Definitions



Chronic Bronchitis (clinical)

Sputum production more days than not for at least 3 months a year for at least 2 years

Blue bloaters

Emphysema (pathologic)

Parenchymal destruction airspace walls distal to terminal bronchioles, without fibrosis

Pink Puffers

Epidemiology:

Fourth leading cause of death in U.S.

100,000 American deaths each year

15-20% of chronic smokers develop COPD

2.5% mortality for COPD hospital admissions

COPD with acute respiratory failure:

24% in hospital mortality

59% one year mortality

Epidemiology Diagnosis:

Symptoms

Dyspnea

Cough

Sputum production (especially in the morning)

Recurrent acute chest illnesses

Headache in the morning ? possible hypercapnia

Cor pulmonale (R heart failure)

Diagnosis:

Signs

Prolonged expiratory time

Expiratory wheezes

Increased AP diameter of chest

Decreased breath sounds (especially upper lung fields)

Distant heart sounds

End stage: accessory muscles, pursed lip breathing, cyanosis, enlarged liver

Radiology

Chest X-ray

Bullae, often bilateral upper lobes in smokers

Flat diaphragms (best seen on lateral) and retrosternal airspace can indicate air trapping

High Resolution CT of Chest

Most sensitive to detect above changes

No role in routine care of COPD patients

Can be useful for giant bullous disease surgeries or lung volume reduction surgery planning

GOLD Staging Criteria:

GOLD Staging Criteria

Stage O: Normal spirometry; chronic sx

Stage 1 (Mild):

FEV1> 80%

Stage 2 (Moderate):

2A: FEV1 50-80% predicted

2B: FEV1 30-50% predicted

Stage 3 (severe):

FEV1/FVC < 70% AND:

FEV1 < 30% predicted and clinical evidence of R heart failure

Managing Stable COPD:

Smoking Cessation Is KEY!

YOUR intervention will make a difference ? must address at each visit

Medication, accupuncture, hypnotherapy

Two therapies ONLY have been shown to improve mortality in stable COPD:

1) Smoking Cessation

2) Oxygen Therapy

Bronchodilator Technique

Inhalers get better drug deposition than nebs

Use a spacer device with MDI's

Technique is key ? impt for patient and MD

Inadequate dosing can hamper treatment

Sympathomimetics

Beta-2 selectivity is good

Unclear if prn vs. scheduled is better

Some additive vs. slightly synergistic effects of combining beta-2 agonist and ipratropium (Combivent)

Some data to support decreased H.influenzae pneumonia incidence with Serevent

Anticholinergic Agents (Atrovent, etc)

Similar ability to bronchodilate (in appropriate doses) as beta-agonists

Also reduces sputum volume; no change in viscosity

Usually under dosed

Recommend 4-6 puffs qid

Theophylline ? Be careful

Data supporting use are scant, but some improvement in resp muscle function, ABG's ? only very modest

Significant side effect profile

If using, target a serum level of 8-12 mcg/mL

RARELY of significant clinical benefit

Mucokinetic agents

Of no significant clinical benefit in large studies

Increased fluid intake DOES NOT affect sputum viscosity significantly

Postural drainage and chest PT are generally not useful unless there is a significant bronchiectasis component

Oxygen. Yes.

Demonstrated to improve exercise performance, symptom indices and mortality

Goal in hypercapnic patients for SpO2 need not be greater than 88-90%

Always test COPD patients for oxygenation with ambulation if baseline at rest room air SpO2.

Systemic Corticosteroids

Never demonstrated to significantly impact mortality or exercise capacity

Slight improvements in symptom indices

Significant side effects

Rarely of benefit, generally of harm to your patient

Occasionally useful in a small subset failing other therapies AND with demonstrated bronchodilator response on PFT's

Inhaled Corticosteroids

Lots of recent research with some favorable data supporting its use

May be part of standard regimens in the future

Vaccines

Pneumovax, annual flu shots

Chronic antibiotic therapy ? BAD IDEA

Nutritional status ? Important

Pulmonary Rehabilitation

Improved exercise capacity, symptom scores

Lung Volume Reduction Surgery

Transplant

Common precipitants:

Infection ? esp viral or bacterial

Acute bronchospasm

Sedation

Who To Admit

Countless studies, few definite answers

Worsening hypoxemia and/or hypercapnia

Otherwise, mostly a clinical decision.

Key points to consider:

Oxygen

Bronchodilators

Steroids

Antibiotics