copd review

CHRONICOBSTRUCTIVE

PULMONARY DISEASE

Jongsiriyunyong K. EP rj

INTRODUCTION Progressive and Non fully reversible

airflow limitation

COPD is a disorder in which subsets have dominant features of

chronic bronchitis chronic productive cough for 3 months during

each of 2 consecutive years emphysema, or asthma

permanent enlargement of the air spaces distal to the terminal bronchioles, without obvious fibrosis

INTRODUCTION The Global Initiative for Chronic Obstructive

Lung Disease (GOLD) guidelines define COPD as a disease state characterized by

Airflow limitation that is not fully reversible, is usually progressive, and

Associated with an abnormal inflammatory response of the lungs to inhaled noxious particles or gases

Venn diagram of chronic obstructive pulmonary disease (COPD).

1 21

3 45

6 78

9 10

Histopathology of chronic bronchitis showing hyperplasia of mucous glands and infiltration of the airway wall with inflammatory cells

Gross pathology of advanced emphysema. Large bullae are present on the surface of the lung.

At high magnification, loss of alveolar walls and dilatation of airspaces in emphysema can be seen.

Pathophysiological

This phenomenon is called dynamic hyperinflation

ETIOLOGY I/II Cigarette smoking- 90%

Environmental factors Biomass fuels with indoor cooking and heating Traffic-related air pollution

Airway hyperresponsiveness

Alpha1-antitrypsin deficiency Panacinar emphysema Premature emphysema at an average age of 53 years for

nonsmokers and 40 years for smokers

Intravenous drug use Pulmonary vascular damage

Insoluble filler (eg, cornstarch, cotton fibers, cellulose, talc) contained in methadone or methylphenidate

Cocaine or heroin

ETIOLOGY II/II Immunodeficiency syndromes

Independent risk

Vasculitis syndrome Hypocomplementemic vasculitis urticaria syndrome

(HVUS)

Connective tissue disorders Cutis laxa is a disorder of elastin , various forms of

inheritance Marfan syndrome is an autosomal dominant inherited

disease of type I collagen Ehlers-Danlos syndrome

Salla disease Autosomal recessive storage disorder , sialic acid

PROGNOSIS For assess an individual’s risk of death or

hospitalization

History

Multifactorial with Individual lifestyle Socioeconomic factors Education / Knowledge

BODE INDEX

4-year survival

0-2 points = 80%

3-4 points = 67%

5-6 points = 57%

7-10 points = 18%

Click icon to add picture

CHARACTERISTIC I/II

Cough worsening dyspnea progressive exercise

intolerance sputum production alteration in mental

status Productive cough or

acute chest illness Breathlessness Wheezing

Systemic manifestations decreased fat-free mass impaired systemic

muscle function Osteoporosis Anemia Depression pulmonary hypertension cor pulmonale left-sided heart failure

Typically combination of signs and symptoms of chronic bronchitis, emphysema, and reactive airway disease.

CHARACTERISTIC II/II Hx of more than 40 pack-yrs of smoking

was the best single predictor of airflow obstruction

If all 3 signs are absent, airflow obstruction can be nearly ruled out Self-reported smoking Hx of > 55 pack-yrs Wheezing on auscultation Self-reported wheezing

PHYSICAL EXAMINATION Hyperinflation (barrel chest)

Wheezing – Frequently heard on forced and unforced expiration

Diffusely decreased breath sounds

Hyperresonance on percussion

Prolonged expiration phase

CHARACTERISTICS ALLOW DIFFERENTIATION

Chronic bronchitis Emphysema

obese Frequent cough and

expectoration Use of accessory

muscles of respiration is common

Coarse rhonchi and wheezing may be heard on auscultation

signs of right heart failure Cor pulmonale

edema and cyanosis

thin with a barrel chest little or no cough Breathing may be

assisted by pursed lips patients may adopt the

tripod sitting position hyperresonant, and

wheezing may be heard Distant Heart sounds

DIFFERENTIALS DIAGNOSIS Alpha1-Antitrypsin def

Bronchitis

Emphysema

Nicotine Addiction

Pulmonary Embolism

INVESTIGATION I/II Pulmonary Function Tests

For diagnosis Assessment of severity Following its progress

ABG Hypoxemia / hypercapnia Acidosis

Serum Chemistries Retain sodium /Lower potassium levels

/bicarbonate Chronic respiratory acidosis leads to compensatory

metabolic alkalosis

INVESTIGATION II/II CBC

Secondary polycythemia Hct>52% in men or 47% in women

Alpha1-Antitrypsin all patients < 40 yrs or Fm Hx of emphysema at

early age

Sputum Evaluation Streptococcus pneumoniae  Haemophilus influenzae Moraxella catarrhalis Pseudomonas aeruginosa

Chest Radiography +/- CT scan

COPD: Hyperinflation, depressed diaphragm, increased retrosternal space, and hypovascularity of lung parenchyma are demonstrated.

