Chronic Obstructive Pulmonary Disease - Copd

By Author: Ibrahim Machiwala
Total Articles: 463
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Definitions
A disease state characterized by airflow limitation that is not fully reversible.

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