Lec 4 COPD R PDF

Lec: 4 Dr. Mohammed Alhamdany Objective: 1. To know the management of chronic obstructive pulmonary disease. 2. To identify the roles of Bronchodilator in chronic obstructive pulmonary disease. 3. To identify the roles of Combined inhaled glucocortico...

Lec: 4 Dr. Mohammed Alhamdany Objective: 1. To know the management of chronic obstructive pulmonary disease. 2. To identify the roles of Bronchodilator in chronic obstructive pulmonary disease. 3. To identify the roles of Combined inhaled glucocorticoids and bronchodilators in chronic obstructive pulmonary disease. 4. To identify the roles of Long-term domiciliary oxygen therapy in COPD. 5. To identify the roles of surgical intervention in COPD. 6. To know the prognosis of COPD 7. To identify the management of acute exacerbations of COPD. Management of COPD The following can improve COPD mortality: 1. Smoking cessation. 2. Long-term oxygen therapy. 3. lung volume reduction surgery in small subsets of COPD patients Reducing exposure to noxious particles and gases: Sustained smoking cessation in mild to moderate COPD is accompanied by a reduced decline in FEV1 compared to persistent smokers, and cessation remains the only strategy that impacts favourably on the natural history of COPD. 1 Pulmonary rehabilitation: Exercise should be encouraged at all stages. Bronchodilators: Bronchodilator therapy is central to the management of breathlessness. Short-acting bronchodilators are used as relievers and may be used as sole treatment for patients with very mild disease but combination longer- acting bronchodilators are preferred. Long-acting beta agonists (LABA) and long-acting muscarinic-antagonists (LAMA) are available in single agent or combination inhalers. Nebulised short-acting bronchodilators can be used in those unable to take inhalers. Significant improvements in breathlessness may be reported despite minimal changes in FEV1; probably reflecting improvements in lung emptying that reduce dynamic hyperinflation and ease the work of breathing. Oral bronchodilator therapy, such as theophylline, is only recommended when other long-acting bronchodilators are not available. Combined inhaled glucocorticoids and bronchodilators: Those with frequent exacerbations and/or persistent breathlessness despite long-acting bronchodilators may benefit from inhaled glucocorticoids, in the form of either a LABA/LAMA/ICS or LABA/ICS combination inhaler. These combined therapies: 1- Improve lung function 2- Reduce the frequency and severity of exacerbations 3- Improve quality of life. However, these advantages may be accompanied by an increased risk of pneumonia, particularly in older people. Oral anti-inflammatories: 2 1- Oral glucocorticoids are useful during exacerbations but maintenance therapy contributes to osteoporosis and impaired skeletal muscle function, and should be avoided. 2- Roflumilast, a phosphodiesterase-4 inhibitor, improves lung function and reduces moderate to severe exacerbations in patients with severe or very severe COPD. 3- Azithromycin 500 mg three times weekly can reduce the number of exacerbations. Other maintenance measures: Patients with COPD should be offered pneumococcal vaccination and annual influenza vaccination. Obesity, poor nutrition, depression and social isolation should be identified and, if possible, addressed. Chest physiotherapy techniques and devices and mucolytic agents ease sputum expectoration and may reduce exacerbations. Oxygen therapy and home ventilation Long-term domiciliary oxygen therapy (LTOT) improves survival in selected patients with COPD complicated by severe hypoxaemia (arterial PaO2 < 7.3 kPa (55 mmHg); the patients should be instructed to use oxygen for a minimum of 15 hours a day; greater benefits are seen in those who use it for more than 20 hours a day. The aim of therapy is to increase the PaO2 to at least 8 kPa (60 mmHg) or SaO2 to at least 90%. Ambulatory oxygen therapy should be considered in patients who desaturate on exercise and show objective improvement in exercise capacity and/or dyspnoea with oxygen. Oxygen flow rates should be adjusted to maintain SaO2 above 90%. Home non-invasive ventilation improves quality of life and prolongs time to readmission in patients with persistent hypercapnia. 3 Indication of LTOT ‫ﻣﮭﻢ‬ 1- PaO2 55%). Note: 1- The patient has stopped smoking. 2- Arterial blood gases are measured in clinically stable patients on optimal medical therapy on at least two occasions 3 weeks apart. 