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TWO CATEGORIES THAT MAKE UP COPD:
- 1. Chronic bronchitis- recurrent productive cough associated with inflammation of the bronchioles: Major symptom is a productive cough.
- 2. Emphysema- permanent destruction and enlargement (loss of elasticity) of airspaces distal to bronchioles: Major symptom is dyspnea.
DEFINITION OF COPD:
- 1. Small airway obstruction
- 2. Reduced expiratory flow (CO2 retention)
INCIDENCE OF COPD:
- 1. 12.1 million (2001)
- 2. 4th leading cause of death
- 3. By 2020: expected to be 3rd leading cause of death
RISK FACTORS OF COPD:
- 1. Smokers (30 xs greater r/f death)
- 2. Air pollution
- 3. Occupational exposure (ex. aspestis)
- 4. Genetic (protein alpha 1 antitrypsin deficiency)
PRINCIPLE RISK FACTORS:
- 1. Smoking
- 2. Advanced age
BOTH EMPHYSEMA AND CHRONIC BRONCHITIS RESULT IN?
- 1. Airway obstruction which is IRREVERSIBLE
- 2. Dyspnea
- 3. Decreased blood oxygen concentrations
- 4. Elevated blood CO2 concentrations
STAGES OF COPD:
- 1. Stage 0: At risk (lung function normal/chronic cough)
- 2. Stage I: Mild (mild airflow limitation)
- 3. Stage II: Moderate (airflow limitation)
- 4. Stage III: Severe (worsening airflow limitation/repeated exacerbations)
- 5. Stage IV: Very severe (severe airflow limitation)
COPD PHARMACOLOGIC MANAGEMENT:
- 1. Beta 2 Agonists
- 2. Combination B2 and Anti-cholinergic
- 3. Combination B2 and Inhaled steroids
- -Advair Diskus
- 4. Anti-cholinergics
- -Spiriva and Ipratropium bromide
- 5. Methylxanthines
RECOMMENDED ORDER FOR COPD TREATMENT IN PRIMARY CARE:
- 1. 1st line: short acting bronchodilator
- 2. 2nd line: inhaled beta 2 agonist and anticholinergics
- 3. 3rd line: Beta 2 agonist and theophylline, rescue inhaled steroid
- 4. 4th line: referral to pulmonary specialist.
COPD STEP-PROGRESSION OF THERAPY:
- Stage 0: at risk- avoid risk factors (smoking)/ vaccines (flu/pneumo)
- Stage I: above and short-acting bronchodilator
- Stage II: abopve andlong acting bronchodilator
- Stage III: above and rehab and inhaled gluocoricoids
- Stage IV: above and supportive O2 (O2 can be whatever stage that it is clinically indicated).
BETA 2 AGONISTS:
- 1. Albuterol
- 2. Terbutaline
- Relaxes smooth muscle, dilate airways, relieve symptoms of SOB in COPD
- Cannot exceed 12 inhalations daily or can get rebound effect.
- Combo therapy: Combivent-
- action: combines bronchodilator effect of albuterol and anticholinergic effect of ipratropium.
- COMBO THERAPY IS BEST- IT IS THE CORNERSTONE FOR MANAGING COPD
- 1. Atrovent-short acting
- 2. Spiriva- long acting
- Relax bronchial muscles
- Act as Bronchodilator
- 1. Short acting: onset after 15 min-duration 3-4 hrs.
- 2. Longacting: 1 capsule qd (duration 24 hrs)
- 3. Not used in ACUTE episodes
- 4. contra-indicated: glaucoma, BPH, pregnancy/lactiation, peanut allergies
- Adverse Events: Restlessness, dizziness, h/a, blurred vision, palpitations, urinary retention.
COPD ADJUNCTIVE THERAPIES:
- 1. Smoking cessation
- 2. Oxygen support: must be able to demonstrate need for payment:
- Group 1- PaO2 less than 55 mmHg
- ABG less than 88%
- Group 2- PaO2 56-59
- ABG less than 88%
- 3. Concurrent diagnosis- have to have at least one of GROUP 2 and 1 of these comorbidities: CHF or Erythrocythemia (Hct greater than 56%)
- 4. Pulmonary rehab programs