COPD

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Author:
robinlhx
ID:
187984
Filename:
COPD
Updated:
2012-12-08 22:46:13
Tags:
Theraputics
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Description:
Chronic obstructive pulmonary disease
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  1. what should COPD do?
    • -they should have influenza caccine(one per year) and a pneumococcal vaccin(one per lifetime).
    • -if you got your first does of pneumococcal vaccine more than 5 years when you reach your age 65, you should get your second dose at 65.
  2. Two types of COPD
    • -Brochitis
    •  -wet, lot's of mucus
    •  -more infection
    • -usually die of pneumonia
    •   - go to hospital more often
    • -Emphysema
    •  -don;t usually get sick, but once you sick, then death!!
    •  -dry, people live longer with this type.
  3. COPD Definition
    COPD is a disease state chgaracteruzed by airflow limitation that is not fuly reversible, associate inflammatory response.
  4. diffences between Asthma vs. COPD
    -onset
    -symptoms
    -history
    -type of airflow limitation
    • Asthma
    • -onset early in life
    • -symptoms vary day to day
    • -allergy, rhinititis, eczema also present
    • -family history
    • -Largely reversible airflow limitation

    • COPD
    • -onset in midlife (really slow)
    • -symptoms slowly progressive
    • -long smkoing history
    • -dyspnea on exertion
    • -largely Irreversible  airflow limitation
  5. facts about COPD
    • -COPD is now the Third leading casuse of death.
    • -for all age group > 55 yrs old
  6. Risk factors for COPD
    • -Genes
    • -Exposure to particles
    •   -tobacco smoke
    •   -occupatiobnal dust
    •   -indoor air pollution from heating and cooking with biomass
    •   -outdoor air pollution
    • -lung growth and delopment
    • -oxidative stress
    • -gender
    • -age
    • -repiratory infections
    • -socioeconimic status
    • -comorbidities
  7. Etiology/ Risk factors
    • -cigratte smoking
    • -genetic factors
    • -----emphysema-a1-antutrypsin deficiency, it makes you possibly have COPD in early life instead of midlife
    • ----very high risk!!! take the test on it!!
    • -low birthweight
  8. Pathogenesis of COPD
    • -chronic inflammtion throughout the aiways, parenchymam, and pulmonary vasculature
    • -Oxidative stress -------cigrette smoking
    • ---blue berry is good shit of anti-oxidants
  9. pathophysiology progression of COPD
    • -mucus hypersecretion
    • -ciliary dysfunction
    • -Airflow limitation ---(hallmark of physiologic change-key to diagnosis)
    • -pulmonary hyperinflation
    • -gas exchange abnormalities (turning blue/pink)(
    • pulmonary hypertension
    • -cor pulmonale (right heart failure due to lung problem)
  10. Smoking and lung fucntion
    • -tabacco smkong will lead to serve lung faliure
    • -it is always better than try to quit off on several times than those who never try to quit. your lung function still improving~!!!
    • -COPD is caused majority by Smoking ( 90-95%)
  11. COPD Diagnosis
    • -symptoms of cough
    • -sputum prodcution (change color, green/grey)
    • -dyspnea or
    • -history of exposure of risk factors for the diease
    • -have problem with expiration
  12. other diagnostic tests
    • -Arterial blood gas
    • -should be consider for all pt with FEV1<40% of standards
    • -Bronchodilator REversiblity Test
    • -Glucocorticosteroid REversiblity Test ( use inhaled steroid for 6 weks. if improve 15% -----> COPD)
    • -Chest X-ray
    • -a1-antitrypsin deficiency screening
    • ---yong age  of onset
    • ---strong family history
  13. Classification of Severity of Airflow inCOPD: FEV1/FVC < 0.70
    -COPD: FEV1/FVC < 0.70 (diagnostic)