3- Use at least 15 hrs/day at the necessary flow rate to achieve a PaO2> 8 kPa (60 mmHg) without unacceptable rise in PaCO2. Surgical intervention Bullectomy may be considered when large bullae compress surrounding normal lung tissue. Patients may benefit from lung volume reduction surgery (LVRS) in: (Egypt) 1- Predominantly upper lobe emphysema 2- Preserved gas transfer 3- No evidence of pulmonary hypertension. LVRS involves resection of peripheral emphysematous lung tissue with the aim of reducing hyperinflation and decreasing the work of breathing. Both bullectomy and LVRS can be performed thorascopically, minimising morbidity. 4 Bronchoscopic LVRS involves the use of one-way valves, lung coils or thermal ablation to collapse down areas of ineffective emphysematous lung. This enables the neighbouring areas of healthier lung to expand and work more efficiently. Lung transplantation may benefit carefully selected patients with advanced disease. Palliative care: Addressing end-of-life needs is an important aspect of care in advanced COPD. Morphine preparations may be used for palliation of breathlessness and low-dose benzodiazepines may reduce anxiety. Prognosis COPD has a variable natural history but is usually progressive. The prognosis is inversely related to age and directly related to the post- bronchodilator FEV1. Additional poor prognostic indicators include weight loss and pulmonary hypertension. A composite score comprising the body mass index (B), the degree of airflow obstruction (O), a measurement of dyspnoea (D) and exercise capacity (E) (BODE index) may assist in predicting death from respiratory and other causes. Respiratory failure, pneumonia, cardiac disease and lung cancer represent common modes of death. 5 Acute exacerbations of COPD Acute exacerbations of COPD (AECOPD) are characterised by 1- An increase in symptoms 2- Deterioration in lung function 3- Deterioration health status. They become more frequent as the disease progresses and are usually triggered by 1- infection or 2- a change in air quality. They may be accompanied by the development of 1- respiratory failure 2- and/or fluid retention 3- and represent an important cause of death. Many patients can be managed at home with the use of increased bronchodilator therapy, a short course of oral glucocorticoids and, if appropriate, antibiotics. 1- The presence of cyanosis, 2- peripheral oedema or 3- an alteration in consciousness should prompt referral to hospital. Oxygen therapy In patients with an exacerbation of severe COPD, high concentrations of oxygen may cause respiratory depression and worsening acidosis. 6 Controlled oxygen at 24% or 28% should be used with the aim of maintaining SaO2 of 88%–92% or PaO2 of more than 8 kPa (60 mmHg) without worsening acidosis. Bronchodilators Nebulised short-acting β2 -agonists combined with an anticholinergic agent (e.g. salbutamol and ipratropium) are routinely administered. Glucocorticoids Oral prednisolone reduces symptoms and improves lung function. Doses of 30 mg for 5 days are currently recommended. Antibiotic therapy The role of bacteria in exacerbations remains controversial. There is little evidence for the routine administration of antibiotics, but they are recommended for patients reporting 1- An increase in sputum purulence, 2- Sputum volume 3- Breathlessness. Non-invasive ventilation Non-invasive ventilation (NIV) reduces mortality and invasive ventilation rates in patients with an acute exacerbation of COPD complicated by mild to moderate respiratory acidosis (pH6.5 kPa). It should be considered when respiratory acidosis is not corrected within an hour of identification, despite optimal medical therapy, including controlled oxygen therapy with a target saturation of 88%–92%. Invasive ventilation should be considered in : 1- Patients with deteriorating acidosis despite optimal NIV settings, 2- Those unable to tolerate or wear the interface (e.g. due to facial injury) 7 3- Those who cannot protect their airway. Additional therapy Exacerbations may be accompanied by the development of peripheral oedema; this usually responds to diuretics. References: Ian D. Penman, Stuart H., et al., editors. Davidson's Principles and Practice of Medicine. 24th ed., Elsevier Health Sciences, 2022. Further information goldcopd.org Global Initiative for Chronic Obstructive Lung Disease: comprehensive overview of COPD. brit-thoracic.org.uk :British Thoracic Society: access to guidelines on a range of respiratory conditions. ersnet.org :European Respiratory Society: provides information on education and research, and patient information. thoracic.org :American Thoracic Society: provides information on education and research, and patient information. With best regard 8