COPD: management
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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