    • 􀂄Gold 1 Mild
    • 􀂄FEV1 ≥ 80% predicated
    • 􀂄 Gold 2 Moderate
    • 􀂉 50% ≤ FEV1 < 80% predicated
    • 􀂄 Gold 3 Severe
    • 􀂉 30% ≤ FEV1 < 50% predicated
    • 􀂄 Gold 4 Very Severe
    • 􀂉 FEV1 < 30% predicted
  14. Assessing Symptoms (different questionnaires)
    • 􀂄 COPD Assessment Test (CAT)
    • 􀂄 Modified Medical Research Council (MMRC)
    • Dyspnea Scale
  15. combined Assessment
    • 􀂄 A (low risk, low symptoms)
    • -- Gold 1-2
    • -- ≤ 1 exacerbation per year
    • --MMRC 0-1
    • -- CAT < 10
    • 􀂄 B (low risk, more symptoms)
    • -- Gold 1-2
    • -- ≤ 1 exacerbation per year
    • -- MMRC ≥ 2
    • --CAT > 10
    • 􀂄 C (high risk, less symptoms)
    • --Gold 3-4
    • -- ≥ 2 exacerbations per year
    • -- MMRC 0-1
    • -- CAT < 10
    • 􀂄 D (high risk, more symptoms)
    • -- Gold 3-4
    • -- ≥ 2 exacerbations per year
    • -- MMRC ≥ 2
    • -- CAT > 10
  16. Chronic Bronchitis
    ----Pathophysiology
    • -Normal V (ventilation) is 4 L of air per minute.
    • -Normal Q (perfusion) is 5L of blood perminute.
    • -When the V/Q is < 0.8, there is a VQmismatch caused by poor ventilation.
    • -Impairs ventilation (V) more than perfusion (Q),leading to V/Q mismatch and hypoxemia.
    • -Cor Pulmonale
  17. Chronic Bronchitis
    --------Clinical Presentation
    • 􀂄Frequent respiratory tract infections
    • 􀂄 The “Blue Bloater” presentation
    • 􀂄 Tend to be overweight
    • 􀂄 Present with increasingly productive cough
    • 􀂄 Dyspnea is common
    • 􀂄 Hypercarbia (“CO2 retainers”)
    • 􀂄 “Barrel Chested” appearance
    • 􀂄 Have frequent hospitalizations for acuteexacerbations
  18. Emphysema
    --------Pathophysiology
    • Destruction of the walls within the acinus
    • Surface area for gas exchange is lost
    • Ventilation (V) and perfusion (Q) both lost,leading to maintenance of V/Q match
    • No Cor Pulmonale
  19. Emphysema
    Clinical Presentation
    • Pink Puffer”
    • Older than the chronic bronchitic
    • Chief complaint is dyspnea without cough
    • “Pursed lip” breathing is common.
    • Acute exacerbations are less common.
    • Respiratory failure and intubation isoften a “terminal event”
  20. Differences between Emphysema and Chronic Bronchitis
  21. Risk Factor Reduction
    • Smoking cessation is the single mosteffective-and cost-effective- intervention toreduce the risk of developing COPD andstop its progression (Evidence A).
    • Reducing the risk from indoor and outdoor airpollution is feasible
  22. Goals of Therapy of COPD
    • Relieve symptoms
    • Improve lung function
    • Improve exercise tolerance
    • Prevent and treat complications
    • Exacerbations and hospitalizations
    • Improve quality of life
    • Prevent disease progression
    • Increase life expectancy
    • Accomplish in a cost effective manner
  23. Manage Stable COPD
    • The principal Bronchodilator treatments are:
    • ß- agonists,
    • anticholinergics,
    • methylxanthines --------used singally or in combination
    •  long-actingbronchodilatorsis good to add in treatment with short-actingbronchodilators
    • addition of regular treatment with inhaledglucocorticosteroids to bronchodilator treatmentis appropriate for symptomatic COPD patientswith an FEV1 < 50% predicted
    • All COPD patients benefit from exercisetraining programs!!!
      Don't use systemic Glucocorticosteroid for LONG TERM!!!
  24. Non-Pharmacologic Therapy
    • Pulmonary Rehabilitation-------Exercise
    • Oxygen Therapy  (> 15hours per day)
    • Lung Volume Reduction Surgery
  25. Pharmacologic Therapy
    • Bronchodilators:
    • 􀂄 ß2-agonists (short acting and long acting)
    • 􀂄 Anticholinergics
    • 􀂄 Methylxanthines - Theophylline
    • Non-Bronchodilators:
    • 􀂄 Corticosteroids
    • 􀂄 Antibiotics
    • 􀂄 Future therapies
  26. Bronchodilators
    • --Bronchodilators (anti-cholinergics and ß2-agonists) are first-line treatmentfor symptomatic COPD and should be maximized before moving to othermedications.
    • --Combination of Bronchodilators are better than single one.
    • --------increase efficacy and decrese Side Effect
    • Metered dose or dry powder inhalers are preferred over wet nebulizers for stable  COPD
  27. Inhaled Bronchodilators
    Drug type and Name
    • 􀂄 Anticholinergic
    • 􀂉 ipratropium (Atrovent®)
    • 􀂉 Tiotropium (Spiriva®)
    • 􀂉 Aclindium Bromide (Tudorza®)

