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Definition of COPD: COPD is a syndrome of chronic limitation in expiratory airflow encompassing emphysema or chronic bronchitis. Airflow obstruction may be accompanied by airway hyper-responsiveness and may be not be fully reversible. 2
1. Chronic bronchitis : Consists of persistent cough plus sputum production for most days for at least 3 months of the year for at least 2 consecutive years. 2. Emphysema : Is abnormal permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis. 3
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Diagnosis and Assessment of COPD: 1. The diagnosis of COPD is based on : - a history of exposure to risk factors and - the presence of airflow limitation that is not fully reversible - with or without the presence of symptoms 6
2. For the diagnosis and assessment of COPD, spirometry is the gold standard. a. Spirometry showing an FEV1/FVC < 70% of predicted is the hallmark of COPD. Bronchodilator reversibility testing is no longer recommended. b. Measuring (ABG) tension should be considered for all patients with FEV1 < 50% of predicted or clinical signs suggestive of respiratory failure 7
Significant changes in arterial blood gases (ABG) are not usually present until is less than 1 L. At this stage, FEV1 hypoxemia and hypercapnia may become chronic. Hypoxemia usually occurs initially with exercise but develops at rest as the disease progresses. 8
Management of Stable COPD Medications not modify the long-term decline in lung function (only symptoms and complications) 11
NONPHARMACOLOGIC THERAPY Smoking cessation is the only intervention proven to affect long-term decline in FEV1 and slow COPD progression. Pulmonary rehabilitation programs include exercise training, breathing exercises, optimal medical treatment, psychosocial support, and health education. Administer vaccinations as appropriate (eg, pneumococcal vaccine, annual influenza vaccine). 12
Once patients are stabilized as outpatients and pharmacotherapy is optimized, institute long-term oxygen therapy if either (1) resting Pao2 less than 55 mm Hg or SaO2 less than 88% with or without hypercapnia, or (2) resting Pao2 55 to 60 mm Hg or SaO2 less than 88% with evidence of right-sided heart failure, polycythemia, or pulmonary hypertension. The goal is to raise PaO2 above 60 mm Hg. 13
pharmacotherapy Bronchodilator medications are central to the symptomatic management of COPD. a. Regular or/and PRN. b. The principal bronchodilator are β2-agonists, anticholinergics, or a combination of these drugs. c. Theophylline given on a (regular basis) 14
d. Inhaled therapy is preferred. e. Regular treatment with a LABA is more effective and convenient than regular treatment with SABAs. f. Combining bronchodilators (different pharmacologic) efficacy & same or ADR. g. Adding a LABA/ICS to tiotropium appears to provide additional benefits. 15
h. Treatment with a long-acting anticholinergic delays first exacerbation, reduces the overall No of COPD exacerbations and related hospitalizations. 16
ICSs improve { symptoms, lung function, quality of life and decrease the frequency of exacerbations} in pt with FEV1 < 60% of predicted; they do not modify the progressive decline in FEV1 or decrease mortality. 17
ICS combined with a LABA is more effective than the individual components. Monotherapy with ICS is not recommended. Chronic treatment with OCSs should be avoided because of an unfavorable benefit-risk ratio. 18
Pt assessment and selection of therapy New GOLD guidelines combine symptoms (based on scores), airflow limitation (based on postbronchodilator FEV1), and frequency of exacerbations to determine patient risk group and recommended treatment. 19
NB: - low risk 50% - high risk < 50 %. - Less symptoms mmrc of 1 and CAT of < 10. - more symptom mmrc of 2 and CAT of 10 mmrc = modified British Medical Research Council breathlessness scale (validated questionnaire); CAT = COPD Assessment Test (validated questionnaire). 20
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NB: SAAC or SABA are preferred for group (A) only. LAAC could be selected alone in all groups (B, C or D). ICS never used alone but combined with LABA in group (C or D). 22
Other pharmacologic treatments: Phosphodiesterase-4 inhibitor: Roflumilast Indication: As a daily treatment to reduce the risk of COPD exacerbations in patients with severe COPD (FEV1 < 50% of predicted) associated with chronic bronchitis and a history of frequent exacerbations. 23
