generally occurs within 3 to 7 days of commencement. There are several types of corticosteroid inhalers: • beclometasone • budesonide, • fluticasone Each corticosteroid appears to be equally effective. Combination inhalers containing both bronchodilators and corticosteroids are often

prescribed for patients with COPD as one inhaler only needs to be used instead of two. (eg) Seretide® Diskhaler, Symbicort® Turbohaler. Proper inhaler technique is very important, and should be assessed and explained by the pharmacist. Current and previous smoking reduces the effectiveness of corticosteroids and higher doses may be needed. OTHER MEDICATION Theophylline tablets Theophylline allows the muscles of the airways to relax and open up. Theophylline increases the strength of the diaphragm (the large muscle at the base of the chest that is used when breathing) and speeds up the clearance of mucus and phlegm from the lungs. This helps the patient to breathe more easily. It is used as a bronchodilator in stable COPD and is generally not effective in exacerbations of COPD. Theophylline is generally added to inhaler therapy if the symptoms are not under control. Toxic doses of theophylline are close to the therapeutic dose and with most patients satisfactory bronchodilation is associated with a plasma theophylline concentration in the range of 10 to 20mg/ litre although a lower plasma theophylline concentration may be effective. Adverse effects can occur within the range 10 to 20mg/litre but is more common at a plasma theophylline concentration of 20mg/ litre. Plasma theophylline concentration is increased with heart failure, hepatic impairment, viral infections, the elderly and drugs which inhibit its metabolism. Plasma theophylline concentration is decreased in smokers, with alcohol consumption and drugs which increase metabolism. Measuring the plasma theophylline concentration should be done at regular intervals. Due to the risk of potential side effects, such as increasing heart rate and headaches, other options such as a bronchodilator are usually tried first, before theophylline. Other side effects include palpitations, nausea and other gastrointestinal problems and insomnia. Mucolytic tablets or capsules Mucolytics, such as carbocisteine, make the mucus and phlegm in the throat thinner and easier to cough up. Their effectiveness is questionable. They may be beneficial for patients with moderate and severe COPD, who have frequent or bad flare-ups.(Eg) Viscolex® liquid, Exputex® liquid, Erdotin® caps. Antibiotics and corticosteroids Patients with COPD often suffer from chest infections so are frequently prescribed a short course of broad spectrum antibiotics

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such as amoxicillin, tetracycline or erythromycin. Oral corticosteroids may also be prescribed as a short course for one or two weeks when there is a bad flare-up. They work best if they're taken as the flare-up starts. Steroids (30mg prednisolone for 7-10 days) are of most benefit when the FEV1 is <50% predicted and if the patient has had two or more exacerbations in the previous year.11 Long term use of corticosteroids cause side effects including weight gain, osteoporosis, stomach ulcers and fluid retention. Side effects are minimal for short term courses. They should be taken as a single dose in the morning and after food. Enteric coated versions such as Deltacortil® reduce stomach irritation. Nebulisers A nebuliser can be used for the administration of bronchodilators and corticosteroids for severe cases of COPD. Nebulisers enable a large dose of the drug to be administered in one go. Aminophylline may be given intravenously if response to nebulised bronchodilators is poor. OTHER TYPES OF TREATMENT Long-term oxygen therapy In extreme cases of COPD, when the oxygen in the blood is low, the patient may need to take oxygen from an electronically operated oxygen concentrator through nasal tubes or through a mask. Hypoxic patients (PaO2 < 7.8 kPa) with evidence of cor pulmonale (enlargement of right ventricle in heart) have a 5-year survival of less than 50%.11 Long term oxygen therapy has been shown to increase survival in persistent daytime hypoxaemia (PaO2 < 7.3 kPa).13,14,15 There is no survival benefit of oxygen in patients with lesser degrees of hypoxaemia.16 However oxygen does increase survival for patients

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CPD 18: CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) with severe chronic COPD with hypoxaemia. Oxygen must be used for at least 15 hours a day. The tubes from the machine are long enough to enable a patient to move around their home while connected.

important for keeping the immune system strong and healthy. Eat plenty of fruit and vegetables (at least five portions a day) and reduce the amount of fat, sugar and salt, in the diet.

Patients must not smoke when using an oxygen concentrator. The increased level of oxygen that is produced is highly flammable, and a lit cigarette could trigger a fire or an explosion.

Drink plenty of fluids

8. Barnes PJ Small airways in COPD.NEJM 2004; 350: 2635-2635

Drink plenty of fluids, particularly water, to help to reduce the amount of mucus and phlegm in the throat and lungs.

9. Pauwels RA, Rabe KF. Burden and clinical features of chronic obstructive pulmonary disease (COPD) Lancet 2004; 364: 613-20


Use a steam inhalator or humidifier

10. Rennard S. Looking at the patient – approaching the problem of COPD. NEJM 2004; 350:965-66

In rare cases, hospitalisation may be necessary during an exacerbation of COPD. In hospital, patients usually receive oxygen, antibiotics (if necessary) and a nebuliser to help ease symptoms. If COPD is very severe, a stay in hospital is nearly always more effective than resting at home because the condition can be constantly monitored by medical professionals.

A steam inhalator or humidifier can be used at home to help to reduce excess mucus and phlegm. They can also reduce the feeling of being blocked up and being unable to breathe properly.

