Chronic Obstructive Pulmonary Disease

Transcription

1 Chronic Obstructive Pulmonary Disease 07 Contributor Dr David Tan Hsien Yung Definition, Diagnosis and Risk Factors for (COPD) Differential Diagnoses Goals of Management Management of COPD THERAPY AT EACH STAGE OF COPD Management of Acute Exacerbation of COPD Indications for Specialist Referral Advisor Prof Lim Tow Keang 72 nhg_guideline_ _1112.indd 72

2 Definition A disease state characterized by airflow limitation that is not fully reversible, usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. Diagnosis Consider COPD in patient > 35 years of age with chronic cough, sputum production or dyspnoea and/or history of exposure to risk factors. KEY INDICATORS FOR COPD DIAGNOSIS 5. Exposure to Risk Factors Tobacco smoke. Occupational dusts and chemicals. Smoke from home cooking and heating fuel. The diagnosis should be confirmed by spirometry, but in cases where spirometry is inaccessible, COPD can be diagnosed and managed based on symptoms alone. However, clinical diagnosis alone is unreliable, and the diagnosis needs to be reviewed periodically especially after treatment. KEY INDICATORS FOR COPD DIAGNOSIS 1. Chronic Cough Present intermittently or everyday. Often present throughout the day, seldom only nocturnal 2. Chronic Sputum Production Any pattern of chronic sputum production 3. Acute Bronchitis Repeated episodes 4. Dyspnea Progressive or persistent. Worse on exercise or respiratory infections. Risk Factors HOST FACTORS Genes Hyperresponsiveness Lung Growth ENVIRONMENTAL FACTORS Tobacco Smoke Occupational Dusts / Chemicals Infection Socio-economic Status Differential Diagnosis Onset in midlife COPD ASTHMA CONGESTIVE HEART FAILURE Symptoms slowly progressive Long smoking history Dyspnoea during exercise Largely irreversible airflow limitation Onset early in life Symptoms vary from day to day Symptoms at night / early morning Allergy, rhinitis and / or eczema Family history of asthma Largely reversible airflow limitation Fine basilar crackles on auscultation Chest X-ray shows dilated heart, pulmonary oedema Pulmonary function tests indicate volume restriction, not airflow limitation BRONCHIECTASIS Large volumes of purulent sputum Commonly associated with bacterial infection Coarse crackles on auscultation Chest X-ray / CT shows bronchial dilation, bronchial wall thickening TUBERCULOSIS Onset all ages Chest X-ray shows lung infiltrates or nodular lesions Microbiological confirmation High local prevalence of tuberculosis 73 nhg_guideline_ _1112.indd 73

3 Goals of Management Relieve symptoms Reduce mortality Improve health status Improve exercise tolerance Prevent disease progression Prevent and treat exacerbations Prevent or minimize side-effects from treatment Management of COPD Four Important Components 1. Assess and monitor disease 2. Reduce risk factors 3. Manage stable COPD 4. Manage acute exacerbations Medical History Exposure to risk factors Past medical history asthma, sinusitis, other respiratory diseases History of exacerbations and hospitalizations Presence of co-morbidities Current medical treatments Impact of disease to patient s and family life, limitation of activities, missed work Psychosocial issues and support Useful Investigations Chest X-ray Spirometry Bronchodilator reversibility test to exclude asthma Indications for Spirometry Diagnosis Reassessment and monitoring (yearly in Stage I-IV, or increased severity of symptoms) Identify superimposed asthma Treatment NON-PHARMACOLOGICAL PHARMACOLOGICAL Patient Education Recommended Not Recommended Smoking cessation Influenza / pneumoccocal vaccination Regular anti-tussives Pulmonary rehabilitation Bronchodilators Respiratory stimulants Oxygen therapy Inhaled glucocorticosteroids in selective patients Mucolytics Surgery in selective patients Smoking cessation (nicotine / bupropion) Routine antibiotics 74 nhg_guideline_ _1112.indd 74