Cardioselective β-blockers: i. New observational data suggest that long-term treatment with β-blockers reduces risk of exacerbations and improves survival, even in patients without overt cardiovascular disease ii. β-blockers should not be withheld in patients with COPD who also have (CHF), or other cardiovascular conditions in which β- blockers are beneficial iii. M of A is unknown, but β-blockers can up-regulate β2- receptors in the lungs, which may improve the effectiveness of inhaled β-agonists. 24
α1-antitrypsin augmentation therapy: i. A once-weekly intravenous therapy of α1- proteinase inhibitor (Prolastin) ii. For young patients with severe hereditary α1- antitrypsin deficiency and established emphysema, but an expensive treatment iii. Patients with α1-antitrypsin deficiency usually are white, usually develop COPD at a young age (younger than 45 years), and have a strong family history. It may be worthwhile to screen such patients. 25
Antibiotics are recommended only for treating infectious exacerbations of COPD. Smoking cessation (all pt groups A D) Influenza vaccine annually (all pt groups A D) Pneumococcal vaccine (all pt groups A D) 26
Management of Acute Exacerbations of COPD: A COPD exacerbation is an acute worsening of symptoms (dyspnea and/or cough and/or an increase in quantity or purulence of sputum) that is worse than normal day-today variation Diagnosis is based purely on clinical presentation. Spirometry is not accurate during an exacerbation and is not recommended unlike in asthma. 27
Goals of Treatment: The goals are to: 1) Prevent hospitalization or reduce length of hospital stay. 2) Prevent acute respiratory failure and death. 3) Resolve symptoms. 4) Return to baseline clinical status and quality of life. 28
NONPHARMACOLOGIC THERAPY Consider oxygen therapy for patients with hypoxemia. Use caution because many COPD patients rely on mild hypoxemia to trigger their drive to breathe. Overly aggressive oxygen administration to patients with chronic hypercapnia may result in respiratory depression and respiratory failure. Adjust oxygen to achieve PaO2 greater than 60 mm Hg or oxygen saturation (SaO2) greater than 90%. Obtain ABG after oxygen initiation to monitor CO2 retention resulting from hypoventilation. 29
Noninvasive positive-pressure ventilation (NPPV) provides ventilatory support with oxygen and pressurized airflow using a face or nasal mask without endotracheal intubation. NPPV is not appropriate for patients with altered mental status, severe acidosis, respiratory arrest, or cardiovascular instability. Intubation and mechanical ventilation may be needed in patients failing NPPV or who are poor candidates for NPPV. 30
PHARMACOLOGIC THERAPY 1- Inhaled bronchodilators (inhaled SABAs with or without SAAC ) are the preferred treatment of COPD exacerbations. SAAC (ipratropium) are generally added for acute exacerbation. 2- Systemic (oral or I.V) corticosteroids are effective, and they shorten recovery time, improve FEV1 and improve hypoxemia. They may also lower the risk of treatment failure, early relapse rate, and length of hospital stay. Systemic corticosteroids should be used in most exacerbations. 31
3- Antibiotic treatment Should be initiated for exacerbations if criteria below are met. The 3 cardinal symptoms are : - increased dyspnea, increased sputum volume, and increased sputum purulence. AB should be given if all three cardinal symptoms are present Antibiotics should be given if two of the three cardinal symptoms are present AND if increased sputum purulence is one of the two present symptoms. Antibiotics should be given to patients with a severe exacerbation requiring mechanical ventilation. 32
Recommended duration of antibiotic treatment is usually 5 10 days. Recommended antibiotics: i.usual initial antibiotics for uncomplicated COPD: Azithromycin, clarithromycin, doxcycline, or trimethoprim/sulfamethoxazole. ii. In complicated COPD with risk factors: use Amoxicillin/clavulanate, levofloxacin, moxifloxacin. 33
If at risk of Pseudomonas infection: use High-dose levofloxacin (750 mg) or ciprofloxacin If exacerbation does not respond to initial antibiotic, then sputum culture and sensitivity should be performed. 34
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