Introduction
Chronic Obstructive Pulmonary Disease has been
defined by GOLD (Global Initiative for Chronic Obtructive Lung Disease) as a disease state characterised by increased airflow resistance that is not fully reversible. Emphysema abnormal, permanent enlargement of the distal air spaces distal to the terminal bronchiole, accompanie by destruction of their walls Bronchitis cough with sputum production at least for 3months in a year, for two or more consecutive years. Acute Exacerbation of COPD
Defined as episodes of increased dyspnoea,
cough and change in the amount and character of the sputum with other signs of infection-
Precipitating factor
Infection
Most commonly encountered organisms: Streptococcus pneumoniae Hemophilus influenzae Moraxella catarrhalis Pseudomonas aeruginosa Viruses 1/3 of the cases
Allergen - air pollution, dust, pollen, cold Smoking - active or passive Occupation coal miners, exposure to fumes Low socio economic status Genetic Alpha 1 antitrypsin deficiency (early onset of emphysema)
Pathophysiology
Airflow obstruction air-trapping
increase residual volume increase the ratio of residual volume to total lung capacity
which occurs in the lungs whereby ventilation (the exchange of air between the lungs and the environment) and perfusion (the passage of blood through the lungs) are not evenly matched)
Pathophysiology contd
Hyperthrophy of mucous producing glands
Clinical features
Symptoms of COPD
Cough with sputum and exertional dyspnoe (more
than 2 years)
Symptoms of acute exacerbation
Fever, tachycardia, tachypnoea, difficulty in speech,
Investigation
CBC leucocytosis
Investigation contd
Radiology
Chest X-ray Hypertranslucent (Black) Lungs Tubular (Narrow) heart Pushed down diaphragm Widely placed horizontal ribs Pulmonary arteries prominent CT scan
Management
Aims
To assess the severity of illness To identify the precipitant and plan strategies to
III
IV
Severe
Very severe
History
Symptoms- fever, change of characters of sputum, Ill contact; associates symptoms- nausea, vomitting,
diarrhea, myalgias, and chills Functional capacity when well using the MRC dyspnoea scale: Grade 1: Not troubled by breathlessness except on strenuous exercise. Grade 2: Short of breath when hurrying or walking up a slight hill. Grade 3: Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace. Grade 4: Stops for breath after walking about 100m or after a few minutes on level ground. Grade 5: Too breathless to leave the house, or breathless when dressing or undressing. *MRC- Medical Research Council
History contd
Frequency and severity of prior exacerbations.
intubation). Usual treatment including oxygen (specifying whether short burst, portable, long term i.e. 16 hours per day or a combination of oxygen treatments). Concurrent illnesses (co-morbidities are common in these patients). Check for previous blood gas and lung function results.
Physical Examination
Respiratory rate (Tachycardia) Degree of distress Sign of perioral or peripheral cyanosis Ability to speak full sentences Patients mental status Use of accessory muscles or paradoxical chest wall movements. Oxygen saturation and FIO2 Signs of hypercapnoea (warm peripheries, bounding pulse, flap, confusion). Cor pulmonale (peripheral oedema). Heart rate and rhythm. Chest examination- presence/absence focal finding, degree of air movement, presence/absent of wheezing, asymetry in the chest
Smoking
Allergen
pneumonia, cardiac arrhythmia, congestive heart failure, diabetes mellitus, renal or liver failure Inadequate response of symptoms to outpatient management Marked increase in dyspnoea Inability to eat or sleep due to symptoms Worsening hypoxaemia Worsening hypercapnia Changes in mental status Inability of the patient to care for her/himself Uncertain diagnosis Inadequate home care
Treatment
Hospitalisation Oxygen therapy Controlled oxygen at 24%-28% to maintain a PaO2>8