4 Bronchodilators in Stable COPD Bronchodilator medications are central to symptom management and increase in exercise tolerance in COPD Inhaled therapy is preferred The choice between β 2 -agoinst, anticholinergic, theophylline, or combination therapy depends on availability and individual response in terms of symptom relief and side effects Bronchodilators are prescribed on an as needed or on a regular basis to prevent or reduce symptoms A regularly scheduled long-acting bronchodilator should be added if symptoms are inadequately controlled with short-acting bronchodilator therapy Long-acting inhaled bronchodilators are more effective and can be considered in moderate to severe COPD Combining bronchodilators may improve efficacy and decrease the risk of side effects compared to increasing the dose of single bronchodilator Theophylline is useful as an adjunct to inhaled bronchodilators, especially in patients who have difficulty using inhaled bronchodilators effectively Role of Inhaled Glucocorticosteriods Inhaled steroids are indicated for maintenance therapy if FEV1 < 50% predicted or if there is presence of frequent exacerbations Long-term oral steroids are not recommended Combination inhalers can be used if both steroid and bronchodilator effects desired for optimization of control 75 nhg_guideline_ _1112.indd 75

5 Therapy at each stage of copd Characteristics FEV1 / FVC < 70% Management I: MILD II: MODERATE III: SEVERE IV: VERY SEVERE FEV 1 80% predicted With or without symptoms Avoidance of risk factor(s): 1. Influenza vaccination 2. Consider pneumococcal vaccination FEV / FVC < 70% 50% FEV 1 < 80% predicted With or without symptoms FEV / FVC < 70% 30% FEV 1 < 50% predicted With or without symptoms Add short-acting bronchodilator when needed Add regular treatment with one or more long-acting bronchodilators Add rehabilitation FEV / FVC < 70% FEV 1 < 30% predicted or presence of chronic respiratory failure or right heart failure Add inhaled glucocorticosteroids if repeated exacerbations Add long-term oxygen if chronic respiratory failure Consider surgical treatments 76 nhg_guideline_ _1112.indd 76

6 Management of Acute Exacerbation of COPD Identify a change from stable condition* Exclude differential diagnosis- CXR** RR < 20/min No use of accessory Muscles / retractions RR 20/min Use of accessory Muscles / retractions Nebulized Ventolin : Atrovent : Normal Saline 1ml : 2ml : 1ml stat Post Neb better Post Neb NOT better Home Management Brochodilator Therapy, +/-Anticholinergic therapy Prednisolone 30 mg om x 7-10 days (consider in all patients with FEV 1 < 50%) Antibiotics: if patients have Anthonisen criteria Type I or Type II (ie 2 out of 3 symptoms of dyspnoea, increased sputum volume and/or purulence) Refer to Hospital Arrange Transfer to hospital Controlled Oxygen Therapy:start O2 at lowest flow that can maintain SaO 2 > 90% - if pulse oximeter available maintain SaO 2 above 90% within minimum effective flow of oxygen - If no pulse oximeter available, limit O2 to 28% with mask or no more than 2L/ min via prongs Continuous Nebulized Ventolin:NS *Symptoms suggesting destabilization - increased breathlessness, wheezing, chest tightness - increased cough and sputum - change of colour / tenacity of sputum - fever - malaise, insomnia, sleepiness, fatigue confusion, depression **Different diagnosis of COPD exacerbation - Pneumonia - Pleural effusion - Pulmonary embolism - Arrhythmia ***Red flags to suggest severe COPD - marked increase in intensity of symptoms - background of severe COPD - onset of cyanosis, peripheral oedema, arrhythmias - significant co-morbidities - > 65 years old - insufficient home support - SaO2 < 90% 77 nhg_guideline_ _1112.indd 77

7 Indications for Specialist Referral Stage III or IV diseases Suspected severe COPD Cor pulmonale Bullous disease Home oxygen therapy Home nebulizer therapy Disease with age < 40 years Disease with < 10 pack-years (1 pack-year = 20 cigarettes/day for 1 year) Rapid decline in FEV, (> 60 ml/year decrease in FEV 1 ) Symptoms disproportionate to FEV 1 Frequent infections Uncertain diagnosis Development of new symptoms e.g. haemoptysis, or new physical signs e.g. cyanosis, peripheral oedema Indications for Emergency Department Referral 1. Marked dyspnoea and tachynoea (> 30 bpm) 2. Use of accessory muscles at rest 3. Cyanosis 4. Confusion 5. SaO 2 < 90% 6. Failure of outpatient treatment Abbreviations CT Computer Tomography FEV 1 Forced Expiratory Volume in 1 second FVC Forced Vital Capacity References 1. Global Strategy for the Diagnosis, Management and Prevention of COPD: The GOLD Expert Panel. Available from URL: www. goldcopd.com 2. British Thoracic Society guidelines for the management of chronic obstructive pulmonary disease: The COPD Guideline Group of the Standards of Care Committee of the BTS. Thorax 1997; 52(suppl 5): S1-S MOH CPG 4/ nhg_guideline_ _1112.indd 78