Download - Copd Abhinay
-
8/2/2019 Copd Abhinay
1/62
Chronic
ObstructivePulmonary DiseaseBy Abhinay Sharma Bhugoo
Ml-610
-
8/2/2019 Copd Abhinay
2/62
Why COPD is Important ?
COPD is the only chronic disease that is showingprogressive upward trend in both mortality andmorbidity
It is expected to be the third leading cause of death by2020
Approximately 14 million Indians are currently sufferingform COPD*
Currently there are 94 million smokers in India
10 lacs Indians die in a year due to smoking relateddiseases
*The Indian J Chest Dis & Allied Sciences 2001; 43:139-47
-
8/2/2019 Copd Abhinay
3/62
Disease Trajectory of a
Patients with COPD
Symptoms
Exacerbations
Exacerbations
ExacerbationsDeterioration
End of Life
-
8/2/2019 Copd Abhinay
4/62
New Definition Chronic obstructive pulmonary disease (COPD) is
a preventable and treatable disease statecharacterised by airflow limitation that is not fullyreversible.
The airflow limitation is usually progressive and isassociated with an abnormal inflammatoryresponse of the lungs to noxious particles orgases, primarily caused by cigarette smoking.
Although COPD affects the lungs, it also producessignificant systemic consequences.
ATS/ERS 2004
-
8/2/2019 Copd Abhinay
5/62
introduction
COPD is a disorder in which subsets have dominant features of
chronic bronchitis
chronic productive cough for 3 months during each of 2 consecutive
years
emphysema permanent enlargement of the air spaces distal to the terminal
bronchioles, without obvious fibrosis
-
8/2/2019 Copd Abhinay
6/62
Obstructive Airway Disease
Asthma
Explosion in
research
Revolution in
therapy
COPD
Little research
(? neglect)
Few advances in
therapy
-
8/2/2019 Copd Abhinay
7/62
-
8/2/2019 Copd Abhinay
8/62
introduction
The Global Initiative for Chronic Obstructive LungDisease (GOLD) guidelines define COPD as a disease
state characterized by
Airflow limitation that is not fully reversible, is usually
progressive, and Associated with an abnormal inflammatory response of the lungs
to inhaled noxious particles or gases
-
8/2/2019 Copd Abhinay
9/62
Venn diagram of chronic obstructive pulmonary disease (COPD).
1 213 45
6 789 10
-
8/2/2019 Copd Abhinay
10/62
Histopathology ofchronic bronchitis showing hyperplasia of mucous glands andinfiltration of the airway wall with inflammatory cells
-
8/2/2019 Copd Abhinay
11/62
Gross pathology ofadvanced emphysema. Large bullae are present on the surface of
the lung.
-
8/2/2019 Copd Abhinay
12/62
At high magnification, loss of alveolar walls and dilatation of airspaces in emphysema
can be seen.
-
8/2/2019 Copd Abhinay
13/62
Etiology I/II
Cigarette smoking- 90%
Environmental factors Biomass fuels with indoor cooking and heating
Traffic-related air pollution
Airway hyperresponsiveness
Alpha1-antitrypsin deficiency Panacinar emphysema
Premature emphysema at an average age of 53 years for nonsmokers and 40 years forsmokers
Intravenous drug use Pulmonary vascular damage
Insoluble filler (eg, cornstarch, cotton fibers, cellulose, talc) contained in methadone ormethylphenidate
Cocaine or heroin
-
8/2/2019 Copd Abhinay
14/62
Etiology II/II
Immunodeficiency syndromes
Independent risk
Vasculitis syndrome Hypocomplementemic vasculitis urticaria syndrome (HVUS)
Connective tissue disorders
Cutis laxa is a disorder of elastin , various forms of inheritance
Marfan syndrome is an autosomal dominant inherited disease of type I
collagen
Ehlers-Danlos syndrome
Salla disease
Autosomal recessive storage disorder , sialic acid
-
8/2/2019 Copd Abhinay
15/62
Prognosis
For assess an individuals risk of death or hospitalization
History
Multifactorial with
Individual lifestyle
Socioeconomic factors Education / Knowledge
-
8/2/2019 Copd Abhinay
16/62
-
8/2/2019 Copd Abhinay
17/62
-
8/2/2019 Copd Abhinay
18/62
-
8/2/2019 Copd Abhinay
19/62
-
8/2/2019 Copd Abhinay
20/62
-
8/2/2019 Copd Abhinay
21/62
Pathophysiological changes
This phenomenon is called dynamichyperinflation
-
8/2/2019 Copd Abhinay
22/62
-
8/2/2019 Copd Abhinay
23/62
-
8/2/2019 Copd Abhinay
24/62
COPD classification based on spirometry
GOLD 2003
SPIROMETRY is not to substitute for clinical judgment in the
evaluation of the severity of disease in individual patients.
