Management of COPD

• Assess and monitor the disease
• Prevention of risk factors
• Treatment of COPO
•  Treatment of exacerbations

Diagnosis of COPD is considered in any patient with

• Chronic central cyanosis occurs in advanced stages of COPD and may be aggravated by exertion.
• Examination reveals wheezing and hyperresonant lung fields.
• cough,
• sputum production,
• dyspnoea and risk fac­tors.
• Spirometry is done for airflow limitation.
• Barrel chest and clubbing are late signs.
• Tachycardia, diaphoresis, and flushing may also accompany COPD.
• Associated signs and symptoms include exertional dyspnea, a productive cough with thick sputum, anorexia, weight loss, pursed-lip breathing, tachypnea, and the use of accessory muscles.

Spirometry —

• Measure the maximal volume of air forcibly exhaled from the point of maximum inhalation (FVC – forced vital capacity).
• Measure volume of air exhaled during 1S^t second of the maneuver (forced expiratory volume in one sec­ond) – FEV₁•
• Calculate ratio of FEV₁/ FVC.
• Post bronchodilator FEV₁ <80% of predicted value and FEV₁/ FVC <70% is an airflow limitation which is not fully reversible.

Chest X-ray for changes of COPD and other associated lesions.

Presence of respiratory failure and right heart failure indicates severe COPD.

• Clinical signs of respiratory failure or right heart fail­ure are central cyanosis, ankle swell~, and raised JV
• Respiratory failure is indicated by PaO₂ <60 mmHg, PaCO₂ >50 mmHg.

Difference between COPD and Asthma

COPD —

• Onset in middle life Symptoms slowly progressive Dyspnoea during exercise Long smoking history
• Family history variable
• Largely irreversible airflow limitation

Asthma —

• Onset in childhood
• Symptoms vary day to day Symptoms at night or early morning H/o allergy, rhinitis, eczema
• Family history of asthma
• Largely reversible airflow limitation

MANAGEMENT OF COPD ACCORDING TO GOLD STAGING

• Stage 0 – Avoidance of risk factors.
• Stage I – Avoidance of risk factors, short acting bronchodilators.
• Stage II – Avoidance of risk factors, short acting bronchodilators, long acting bronchodilators, rehabili­tation.
• Stage III – Avoidance of risk factors, short acting bronchodilators, long acting bronchodilators, rehabili­tation, inhaled glucocorticoids.
• Stage IV – Avoidance of risk factors, short acting bronchodilators; long acting bronchodilators, rehabili­tation, inhaled glucocorticoids, plus long term oxy­gen if chronic respiratory failure, surgical treatment if required.

DRUG MANAGEMENT BRONCHODILATOR MEDICATIONS

• B2 agonists Short acting :

   

• Salbutamol – Inhaler
  • 100, 200 MOl (Metered Dose Inhaler) and DPI (Dry Powder Inhaler).
  • 5 mg tab/cap 6-8 hrly, for oral use.
•  Terbutaline – Inhaler 400, 500 DPI
  • 2.5, 5 mg tablets 6-8 hrly, injection 0.2 mg vi­als.
• Long acting
  • Formeterol inhaler – BD dose – 12 hrly
  • Salmeterol inhaler – 12 hrly

• Anti-cholinergics

• Short acting:
  • or Ipratropium bromide inhaler – 8 hrly, Solution for nebulizer is also available.
• Long acting:
  • Tiotropium – inhaler – OD – 24 hours dose. Combinations of short acting P2 agonists plus an­ticholinergics are available in inhalers.
• Methylxanthines Aminophylline
  • 200 – 600 mg tab
  • 240 mg vial for injection Theo hylline
  • 100 – 600 mg tab., action up to 24 hours.
• 
  

  Inhaled glucocorticoids

   

  • Beclomethasolle
  • Budesonide
  • Fluticasone
  • Triamcinolone

Combination of long acting P₂ agonists plus glu­cocorticoids

• Systemic glucocorticoids

  • Prednisone – 5 – 60 mg tab.
  • Meth prednisolone – 4, 8, 16 mg tabs.

• For acute episodes

  • Nebulization with P₂ agonists or anticholinergics is used.
  • Regular glucocorticoid inhalers with long acting P₂ agonists is useful for symptomatic COPD patients.
• 
  

  Other Pharmacologic treatments

  • Vaccines – influenza and pneumococcal vaccine
  • Alpha 1 anti-trypsin augmentation therapy
  • Antibiotics
  • Mucolytics – Ambroxol, Carbocysteine, Erdosteine
  • Antioxidants – N- acetyl cysteine Immuno modulators Anti-tussives
  • Narcotics
  • Nedocromil, leukotrine modifiers.

REHABILITATION  for COPD

• Patient Care: The respiratory therapist teaches breathing and coughing exercises and postural drainage to strengthen respiratory muscles and to mobilize secretions.
• The patient and family are assisted with disease-related lifestyle changes and are encouraged to express their feelings and concerns about the illness and its treatment.
• The patient is encouraged to participate in a pulmonary rehabilitation program, as well as to stop smoking and avoid other respiratory irritants.
• Frequent small meals and adequate fluid intake are encouraged.
• The patient’s schedule alternates periods of activity with rest.
• Patients are instructed to avoid contact with other persons with respiratory infections and taught the use of prescribed prophylactic antibiotics and bronchodilator therapy.
• · Exercise programs
• · Breathing exercises
• SURGICAL TREATMENTS Bullectomy (excision of bulla)
• , Lung volume reduction surgery
• • Lung transplantation
• Aerosolized bronchodilators are used to reduce dyspnea and promote improved cough.
• Low-concentration oxygen therapy is applied as needed to keep the PAo₂ between 60 and 80 mm Hg.

VENTILATORY SUPPORT In COPD

• • For respiratory failure
•  Non invasive intermittent positive pressure ven­tilation (NIPPV)
  • Improves blood gases, reduces pH, reduces mortality.
  • · NIPPV must be started if pH <7.35 i.e. severe acidosis, hypercapnia i.e. PaCo₂ >45 mmHg and respiratory rate >25 breaths/ minute, severe dyspnoea.

SUMMARY OF TREATMENT OF COPD

• Anticholinergics and theophylline may be used in combination.
• For regular treatment, long-acting bronchodi­lators are better.
• Inhaled glucocorticosteroids + bronchodilators must be given if FEV₁ <50% predicted i.e. severe CoPD.
• Exercise training program.
• Oxygen more than 15 hours per day in patients with chronic respiratory failure improves survival.