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
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
Smoking: Previous episodes Details of previous admissions Current treatment
Precipitating factor in this case: P/E Tachypnea Prolonged expiratory time Expiratory wheezes Increased AP diameter of chest Decreased breath sounds (especially upper lung fields) Distant heart sounds End stage: accessory muscles, cyanosis, enlarged liver
Stage 0: N Spirometry with symptoms Stage 1: Mild COPD FEV1>/= 80% Stage 2: Mod COPD FEV1 30% to 80% Stage 3:Severe COPD FEV1 <30%
Guidelines from the Global Initiative for Chronic (GOLD) state that the airflow limitation in COPD is characterized by an FEV1 value that is less than 80 percent of the predicted normal valu
Management of the acute exacerbation: 1. O2 2. IV steroid should not be used d in the community unless - the patient is already on oral corticosteroids; only if there is a previously documented response 3. Bronchodilators Neb - better in acute setting Continuous nebulizer treatments confer no benefit over treatments every 1-2 hours should avoid subcutaneous beta-agonists S/E Hypokalemia, tachycardia (occasional)
Anticholinergics: May decrease secretions Few side effects
B2 agonists 3 Oral corticosteroids dose of 30 mg per day for one week.
IF? this is the first presentation of airflow obstruction ? multiple previous admissions in the past five yrs including intensive care unit . usually given in an intensive therapy unit ? smoking history . should not normally be continued long term. 4 Antibiotic (maximum of seven days of treatment is sufficient)
Winnipeg? Criteria ? increased breathlessness ? increased sputum volume ? development of purulent sputum
Amoxicillin, Doxycycline, TMP/SMX, Azithromycin, Clarithromycin - all acceptable
Non-Invasive Positive Pressure Ventilation: ? BiPAP! ? Set FiO2, inspiratory (IPAP) and expiratory (EPAP) ? Difference between IPAP and EPAP augments tidal volume, therefore improving minute ventilation. CO2 then gets blown off ? MORTALITY BENEFIT in patients who will tolerate
Mechanical Ventilation: ? Respiratory distress ? Acidemia that does not correct quickly with therapy ? Inability to oxygenate adequately ? Often a clinical decision relative to patient's work of breathing
Ibrahim Lodhi has sinced written about articles on various topics from Religion, Nutrition and Pets. Dr. D.S. Merchant is a Gold Medalist in (Anatomy & Histology), Resident AKUH, Pakistan. For more information on Chronic Obstructive or visit. Ibrahim Lodhi's top article generates over 90500 views. Bookmark Ibrahim Lodhi to your Favourites.