Severity PostbronchodilatorFEV1/FVC
PostbronchodilatorFEV1% predicted
At risk >0.7 >80
Mild COPD 80
Moderate COPD
-
8/2/2019 Copd Abhinay
25/62
-
8/2/2019 Copd Abhinay
26/62
-
8/2/2019 Copd Abhinay
27/62
-
8/2/2019 Copd Abhinay
28/62
Characteristic i/ii
Cough
worsening dyspnea
progressive exerciseintolerance
sputum production
alteration in mental status
Productive cough or acute
chest illness
Breathlessness
Wheezing
Systemic manifestations
decreased fat-free mass
impaired systemic muscle
function
Osteoporosis
Anemia
Depression
pulmonary hypertension
cor pulmonale
left-sided heart failure
Typically combination of signs and symptoms of
chronic bronchitis, emphysema, and reactive airwaydisease.
-
8/2/2019 Copd Abhinay
29/62
Characteristic ii/ii
Hx of more than 40 pack-yrs of smoking was the best
single predictor of airflow obstruction
If all 3 signs are absent, airflow obstruction can be nearlyruled out Self-reported smoking Hx of > 55 pack-yrs
Wheezing on auscultation
Self-reported wheezing
-
8/2/2019 Copd Abhinay
30/62
Physical Examination
Hyperinflation (barrel chest)
WheezingFrequently heard on forced and unforcedexpiration
Diffusely decreased breath sounds
Hyperresonance on percussion
Prolonged expiration phase
-
8/2/2019 Copd Abhinay
31/62
-
8/2/2019 Copd Abhinay
32/62
characteristics allowdifferentiation
Chronic bronchitis(bluebloaters) obese
Frequent cough andexpectoration
Use of accessory muscles ofrespiration is common
Coarse rhonchi and wheezing
may be heard on auscultation signs of right heart failure
Cor pulmonale
edema and cyanosis
Emphysema(pink puffers)
thin with a barrel chest little or no cough
Breathing may be assisted by
pursed lips
patients may adopt the tripod
sitting position hyperresonant, and wheezing
may be heard
Distant Heart sounds
-
8/2/2019 Copd Abhinay
33/62
Differentials diagnosis
Alpha1-Antitrypsin def
Bronchitis
Emphysema
Nicotine Addiction
Pulmonary Embolism
-
8/2/2019 Copd Abhinay
34/62
Investigation i/ii
Pulmonary Function Tests
For diagnosis
Assessment of severity
Following its progress
ABG
Hypoxemia / hypercapnia
Acidosis
Serum Chemistries
Retain sodium /Lower potassium levels /bicarbonate
Chronic respiratory acidosis leads to compensatory metabolic alkalosis
-
8/2/2019 Copd Abhinay
35/62
Investigation ii/ii
CBC Secondary polycythemia
Hct>52% in men or 47% in women
Alpha1-Antitrypsin all patients < 40 yrs or Fm Hx of emphysema at early age
Sputum Evaluation Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Pseudomonas aeruginosa
Chest Radiography +/- CT scan
-
8/2/2019 Copd Abhinay
36/62
COPD: Hyperinflation, depressed diaphragm, increased retrosternal space, and
hypovascularity of lung parenchyma are demonstrated.
-
8/2/2019 Copd Abhinay
37/62
Emphysema : increased AP diameter, increased retrosternal airspace, and flattened
diaphragm on lateral chest radiograph.
-
8/2/2019 Copd Abhinay
38/62
A lung with emphysema shows increased anteroposterior (AP) diameter, increased
retrosternal airspace, and flattened diaphragm on posteroanterior chest radiograph
-
8/2/2019 Copd Abhinay
39/62
A computed tomography (CT) scan shows hyperlucency due to diffusehypovascularity and bullae formation, predominantly in the upper lobes.
-
8/2/2019 Copd Abhinay
40/62
Severe bullous disease as seen on a computed tomography (CT) scan in a patient withchronic obstructive pulmonary disease (COPD).