    • 􀂄 Short acting ß-2 agonists
    • 􀂉 albuterol, salbutamol (Ventolin®, Proventil®)
    • 􀂉 metaproterenol (Alupent®, Tornalate®)

    • 􀂄 Long acting ß-2 agonists
    • 􀂉 salmeterol (Serevent®)
    • 􀂉 formoterol (Foradil®)
  28. Anticholinergics
    Mech. and Side Effects
    • blocks the acetylcholine
    • OFF LABEL USE for Asthma
    • Produce bronchodilation only in the presenceof cholinergic-mediated bronchospasm.

    • Side Effect:
    • --dry mouth,
    • --urinaryretention,
    • --blurred vision,
    • --constipation,
    • --dysgeusia
  29. Anticholinergics
    Ipratropium (Atrovent) MDI
    • MDI 1-2 puffs up to 3-4 times daily
    • Nebulizer 3-4 times daily
  30. Anticholinergics
    Tiotropium (Spiriva) Handihaler
    • Adults/elderly: 18 mcg/day via oral inhalation.
    • One capsule via Handihaler once daily
    • don't know if it is safe for kids
  31. Aclidinium Bromide:
    Tudorza Pressair ®
    • should be discard
    • -----when the device lock or
    • -----45 days after removing fromthe sealed pouch
    • Breathe in quickly and deeply through the mouth (b/c its dry powder)
    • When done, wipe mouthpiece with a DRY tissue or paper towel.
  32. Arformoterol Inhalation Solution:
    Brovana®
    • long-acting beta2-agonist bronchodilator (LABA)
    • 15 mcg BID
    • Nebulizer only
    • -------it is the Only LABA in liquid form
  33. Anticholinergic Combinations
    Albuterol + Ipratropium (Combivent® MDI)
    ADR /  Contraindication
    • Albuterol + Ipratropium (Combivent® MDI)
    • 1 inhalation QID

    • 􀂄 ADR
    • -- Infections of ear, nose, throat
    • -- Runny nose
    • -- Cough
    • -- Shortness of breath
    • Contraindication to Soybean and Peanut (b/c has CFC as propellant)
  34. Anticholinergic Combinations
    Albuterol + Ipratropium (Combivent® MDI)
    Precaution
    • Narrow angle glaucoma
    •  Prostate/urinary problems
    • Heart conditions
    • Seizures
    • Thyroid
    • Low potassium levels
    • Kidney dx
    • Liver dx
  35. Anticholinergic Combinations
    Albuterol + Ipratropium (Combivent® Respimat)
    ADR /  Contraindication / Precaution
    • 1 inhalation QID
    • Dosing indicator
    • No shaking or spacer required
    • Uses NO propellan (so No contraindication on soy or peanut)

    • 􀂄 ADR
    • Infections of ear, nose, throat
    • Runny nose
    • Cough
    • Shortness of breath
    • Precaution: same as Albuterol + Ipratropium (Combivent® MDI)
  36. Inhaled Corticosteroids
    • 􀂄 Fluticasone (Flovent®)
    • 􀂄 Flunisolide (Aerobid®)
    • 􀂄 Budenoside (Pulmicort®)
    • 􀂄 Beclomethasone (Vanceril®, Beclovent®)
    • 􀂄 Triamcinolone (Asmacort®)
    • 􀂄 Mometasone (Asmanex® )
  37. Inhaled Corticosteroids
    • Decreases frequency of exacerbations BUT
    • --------------- Increased risk of pneumonia.
    • Not for monotherapy
    • Combination with LABA
    • Combination with LABA + Spiriva
  38. Roflumilast (Daliresp)
    • Use for Severe COPD (FEV1<50%)
    • Reduces the risk of exacerbations
    • First drug in new category
    • ------ Phosphosdiesterase 4 inhibitor(PDE4 )
    • it will Decrese Sputum (Chronic Bronchitis)
    • 500 mg tablet QD with or without food.
    • No dosage adjustment
    • Not pregnancy nor nursing mothers
    • No liver dysfunction
  39. Theophylline Info
    • Third-line role in COPD
    • May be helpful when patients have poor responseto combination of β2-agonists and anticholinergics
    • Narrow therapeutic index
    • Sustanied release ------use at night
  40. Systemic Corticosteroids Info
    • Chronic treatment with systemic glucocorticosteroids should be avoided
    • too much side effects
  41. Treatments Guideline
    • A (low risk, low symptoms)
    • 􀂉 SABA or SAAC
    • 􀂉 LAAC   or LABA   or SABA + SAAC
    • 􀂉 Theophylline

