Complete Management of COPD

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.

Management of COPD 2

Complete Management of COPD


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 1St 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

Complete Management of COPD


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.
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