-
8/2/2019 Copd Abhinay
41/62
treatment
Acute exacerbation
Stable COPD Rx base on severity of disease
-
8/2/2019 Copd Abhinay
42/62
Treatment
Severity evaluate
Mild to moderate Hemodynamic stable
bronchodilator Pred 30-40 mg/dy for 7dy
Moderate to severe
Risk for respiratory failure
Accessory muscle used:paradoxical chest/abd motion
SpO2 < 90% or PaO2 < 60 mmHg
PaCO2 > 45 mmHg or pH < 7.35
Acute
exacerbation
-
8/2/2019 Copd Abhinay
43/62
Treatment
Indication for admit
Severe exarcerbation
Severe stage of COPD New onset of : cyanosis, peripheral
edema
Unimprove after appropriated Tx
Multi-Comorbit : CAD, DM, HT
New onset Arrhythmia
Undefinite Diagnosis
Old age or Homeless
-
8/2/2019 Copd Abhinay
44/62
ACUTE EXACERBATION
treatment
-
8/2/2019 Copd Abhinay
45/62
Treatment
Bronchodilator
Beta2-agonist
Anticholinergic
Methylxantine
Corticosteroid
Systemic corticosteroids
Oxygen
All pt with SpO2 < 90% keep SpO2 90-94%
Antibiotic
Cover Streptococcus pneumoniae, Hemophilus influenza, Morexellacatarrhalis, Klebsiella pneumoniae ; Pseudomonas aeruginosa
Machanical ventilation
Non-invasive positive pressure ventilation: NIPPV
Invasive mechanical ventilation
Acute exacerbation : 1-3 wk onset
-
8/2/2019 Copd Abhinay
46/62
Treatment
Short acting Beta2-agonist is first
line but recommended combine
of SABA and Anticholinergic forlimited S/E (palpitation,
tachycardia, tremor)
Fenoterol/Ipratropium bromide
Every 15-20 min in 1st hour then 4-6
hr interval
Addition SABA every 1-2 hr
Acute exacerbation
: 1-3 wk onset
-
8/2/2019 Copd Abhinay
47/62
bronchodilator
Medication type Onset (min) duration(hour) Route drug
Beta2agonist Short 3-5 4-6 InhaleOral
IVSalbutamol(ventolin)
Terbutaline
Fenoterol
8-12 InhaleOral
Procaterol
Long 30-45 > 12 Inhale SalmeterolFormoterol
Anticholinergic Short 10-15 6-8Inhale
Ipratopium bromideLong 5 >24 Inhale Tiotropium (Spiriva)
Methylxanthine Uncertained in sustained release OralIV TheophyllineAminophylline
-
8/2/2019 Copd Abhinay
48/62
Treatment
Systemic corticosteroid
Limited systemic inflammation and airway
inflammation
Decrease sputum eosinophil
Decrease serum CRP
Improve FEV1 and PaO2
Minimize treatment failure / Length of stay in Hospital/Exacerbation
No improve of mortality
Prednisoline 30-40 mg/dy for 7-14 dy or
Dexamethasone 5- 10 mg q 6 hr or Hydrocortisone 100-200 mg q 6 hr
Acute exacerbation : 1-3 wk onset
-
8/2/2019 Copd Abhinay
49/62
Treatment
Oxygen
All pt with SpO2 < 90% keep SpO2 90-
94%
Limited S/E of Oxygen supplement
hypoxic drive hypoventilation
ventilation / perfusion mismatch
deadspace ) Haldane effect
rightward displacement of the CO2-
hemoglobin dissociation curve in the presence
of increased oxygen saturation, increasing the
amount of CO2 dissolved in blood
Acute exacerbation
: 1-3 wk onset
-
8/2/2019 Copd Abhinay
50/62
Treatment
Machanical ventilation
Indication of NIV
accessory muscle with abd paradox
Acidosis pH 7.25-7.35 and/or PaCO2 > 45
mmHg
RR > 24 / min
C/I of NIV
Uncooperation
Cardiovascular instability
Life-threatening hypoxemia
Severe acidosis : pH < 7.25
Acute exacerbation
: 1-3 wk onset
-
8/2/2019 Copd Abhinay
51/62
Treatment
Mechanical ventilation
Indication of Invasive mechanical
ventilation Respiratory failure
Severe acidosis : pH < 7.25
RR > 35/min
Accessory muscle used
with C/I for NIV
Fail NIV
Acute exacerbation
: 1-3 wk onset
-
8/2/2019 Copd Abhinay
52/62
STABLE COPD
treatment
-
8/2/2019 Copd Abhinay
53/62
Treatment
Bronchodilator
Beta2-agonist
Anticholinergic
Methylxantine
Corticosteroid
inhaled corticosteroids
Vaccination
Annual influenza vaccine
Pneumococcal vaccination
Pulmonary rehabilitation Improve quality of life
Oxygen therapy
Short term
Long term
surgery
Stable COPD : base on severity
-
8/2/2019 Copd Abhinay
54/62
Treatment
Avoidance of risk factor(s)
Influenza vaccination
Pneumococcal vaccination
Stable COPD : atALL stage
Management based on GOLD
-
8/2/2019 Copd Abhinay
55/62
Post-bronchodilator
FEV1
(% predicted)
Management based on GOLD
-
8/2/2019 Copd Abhinay
56/62
bronchodilator
Medication type Onset (min) duration(hour) Route drug
Beta2agonist Short 3-5 4-6 InhaleOral
IVSalbutamol(ventolin)
Terbutaline
Fenoterol
8-12 InhaleOral
Procaterol
Long 30-45 > 12 Inhale SalmeterolFormoterol
Anticholinergic Short 10-15 6-8 Inhale Ipratopium bromideLong 5 >24 Inhale Tiotropium (Spiriva)
Methylxanthine Uncertained in sustained release OralIV TheophyllineAminophylline
-
8/2/2019 Copd Abhinay
57/62
-
8/2/2019 Copd Abhinay
58/62
Pulmonary rehabilitation
-
8/2/2019 Copd Abhinay
59/62
Oxygen therapy
Oxygen therapy via nasal cannula Home supplemental oxygen
-
8/2/2019 Copd Abhinay
60/62
Bilevel positive airway pressure (BiPAP)
-
8/2/2019 Copd Abhinay
61/62
Bronchodilator medications are central to the symptomatic
management of COPD
GOLD Report 2003
-
8/2/2019 Copd Abhinay
62/62
Thank you