lecture 3 copd.pdf

Chronic Obstructive Pulmonary Disease Lecture 3  why Why COPD is Important ? COPD is the only chronic disease that is showing progressive upward trend in both mortality and morbidity E It is expected to be the third leading cause of death by 202...

Chronic Obstructive Pulmonary Disease Lecture 3  why Why COPD is Important ? COPD is the only chronic disease that is showing progressive upward trend in both mortality and morbidity E It is expected to be the third leading cause of death by 2020  di I Obstructive diseases are by far the most common cause of death. and are secondary only to heart disease as a major factor cause of disability. Therefore their pathophysiology and treatment will be discussed initially in some detail. c c They are: A N'them chronic bronchitis emphysema d Ii 1 chronic bronchitis and emphysema together asthma I bronchiectasis wiki cystic fibrosis. did  was to The survival rate for COPD varies between 5 and 30 years, but eventually cardiac and O ventilatory failure will occur. Avoidance of the 0 precipitating factors listed below will tend to e improve the prognosis: stopping smoking I'M I control of atmospheric pollution prompt treatment of all acute infections maintenance of good general health. Disease Trajectory of a Patients with COPD Us Symptoms Exacerbations 5 Exacerbations 1335 Deterioration Exacerbations End of Life “Despite this burden, COPD is a “Cindrella” conditions that receives limited recognition from both patients and physicians” Respiratory Medicine 2002; 96: S1-S31  Obstructive Airway Disease Asthma COPD Explosion in Little research research (? neglect) Revolution in Few advances in therapy therapy  New Definition Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects the lungs, it also produces significant systemic consequences. ATS/ERS 2004 Risk Factors Smoke from home cooking and heating fuel Occupational dust and chemicals Gender: More common in men. M:F ratio is 5%:2.7% (in India) Increasing age Others: Infection, nutrition and deficiency of 1 antitrypsin Pathophysiology of COPD Increased mucus production and reduced mucociliary clearance - cough and sputum production Loss of elastic recoil - airway collapse Increase smooth muscle tone Pulmonary hyperinflation Gas exchange abnormalities - hypoxemia and/or hypercapnia Key Indicators for COPD Diagnosis Chronic cough Present intermittently or every day often present throughout the day; seldom only nocturnal Chronic sputum production Present for many years, worst in winters. Initially mucoid – becomes purulent with exacerbation Dyspnea that is Progressive (worsens over time) Persistent (present every day) Worse on exercise Worse during respiratory infections Acute bronchitis Repeated episodes History of exposure to risk Tobacco smoke , occupational dusts factors and chemical smoke from home cooking and heating fuel Physical signs Large barrel shaped chest (hyperinflation) Prominent accessory respiratory muscles in neck and use of accessory muscle in respiration Low, flat diaphragm Diminished breath sound Wheezing : mucoid sound during expiration. Spirometry Diagnosis Assessing severity Assessing prognosis Monitoring progression Spirometry FEV1 – Forced expired volume in the first second FVC – Total volume of air that can be exhaled from maximal inhalation to maximal exhalation FEV1/FVC% - The ratio of FEV1 to FVC, expressed as a percentage. TLC : increased. RV: increased. Pharmacotherapy for Stable COPD Bronchodilators Steroids Short-acting 2- Oral – Prednisolone agonist – Salbutamol Inhaled - Fluticasone, Budesonide Long-acting 2- agonist - Salmeterol and Formoterol Anticholinergics – Ipratropium, Tiiotropium Methylxanthines - Theophylline “Bronchodilator medications are central to the symptomatic management of COPD” GOLD Report 2003 How Do Bronchodilators Work? Reverse the increased bronchomotor tone Relax the smooth muscle Reduce the hyperinflation Improve breathlessness Treatment: Goals of management -1 Recognition of disease (early Diagnosis and staging) Smoking cessation (secondary prevention) nicotine replacement and Zyban Improvement of breathlessness Physiotherapy treatment for COPD Aims of COPD Therapy To remove excess bronchial secretion and reduce the airflow obstruction. To establish the coordinated pattern of breathing To promote relaxation and improve posture To improve the mobility of thorax, shoulder girdle and neck To increase the exercise tolerance To encourage a full and active life style. Means of COPD Treatment 1. Postural Drainage(P.D) is necessary for all patients. In Postural Drainage chronic bronchitis regular postural drainage should be given. In case of acute emphysema, postural drainage is not necessary but in an infective episode, where sputum may be present PD may be needed. The optimum position must be established with individual and advice for postural drainage at home. Clapping and Shaking are effective over the affected lung segments and help to loosen and move the secretions to cental airways during expiration. Then ask the patient to take 2-3 coughs to remove the secretions out 2. Breathing exercises should be given in a correct way in treatment for COPD. The main emphasis is given on diaphragmatic breathing with relaxed expiration. The diaphragmatic breathing with decreased upper chest movements and relaxed shoulder girdle is preferred. Expansion of basal lung segments are taught to ventilate these areas. Pursed lip breathing with prolonged expiration is given especially in presence of emphysematous bullae. 3. Posture Correction Patient should be taught to attain maximal relaxation of the upper chest as well as movements of lower chest. The main emphasis is on relaxed and controlled diaphragmatic breathing. For maintaining posture the patient should not be kept with forward head and rounded shoulder. 4. Thoracic mobility exercises are given along with shoulder girdle movements. Free active exercises for whole spine to prevent kyphosis and fixed inspiration. 5. These patients should be as mobile and active as possible. Their exercise tolerance may be increased by gradually increasing the distances walked both on the flat and upstairs or slopes while practising breathing control. A graduated exercise programme can also be given to these patients during the later part of their stay in hospital and should be continued at home. 6. In daily life style patient should avoid smoking and encouraged to keep fit and eat sensibly. For gaining relaxation, swimming helps very much. Jerky and quick movements should be strictly avoided.