Emphysema : increased AP diameter, increased retrosternal airspace, and flattened diaphragm on lateral chest radiograph.

A lung with emphysema shows increased anteroposterior (AP) diameter, increased retrosternal airspace, and flattened diaphragm on posteroanterior chest radiograph

A computed tomography (CT) scan shows hyperlucency due to diffuse hypovascularity and bullae formation, predominantly in the upper lobes.

Severe bullous disease as seen on a computed tomography (CT) scan in a patient with chronic obstructive pulmonary disease (COPD).

TREATMENT Acute exacerbation

Stable COPDRx base on severity of disease

TREATMENT

Severity evaluateMild to moderate

เหนื่��อยเพิ่�มขึ้� นื่ไม�มาก Hemodynamic stable เพิ่�มขึ้นื่าดยาและความถี่��ขึ้อง bronchodilator Pred 30-40 mg/dy for 7dy

Moderate to severe Risk for respiratory failure

AOC Accessory muscle used: paradoxical chest/abd motion SpO2 < 90% or PaO2 < 60 mmHg PaCO2 > 45 mmHg or pH < 7.35

Acute exacerbation

TREATMENT

Indication for admit

Severe exarcerbation Severe stage of COPD New onset of : cyanosis, peripheral edema Unimprove after appropriated Tx Multi-Comorbit : CAD, DM, HT New onset Arrhythmia Undefinite Diagnosis Old age or Homeless

ACUTE EXACERBATION

treatment

TREATMENTAcute exacerbation : 1-3 wk onset Bronchodilator

Beta2-agonist Anticholinergic Methylxantine

Corticosteroid Systemic corticosteroids

Oxygen All pt with SpO2 < 90% keep SpO2 90-94%

Antibiotic Cover Streptococcus pneumoniae, Hemophilus influenza,

Morexella catarrhalis, Klebsiella pneumoniae ; Pseudomonas aeruginosa

Machanical ventilation Non-invasive positive pressure ventilation: NIPPV Invasive mechanical ventilation

TREATMENTAcute exacerbation : 1-3 wk onset

Short acting Beta2-agonist is first line but recommended combine of SABA and Anticholinergic for limited S/E (palpitation, tachycardia, tremor)

Fenoterol/Ipratropium bromide Every 15-20 min in 1st hour then 4-6 hr interval Addition SABA every 1-2 hr

BRONCHODILATOR

Medication type Onset (min)

duration (hour)

Route drug

Beta2agonist Short 3-5 4-6 InhaleOralIV

Salbutamol(ventolin®)

TerbutalineFenoterol

8-12 InhaleOral

Procaterol

Long 30-45 > 12 Inhale SalmeterolFormoterol

Anticholinergic Short 10-15 6-8 Inhale Ipratopium bromide

Long 5 >24 Inhale Tiotropium (Spiriva®)

Methylxanthine Uncertained in sustained release OralIV

TheophyllineAminophylline

TREATMENTAcute exacerbation : 1-3 wk onset

Systemic corticosteroid

Limited systemic inflammation and airway inflammation Decrease sputum eosinophil Decrease serum CRP Improve FEV1 and PaO2 Minimize treatment failure / Length of stay in Hospital/

Exacerbation No improve of mortality

Prednisoline 30-40 mg/dy for 7-14 dy or

Dexamethasone 5- 10 mg q 6 hr orHydrocortisone 100-200 mg q 6 hr

TREATMENTAcute exacerbation : 1-3 wk onset

Oxygen All pt with SpO2 < 90% keep SpO2 90-94%

Limited S/E of Oxygen supplement ลด hypoxic drive ทำ�าให�เกด hypoventilation เพิ่�ม ventilation / perfusion mismatch (เพิ่�ม

deadspace ) Haldane effect

rightward displacement of the CO2-hemoglobin dissociation curve in the presence of increased oxygen saturation, increasing the amount of CO2 dissolved in blood

