Transcript COPD: management

COPD
Management in the Pulmonary
Department of the University
Hospital of Crete
COPD
 An effective COPD management
includes:
– a) Assess and Monitor Disease
– b) Reduce Risk Factors
– c) Manage Stable COPD
– d) Manage Exacerbations
COPD: physical findings
 The physical signs in patients with COPD depend on
the degree of airflow limitation, the severity of
pulmonary hyperinflation, and body build.
 Classical signs: a) wheezing during tidal breathing
b) prolonged forced expiratory time
c) diminished breath sounds
d) diaphragmatic excursion
 These signs are useful indicators of airflow limitation
but of no value as guides to severity
COPD: physical findings
 During exacerbation, the clinical findings depend on:
– the degree of additional airflow limitation
– the severity of the underlying COPD
– the presence of coexisting conditions.
 The severity of an exacerbation is assessed crudely by:
– tachypnoea, tachycardia
– use of accessory respiratory muscles
– cyanosis, pursed-lip breathing
– evidence of respiratory muscle dysfunction or fatigue
COPD
 The classic signs of hypercapnia are
inconsistent and unreliable
 The poor sensitivity of symptoms and
signs emphasizes the need for objective
measurements
 If the severity of an exacerbation is in
doubt, it should always be assessed in
hospital
COPD: investigations
(objective measurements)
 Lung Function Tests : useful not only for
the diagnosis but for the assessment of the
severity, progression and prognosis as well
 The FEV1/VC ratio is a relatively sensitive
index of mild COPD. In moderate to severe
disease, the severity of airflow limitation is
best assessed by the FEV1 in relation to
reference values
COPD: investigation
 According to ERS consensus
the severity of COPD is
estimated based on FEV1.
Severity
– Mild
– Moderate
– Severe
FEV1 (%pred)
≥70
50-69
<50
COPD: investigation
 Routine: FEV1




VC or FVC
Bronchodilator response
Chest radiograph
TLco/Kco
COPD: investigation
 Moderate or severe:






Lung volumes
Blood gases
Electrocardiogram
Ht and Hb
Purulent sputum
Sputum culture and
sensitivity
Young patient
a1-antitrypsin level
Assessment of bullae CT scan
COPD: specific indications
 Disproportionate dyspnoea: Exercise test
 Suspected asthma:
 Suspected OSA:
MIP MEP
Bronchoconstrictor
response
Sleep studies
COPD: management/stable
Aims:
a) to improve symptoms and quality of life
b) to reduce the decline of lung function
c) to prevent and treat complications
d) to increase survival with maintained quality of life
e) to avoid or minimize adverse effects of treatment
COPD: management/mild
stable
 Step One:
Smoking cessation
Protection from or reduction of
environmental exposure
Annual influenza vaccination
 Measure FEV1 at least yearly
 Short-acting bronchodilator when needed
COPD: management /mild stable
 Dyspnoea

Consider and treat other causes of dyspnoea
– heart failure, muscle weakness
Bronchodilators: anticholinergic or b2-agonist
 Ensure adequate inhaler technique
 Review at 4-6 weeks:

– symptom relief or inhaler use ≤ 4/day :
review at 6-12 months
– symptoms persist: switch or add BD
–
review at 4-6 week
–
rehab or other causes
COPD: management of
moderate/stable
 First step plus:
– Regular treatment with one or more
bronchodilators
– Rehabilitation
– Inhaled steroids if significant symptoms and lung
function response or if repeated exacerbations
COPD:management / rehab
Lack of Fitness
COPD
Dyspnea
Depression
Immobility
Social Isolation
COPD: severe/stable
 First step plus:
– Regular treatment with one or more
bronchodilators
– Inhaled glucocorticosteroids if significant
symptoms and lung function response or if
repeated exacerbations
– Treatment of complications
– Rehabilitation
– Long-term O2 therapy if needed
– Consider surgical treatments
COPD: causes of acute
exacerbation
 Infection of the tracheobronchial tree (viral)
 Pneumonia
 Heart failure or arrhythmias
 Pulmonary embolism
 Pneumothorax
 Inappropriate oxygen administration
 Drugs/Poor nutritional status
 Metabolic or other diseases (gast .bleeding)
Case I
 Mr DJ (69 yrs old) is referred to the emergency
department by a general physician for evaluation
of COPD exacerbation.
 The patient had a diagnosis of COPD of mild
severity (FEV1 60% pred) 10 months ago and is on
treatment with inhaled bronchodilators (b2agonists) as needed.
 The patient is febrile (T: 37,5-38,3oC) and he has
a productive cough with purulent sputum for the
last 2 days. He also refers dyspnea on exertion .
PEF 180L/min
COPD: measurements in the
emergency room
– Physical Examination
– FEV1
– Arterial Blood gases :
 breathing room air:
 on O2 therapy
– Chest radiograph
– White blood cell count
– Sputum stain/culture
– Biochemistry (gl, urea, electrolites)
– Electrocardiogram
Case 1
 The physical examination reveals wheezing
and diminished breath sounds bilaterally
 FEV1 :1.8L (68% of pred)
 ABG: (room air) PO2 67mmHg,
PCO2 49mmHg, pH 7.37
 Chest x-ray: lung hyperinflation
 WCC(mm3): 11500
 Sputum stain : gram + bac
Case 1
 The physician decides that the patient does not meet
the criteria for hospital admission. He/she
prescribes
– increases the doses of b2-agonists and adds
anticholinergics
– an antibiotic (amoxycillin/ clavulanic acid)
– rehabilitation of respiratory system
– Furthermore he/she advises him to visit the
Outpatient Hospital department in two weeks for
re-evaluation.(of the progression of the disease)
Case II
 Mr JR, 72 yrs old, arrives to the emergency
department with shortness of breath of three
days duration and increased sputum
production.
 The patient had a previous diagnosis of COPD
of moderate severity (FEV1 67% pred) and is
on
regular
therapy
with
inhaled
bronchodilators.
 He has a smoking history of 40 pack years and
quit smoking 5 years ago. The resident on call
evaluates the patient
COPD: measurements in the
emergency room
– FEV1
– Arterial Blood gases :
 breathing room air:
 on O2 therapy
– Chest radiograph
– White blood cell count
– Sputum stain/culture
– Biochemistry (gl, urea, electrolites)
– Electrocardiogram
Case II
RR :26 br/min HR: 115b/min
Use of accessory resp muscles
Bilateral basal crackles. Wheezing
FEV1 0.8 L (30% of predicted)
ABG: PaO2 45 mmHg, PaCO2 50 mmHg (21%)
On O2 (FIO2 28%) PaO2 57 mmHg,
PaCO2 54 mmHg, pH 7.33
 X-ray “dirty lungs”
 WBC: 12000
 ECG: atrial fibrillation