    • B((low risk, high symptoms)
    • 􀂉 LAAC or LABA
    • 􀂉 LAAC & LABA
    • 􀂉 SABA &/or SAAC
    • C(High risk, Low symptoms)
    • 􀂉 LABA + ICS or LAAC
    • 􀂉 LAAC + LABA
    • 􀂉 PDE-4 Inhibitor or SABA &/or SAAC
    • D(High risk, high symptoms)
    • 􀂉 LABA + ICS or LAAC
    • 􀂉 LAAC + ICS or LABA + ICS + LAAC or LABA + ICS +PDE-4 or LAAC + LABA or LAAC + PDE-4
    • 􀂉 SABA &/or SAAC
    • 􀂉 Theophylline
  42. Oxygen Therapy
    • Reduces mortality and improves quality of life.
    • Indicated if either of following are present:
    • --Resting PaO2 < 55 mm Hg (partial pressure of O2 inthe blood…from ABG)
    • OR
    • SaO2 < 88% (oxygen saturation..pulse oximetry)
    • PaO2 between 55 and 60 mm Hg or SaO2 < 88% if there is evidence of pulmonary hypertension,peripheral edema, or polycythemia (Hct > 55%).
    • Not indicated for lesser severity ofdisease
    • Nocturnal O2 therapy not beneficial
  43. Other Pharmacologic Treatments
    Antibiotic
    Mucolytics
    Antioxidant agents
    Immunoregulators
    • Antibiotics. Acute exacerbations only
    • Others: No  Benefits
  44. Cor Pulmonale
    • Diuretics are mainstay of therapy
    • Oxygen therapy
    • Digoxin is NOT indicated
  45. Miscellaneous Therapy
    • α1-Antitrypsin replacement therapy
    • Anti-Tussives -------- Contraindicated
    • Respiratory Stimulants-------- Not Recommended
  46. Manage Exacerbations
    • Most common cause of exacerbations are infections of tracheobronchial tree and airpollution.
    • Bronchodilators and systemic steroids areeffective for COPD exacerbations.
    • antibiotics are helpful in selectpatients.
  47. COPD Exacerbation
    Differential Diagnosis
    • 􀂄 Pneumonia
    • 􀂄 CHF
    • 􀂄 Pneumothorax
    • 􀂄 Pleural Effusion
    • 􀂄 Pulmonary Embolism
    • 􀂄 Arrhythmia
  48. Exacerbation Classification and Clinical Presentation
    • Severity based upon these 3 symptoms
    • (1)increased dyspnea,
    • (2) increased sputum purulence
    • (3) increased sputum volume:

  49. Three types of Exaecrbation
    Type 1 (Mild) – 1 out of 3 symptoms + at least one of the following:

    • URI in past 5 days:
    • Fever without other cause
    • Increased wheezing
    • Increased cough, or
    • 20% increase in RR or HR.

    • Type 2 (Moderate) – 2 out of 3 symptoms
    • Type 3 (Severe) – All 3 symptoms
  50. Severe Acute Exacerbations Treatment
    • Systemic Corticosteroids (10-14 days max)
    • ----Inhaled steroid not appropriate
    • Bronchodilators
    • Oxygen Therapy
    • Noninvasive Positive Pressure Ventilation(NPPV)
    • Intubation/Mechanical Ventilation if indicated.
    • Antibiotics (Widely prescribed during the treatment ofacute exacerbations.)
    • Nutrition Support
  51. Organisms of greatest concern of acute exacerbation
    • S.pneumoniae,
    • H. Influenzae,
    • M.Catarrhalis.
  52. antibiotic use in Atcute Exacerbation
    • Complicated COPD:
    • Amoxicillin
    • Clavulanate
    • Fluoroquinolone
    • Simple COPD:
    • Doxycycline 
    • Macrolide
    • Cephalosporin

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