TREATMENTAcute exacerbation : 1-3 wk onset

Machanical ventilation

Indication of NIPPV เหนื่��อยมากร่�วมก!บ accessory muscle with abd paradox Acidosis pH 7.25-7.35 and/or PaCO2 > 45 mmHg RR > 24 / min

C/I of NIPPV Uncooperation เสมหะมาก หย$ดหายใจ Cardiovascular instability Life-threatening hypoxemia Severe acidosis : pH < 7.25

TREATMENTAcute exacerbation : 1-3 wk onset

Machanical ventilationIndication of Invasive mechanical

ventilation Respiratory failure

Severe acidosis : pH < 7.25RR > 35/minAccessory muscle used

with C/I for NIPPV Fail NIPPV

STABLE COPD

treatment

TREATMENTStable COPD : base on severity Bronchodilator

Beta2-agonist Anticholinergic Methylxantine

Corticosteroid inhaled corticosteroids

Vaccination Annual influenza vaccine Pneumococcal vaccination

Pulmonary rehabilitation Improve quality of life

Oxygen therapy Short term Long term

sugery

TREATMENTStable COPD : at ALL stage

Avoidance of risk factor(s)

Influenza vaccination

Pneumococcal vaccination

TREATMENTStable COPD : Mild COPD

Short-acting bronchodilator when needed

TREATMENTStable COPD : Moderate COPD

Short-acting bronchodilator when needed

Regular treatment with one or more long-acting bronchodilators

Rehabilitation

TREATMENTStable COPD : Severe COPD

Short-acting bronchodilator when needed

Regular treatment with one or more long-acting bronchodilators

Rehabilitation

Inhaled glucocorticoids if significant symptoms, lung function response, or if repeated exacerbations

COMBINATION ICS/LABA

Combination Dose(ug/dy) Trade name

Fluticasone/Salmeterol 500/100-1000/100

Seretide®

Budesonide / Formeterol 320/9-640/18 Symbicort®

BRONCHODILATOR

Medication type Onset (min)

duration (hour)

Route drug

Beta2agonist Short 3-5 4-6 InhaleOralIV

Salbutamol(ventolin®)

TerbutalineFenoterol

8-12 InhaleOral

Procaterol

Long 30-45 > 12 Inhale SalmeterolFormoterol

Anticholinergic Short 10-15 6-8 Inhale Ipratopium bromide

Long 5 >24 Inhale Tiotropium (Spiriva®)

Methylxanthine Uncertained in sustained release OralIV

TheophyllineAminophylline

TREATMENTStable COPD : Very severe COPD

Short-acting bronchodilator when needed

Regular treatment with one or more long-acting bronchodilators

Inhaled glucocorticoids if significant symptoms, lung function response, or if repeated exacerbations

Treatment of complications : CHF, infection, nutrition

Rehabilitation

Long-term oxygen therapy if chronic respiratory failure

Consider surgical treatment

VACCINATION

PULMONARY REHABILITATION

OXYGEN THERAPY ม� 3 แบบ ค�อ

Short-term therapyLong-term continuous therapyDuring exercise

เป้'าหมายค�อเพิ่�ม PaO2 ให�ได�อย�างนื่�อย 60 mmHg ขึ้ณะพิ่!ก และ/หร่�อ SaO2อย�างนื่�อย 90% ซึ่��งจะทำ�าให�อว!ยวะทำ��ส�าค!ญได�ร่!บ O2

SHORT TERM OXYGEN THERAPY Indication for STOT

Recent Exacerbation with new hypoxemia

Re-evaluate at wk 4 Continue STOT if still hypoxemia

Re-evaluate at Mo 3Treat as LTOT

LONG TERM OXYGEN THERAPY Continue Oxygen supplement > 15 hr/dy

ลด mortality เพิ่�ม exercise toleranceQuality of life: psychotherypyPrevent pulmonary HT

Ind for LTOTPaO2 < 55 mmHg or SaO2 < 88%

PaO2 < 56-59 mmHg or SaO2 < 89% with sign of chronic hypoxemia Pul HT Peripheral edema จาก CHF Polycythemia (Hct > 55%)

Failed STOT

OXYGEN THERAPY

Oxygen therapy via nasal cannulaHome supplemental

oxygen

Bilevel positive airway pressure (BiPAP)

DISPOSITION Hemodynamic stable

Bronchodilator supply less than every 4 hr

SpO2 >90% w/o O2 supplement at least 24 hr

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