COPD Management - HKMU Physiotherapy PDF

HKMU- Physiotherapy Management of COPD Alice Jones Ph.D., FACP Specialist in Cardiopulmonary Physiotherapy Australian College of Physiotherapists AAJ® HKMU- Physiotherapy Intende...

HKMU- Physiotherapy Management of COPD Alice Jones Ph.D., FACP Specialist in Cardiopulmonary Physiotherapy Australian College of Physiotherapists AAJ® HKMU- Physiotherapy Intended learning outcomes Following this talk, students should be able to： describe the pathophysiology, diagnosis, signs and symptoms of Chronic Obstructive Pulmonary Disease (COPD) explain mainstream medical management of COPD conduct an appropriate physiotherapy assessment using the ICF framework provide intervention and education for patients with COPD select appropriate outcome measures to determine effectiveness of the management program be aware of the risks of supplementary oxygen administration in patients with COPD identify global management guidelines for COPD AAJ® 2 HKMU- Physiotherapy Definition of COPD 3rd leading cause of death in the world A common lung disease causing restricted airflow and breathing problems. Sometimes called emphysema or chronic bronchitis WHO 2023 Chronic Obstructive Pulmonary Disease (COPD) is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnoea, cough, sputum production and/or exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction. GOLD 2023 3 AAJ® HKMU- Physiotherapy Chronic obstructive lung disease Blausen.com staff 2014 Preventable diseaseà airflow limitation à progressive à inflammatory response à structural damageà irreversible/not curable AAJ® à Management : improve symptoms 4 HKMU- Physiotherapy Key global demographic characteristics Nearly 90% of COPD deaths in those under 70y of age occur in low and middle-income countries Tobacco smoking accounts for over 70% of COPD cases in high- income countries In lower-middle-income countries smoking accounts for 30–40% of COPD cases, and household air pollution is a major risk factor. à Role of physiotherapy in public health education AAJ® HKMU- Physiotherapy Smoking & pollutants Image by pixabay Etiology Impaired lung function/decline, lung injury Image by pixabay (lung & systemic inflammation) => Not sure why develope diff Destruction of alveolar tissue Inflammation of the airways Over production of mucus Emphysema Chronic bronchitis Airflow limitation, cough, sputum, exacerbation, comorbidities (lung cancer, bronchiectasis) AAJ® 6 HKMU- Physiotherapy Etiology - smoking stimulate macrophages Genetic factor: a 1-antitrypsin neutrophil release 3 Deficiency (AATD) antiprotease elastase inhibitor lysosomal elastase AATD to be screened in patients under 45 years old Emphysema destroys lung tissues AAJ® * If patient under 45 dinguosis 7 COPD - > refer to genetic screening HKMU- Physiotherapy Toxic and infectious stimuli Etiology - à epithelial cells lining smoking à Release of inflammatory mediators & inflammatory cytokines Chronic bronchitis Inflammation of the Hypersecretion of mucus central airways - inflammatory mononuclear cell infiltrate by goblet cells in the airway wall - broncho epithelial cells synthesize IL-8 - neutrophil influx into the airway lumen Sputum production –cough AAJ® – weakening of the airway Hoidal 1994 8 HKMU- Physiotherapy Poor elastic recoil (high compliance): airways likely to be compressed expiration could be difficult Damaged alveolar wall Impaired airway 9 AAJ® HKMU- Physiotherapy 10 AAJ® HKMU- Physiotherapy Blue-bloaters Pink puffers long &Heart thinfailure mediastinum Inflammation flattened diaphragm Congested lung hyperinflated field lung field https://my.clevelandclinic.org/health/diseases/8709-chronic- obstructive-pulmonary-disease-copd AAJ® HKMU- Physiotherapy Common symptoms of COPD n increasing shortness of breath over several years n airway obstruction n over inflated lungs n chronic cough n poor exercise tolerance n impaired gas exchange I Right heart failure AAJ® AAJ® ↑ Blood resistance lead to 12 HKMU- Physiotherapy Association with lung cancer 40%-70% of people with lung cancer have COPD Compared to the general population, the incidence of lung cancer in patients with COPD is 4.3 times higher in males and 4.8 times higher in females Dela Cruz et al 2011, Kiri et al 2010 AAJ® 13 HKMU- Physiotherapy Diagnosis of COPD Spirometry confirmation FEV1/FVC2 or CAT > 10 (not leading to hospital