kPa(60mmhg) or saturation at 80% High oxygen conc. respiratory depression and worsening acidosis
Inhaled bronchodilators Nebulised short-acting B-agonist combined with Anticholinergic
agent -Salbutamol 2.5mg (diluted to a total of 3mL) every hour -Ipratropium 500mcg every 3 hours - Levosalbutamol sulphate 1.25mg and Ipratropium Bromide 500mcg (Duolin respules)
IV infusion theophylline Add theophylline or aminophylline in the drip
250 500 mg in 20ml 25% dextrose over 20 minutes (severe) Infusion 500mg in 500ml 5% dextrose over 24 hours
Antibiotic Quinolones (Levofloxacin) of Co amoxiclav (Augmentin ) Corticosteroid Oral prednisolone 30-40mg x 10-14days IV Hydrocortisone 200mg
Non-invasive ventilation (non invasive positive pressure ventilation) RR>25/minute Mild to moderate respiratory acidosis (pH <7.35) Hypercarbia (Paco2>45mmHg) If the patient remains tachypnoeic and acidotic Ventilatory support by nasal or fullmask, BiPAP Mechanical ventilation support indications: Severe respiratory failure Respiratory rate>35/minute Hypercarbia (Paco2>60mmHg) Acidosis (pH<7.25) Respiratory arrest Altered mental status Hypotension, cardiac failure, shock NIPPV failure Additional therapy Exacerbation may be accompanied by peripheral edema give
BiPAP
frequently than every 4 hrs. Patient is able to walk across room, eat and sleep without frequent awakening by dyspnea. Patient has been clinically stable for 12-24 hrs. Arterial blood gases have been stable for 12-24 hrs. Patient (or home caregiver) fully understands correct use of medications. Follow-up and home care arrangements have been completed (e.g., visiting nurse, oxygen delivery, meal provisions). Patient, family, and physician are confident patient can manage successfully.
follows: Level I: ambulatory (outpatient), Level II: requiring hospitalisation, and Level III: acute respiratory failure.
Level II
Level III
Physical findings
Haemodynamic evaluation Use accessory respiratory muscles, tachypnoea Persistent symptoms after initial therapy Stable Not present No Stable ++ ++ Stable/unstable +++ +++
Diagnostic procedures
Oxygen saturation Arterial blood gases Chest radiograph Blood tests Serum drug concentrations Sputum gram stain and culture Electrocardiogram Yes No No No If applicable No No Yes Yes Yes Yes If applicable Yes Yes Yes Yes Yes Yes If applicable Yes Yes
Bronchodilators
Short-acting 2-agonist and/or ipratropium MDI with spacer or hand-held nebulizer as needed Consider adding long-acting bronchodilator if patient is not already using it.
Antibiotics
May be initiated in patients with altered sputum characteristics Choice should be based on local bacteria resistance patterns - Amoxicillin/ampicillin, cephalosporins - Doxycycline - Macrolides If the patient has failed prior antibiotic therapy consider: - Amoxicillin/clavulanate - Respiratory fluoroquinolones
Corticosteroids
-If patient tolerates, prednisone 3040 mg per os q day for 10 days -If patient can not tolerate oral intake, equivalent dose i.v. for up to 14 days -Consider use inhaled corticosteroids by MDI or hand-held nebulizer
Bronchodilators
-Short-acting 2-agonist (albuterol, salbutamol) and ipratropium MDI with spacer, two puffs every 24 h, or Tiotropium bromide DPI once daily. -If the patient is on the ventilator, consider MDI administration, consider long-acting -agonist
Corticosteroids
-If patient tolerates oral medications, prednisone 3040 mg per os q day for 10 days. -If patient can not tolerate, give the equivalent dose i.v. for up to 14 days. -Consider use inhaled corticosteroids by MDI or hand-held nebulizer.
emergency therapy. Confusion, lethargy, coma. Persistent or worsening hypoxemia (PaO2 < 5.3 kPa, 40 mm Hg), and/or severe/worsening hypercapnia (PaCO2 > 8.0 kPa, 60 mm Hg), and/or severe/worsening respiratory acidosis (pH < 7.25) despite supplemental oxygen and NIPPV.