CaseII
 Does the patient meet the criteria for
admission;
COPD: indications for admission
 ↑ in intensity of symptoms
 Severe background COPD
 New physical signs (cyanosis, edema)
 Failure of exacerbation to respond to initial medical





management
Significant comorbidities
Arrhythmias (newly occurring)
Diagnostic uncertainty
Older age
Insufficient home support
COPD: hospital management
 Goals:
– a) to evaluate the severity, including lifethreatening conditions
– b) to identify the cause of the exacerbation
– c) to provide controlled oxygenation
– d)to return the patient to the best previous
condition
Case II
 Does the patient meet the criteria for
severe exacerbetion;
COPD: management in the
department
 Administer controlled O2 therapy
 Bronchodilators:
 Antibiotics
 Steroids
 Consider noninvasive mechanical
ventilation
 Rehabilitation
COPD: management
 O2 therapy: low inspired O2:
Venturi
mask
Nasal cannula
 Reassess with blood gas mesurement after 30
min:
Increase FIO2 stepwise
Use of NIMV
Case II
 Does the patient meet the criteria for NIPPV;
COPD: criteria for severe exacerbation
 History:
Previous condition
 Symptoms:
Cough / Sputum
Dyspnea at rest

 Sighs:



T>38.8’C, RR>25br/min,
HR>110beats/min, Edema
Worsening cyanosis
Use of accessory muscles
Loss of alertness
 Measurement: PEF<100L/min
–
COPD: management
 Criteria for NIPPV:
– Respiratory asidosis (pH:7.25-7.35,
–
PaCO2> 50-60 mmHg)
– Moderate to severe dyspnea with use of
accessory muscles and paradoxical abdominal
motion
– RR > 25 br/min
COPD: management
 In addition to standard medical
treatment the patients should receive
NIPPV on general ward
– (Plant et al. Lancet 2000 )
COPD: management
 Bronchodilators:
– Increase dose or frequency.
– Combine b2-agonists and anticholinergics.
– Use spacers or air-driven nebulizers.
– Consider adding intravenous
aminophylline.
COPD: management
 Antibiotics:
– Use of Anthonisen’s criteria:
increased dyspnoea
increased cough
increased sputum volume
increased sputum purulence
COPD: pathogens/antibiotics
 Pathogens:
– viruses
– streptococcus pneumoniae
– haemophilus influenzae
– moraxella catarrhalis
 Antibiotics:
– amoxycillin or amoxycillin/clavulanic acid
– cephalosporines,
– macrolides
– quinolones
COPD: management
 Corticosteroids:
– Systemic glucorticosteroids are beneficial
in the management of acute exacerbations.
– They shorten recovery time and help to
restore lung function more quickly
– They should be considered in addition to
bronchodilators if FEV1<50% pred
– We use 30-40mg of prednisolone /day for
10-14 days
COPD: management
 At all times:
– a) Monitor fluid balance and nutrition
– b) Consider subcutaneous heparine
– c) Identify and treat associated conditions:
heart failure
arrhythmias
– Closely monitor condition of the patient
COPD: discharge criteria
 Bronchodilators no more than every 4h
 Patient is able to eat and sleep without
frequent awakening by dyspnea.
 Patient has been clinically stable for 1224h
 Arterial blood gases have been stable for
12-24h
 Patient (or home caregiver) fully
understands correct use of medications
COPD: conclusions I
 Exacerbations of respiratory symptoms requiring
medical intervention are important clinical events in
COPD
 The most common causes are infections and air
pollution
COPD: conclusions II
 Inhaled bronchodilators, systemic steroids
and if there is an evidence antibiotics are
effective for treatments for acute
exacerbations
 NIPPV in acute exacerbations improves
blood gases and pH, reduces in-hospital
mortality, decreases the need for IMV and
decreases the length of hospital stay