admission) and no hospital admission mMRC 0-1 mMRC >2 CAT 10 AAJ® 21 HKMU- Physiotherapy Assessment of symptoms/risk of exacerbations > 2 ,moderate exacerbations or E > 1 leading to hospitalization 0 or 1 moderate exacerbation (not leading to hospital A B admission) GOLD 2023 mMRC 0-1 mMRC >2 CAT 10 AAJ® Symptoms 22 HKMU- Physiotherapy Exacerbation of COPD Type 1 exacerbation Dyspnoea Sputum production Reduced PEFR Type 2 – 2 of these factors Type 3 - 1+signs of common cold 23 AAJ® HKMU- Physiotherapy Management of acute exacerbation of COPD Non-invasive ventilation Oral corticosteroids Antibiotic use Early pulmonary rehabilitation within 3 weeks discharge https://emedicine.medscape.com/article/304235-overview ERS/ATS Task Force Report 2017 (Wedzicha et al) 24 AAJ® HKMU- Physiotherapy Physiotherapy management of acute exacerbation of COPD (AECOPD) Assessment Reason for admission: SOB, chest infection, cough, sputum, fever, asthma Level of SOB Chest expansion Cough effort Sputum SpO2(during activity) Normally not appropriate lung function tests functional assessment (or 6MWT) 25 AAJ® HKMU- Physiotherapy Physiotherapy management of acute exacerbation of COPD Intervention breathing training secretion removal (ACBT) use of adjuncts for secretion mobilization (PEP devices) education on use of medication steroid, antibiotics, bronchodilators exercise (pre-discharge) improve functional capacity and QOL discharge plan referral for pulmonary rehabilitation 26 AAJ® HKMU- Physiotherapy X Contraindicated for people with COPD 27 AAJ® HKMU- Physiotherapy Management of stable COPD Aims Prevent disease progression Relieve symptoms Improve exercise tolerance Outpatient Improve health status Digital service Prevent and treat complications Community care Prevent and treat exacerbations Reduce mortality 28 AAJ® HKMU- Physiotherapy Management of stable COPD COPD cannot be cured Prevention Vaccination Maintenance of stable COPD Pharmacological Non-pharmacological AAJ® 29 HKMU- Physiotherapy Prevention Smoking cessation, Nicotine replacement Monitoring of exhaled CO level AAJ® HKMU- Physiotherapy Vaccination COVID-19 vaccines à effective against SARS CoV-2 Influenza vaccination and pneumococcal vaccination à decreases the incidence of lower respiratory tract infection AAJ® HKMU- Physiotherapy Maintenance therapy for stable COPD Pharmacological therapy Aims / expected outcome of effective managment à reduce symptoms à reduce frequency and severity of exacerbations à improve exercise tolerance and health status à reduce the rate of decline of FEV1 not aiming to improve FEV1 AAJ® HKMU- Physiotherapy Medications Bronchodilators Beta-2agonists (short acting and long acting) (SABA, LABA) Anticholinergics (antimuscarinic drugs) - block the bronchoconstrictors (SAMA, LAMA) Inhaled corticosteroid Anti-inflammatory Combination bronchodilator therapy Combined SABA+SAMA, or LABA+LABA or LABA+ICS triple inhaled therapy – ICS/LAMA/LABA) Mucolytic agents Antibiotics AAJ® 33 HKMU- Physiotherapy Triple therapy inhaler (e.g. Trelegy Ellipta) FF- corticosteroid Vilanterol – β2 agonist Umeclidinium - anticholinergic AAJ® HKMU- Physiotherapy Physiotherapist should be aware of what medication the patient is taking be able to assist in proper usage of an inhaler by the patient AAJ® HKMU- Physiotherapy Non-pharmacological therapy Pulmonary rehabilitation Structured exercise programme Education Self-management strategies Integrated care Long-term oxygen therapy Non-invasive positive pressure ventilation Nutrition management Lung volume reduction AAJ® HKMU- Physiotherapy Physiotherapy for stable COPD Goals Minimise hospitalization Dyspnoea management Increase physical activity Assessment Respiratory function Functional capacity Including assessment of effective use of inhaler Intervention Prescription of appropriate exercise programs during pulmonary rehabilitation Service delivery Face to face supervision - OPD Digital physiotherapy service 37 AAJ® HKMU- Physiotherapy Assessment of stable COPD Dyspnoea (mMRC) scale Spirometry BODE CAT QOL questionnaire 6MWT/ Shuttle walk test AAJ® 38 HKMU- Physiotherapy BODE-index BODE index (0-10) BMI Predicted FEV1% MMRC dyspnoea scale 6MWD High score = high risk of mortality 39 AAJ® HKMU- Physiotherapy BODE-index (N Engl J Med 2004; 350:1005-12) Variable Points on BODE Index 0 1 2 3 B BMI >21 65 50-64 36-49 350 250-349 150-249