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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
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Dr. D.S. Merchant is a Gold Medalist in (Anatomy & Histology), Resident AKUH, Pakistan. For more information on Chronic Obstructive or visit www.articles4free.com is a popular website that offers information on Pulmonary Disease, Mesothelioma Symptoms, VHF Solutions, and VHF Medications. Please leave the links intact if you wish to reprint this article.
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