11. NICE Guidelines on management of COPD Thorax 2004; 59(Supp 1): 1-232 Clinical guideline 12, developed by the National Collaborating Centre for Chronic Conditions


13. Continuous or nocturnal oxygen therapy in hypoxaemic chronic obstructive lung disease: a clinical trial. Nocturnal Oxygen Therapy Trial Group Ann Intern Med 1980; 93: 391

Lung transplantation Lung transplantation is rare in cases of COPD and it is usually only suggested if life expectancy is less than two years. Although lung transplantations are usually very successful, the patient will need to take immunosuppressants medication for the rest of their life to prevent organ rejection. Side effects of immunosuppressants are common and include headaches and hypertension. Lung volume reduction surgery (LVRS) Lung volume reduction surgery (LVRS) is when the damaged parts of the lung are removed during surgery. This can improve symptoms, but may put the patient at increased risk of catching pneumonia or developing an air leak where the lung is resealed. PREVENTING COPD There are aspects of lifestyle that a patient can change in order to reduce the risk of developing chronic obstructive pulmonary disease (COPD), or to help ease symptoms. Give up smoking Not smoking is the best way to prevent COPD. Quitting can slow down the progress of the condition. If symptoms of COPD are mild, stopping smoking may be all that is needed to significantly improve them. Get regular exercise Regular exercise will help to strengthen the heart and lungs, and improve breathing. Build up gradually if not used to exercising. The aim is to do a minimum of 30 minutes of exercise a day, at least five times a week. Losing weight, if overweight can also be beneficial because extra weight can make breathlessness worse.

Physiotherapy can help to clear excess mucus and phlegm. A physiotherapist will be able to teach exercises to do at home, such as arm exercises. Get vaccinated Patients with COPD are at greater risk of catching other illnesses, such as influenza (flu).They should therefore have an annual flu jab every autumn (September to November). A vaccination against pneumococcus (a bacterium that can cause serious chest infections) is also recommended, as a one-off injection. Protection from the pneumoccus vaccine lasts for 5 years or longer. Patients with ephritic syndrome (kidney damage), splenic (injury to spleen) or asplenic dysfunction (no spleen) may need additional vaccinations. COPD and flying Before flying, the patient should check with their GP to ensure they feel they are fit to fly. Before travelling, remember to pack all medication, such as inhalers, in hand luggage. A letter from a doctor or pharmacist explaining why the medication is needed is advised. Patients using oxygen therapy should inform the travel operator and airline before booking a holiday, as a medical form may be needed from their GP. If using long-term oxygen therapy, ensure adequate oxygen supply for the trip. REFERENCES 1. National Medicines information Centre; St James Hospital, Dublin 8. Chronic Obstructive Pulmonary Disease; Volume 10, Number 3, 2004;p1. 2. Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: Global Burden of Disease Study Lancet 1997; 349: 1269-76 3. Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study Lancet 1997; 349: 1436-42

Eat a balanced diet

4. Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study Lancet 1997; 349: 1498-504

Eating a healthy, balanced diet is very

5. White J, Winter R, Chilvers E. COPD: recent

advances Horizons in Medicine 2003; 14: 373-82

6. Barnes PJ. Small airways in COPD. NEJM 2004; 350: 2635-2635 7. Brennan N, O’Connor T. Ireland Needs Healthier Airways and Lungs – the evidence. June 2003

12. Global initiative for Chronic Obstructive Lung Disease Updated 2003;

14. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema Report of the Medical Research Council Working Party Lancet 1981; 1: 681 15. Cochrane Database system – Domiciliary oxygen for COPD Cochrane Database Syst Rev 2000;(2):CD001744 16. Gorecka D, Gorzelak K, Sliwinske P et al. Effect of long term oxygen therapy on survival in patients with chronic obstructive pulmonary disease with moderate hypoxaemia Thorax 1997; 52: 674 17. David M. Mannino. COPD*: Epidemiology, Prevalence, Morbidity and Mortality, and Disease Heterogeneity. Chest 2002; 121;121S-126S.

Pfizer Healthcare Ireland are committed to supporting the continuous professional development of pharmacists in Ireland. We are delighted to be partnering with Irish Pharmacy News in order to succeed with this. Throughout the year, Irish Pharmacy News will deliver 12 separate modules of continuous professional development, across a wide range of therapy areas. These topics are chosen to support the more common interactions with pharmacy patients, and to optimise the patient experience with retail pharmacy. We began the 2011 programme with a section on the Gastrointestinal System. Other topics include Diabetes (Types I and II), the Cardiovascular System, Smoking Cessation, Infections, Parkinson’s Disease, Alzheimer’s Disease, Depression and others. We hope you will find value in all topics. Pfizer’s support of this programme is the latest element in a range of activities designed to benefit retail pharmacy. Other initiatives include the Multilingual Pharmacy Tool, a tailored Medical Communications Programme, Educational Meetings and Grants, our Patient Information Pack, new pharmacy Consultation Room brochures and other patient-assist programmes including the Quit with Help programme and If you would like additional information on any of these pharmacy programmes, please contact Pfizer Healthcare Ireland on 01-4676500 and ask for the Established Products Business Unit. EPBU/2012/039

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