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COPD Defined and Acute Exacerbation Management

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COPD Defined and Acute Exacerbation Management Powered By Docstoc
					CHRONIC OBSTRUCTIVE
 PULMONARY DISEASE
  (COPD) DEFINED AND
 ACUTE EXACERBATION
            INPATIENT
        MANAGEMENT
  COPD DEFINED BY AMERICAN THORACIC
      SOCIET Y BY 1995 GUIDELINES

 COPD as a disease state is characterized by chronic
  airflow limitation due to chronic bronchitis and
  emphysema.
 Chronic bronchitis has been defined in clinical terms:
   the presence of chronic productive cough for at least 3
    consecutive months in 2 consecutive years.
 Emphysema, on the other hand, has been defined by
  its pathologic description:
   an abnormal enlargement of the air spaces distal to the
    terminal bronchioles accompanied by destruction of their
    walls and without obvious fibrosis.
     GLOBAL INITIATIVE FOR CHRONIC
OBSTRUCTIVE LUNG DISEASE (GOLD) UPDATED
        2010 CRITERIA FOR COPD

 A disease state characterized by airflow limitation
  that is not fully reversible. The airflow limitation is
  usually both progressive and associated with an
  abnormal inflammatory response of the lungs to
  noxious particles or gases
 Airflow limitation is the slowing of expiratory airflow
  as measured by spirometry, with a persistently low
  forced expiratory volume in 1 second (FEV1) and a
  low FEV1/forced vital capacity (FVC) ratio despite
  treatment.
 Airflow limitation is defined as an FEV1/FVC ratio of
  less than 70%.
        AMERICAN THORACIC SOCIET Y
(ATS)/EUROPEAN RESPIRATORY SOCIET Y (ERS )
       UPDATED DEFINITION OF COPD

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 associated with an abnormal
 inflammatory response of the lungs to
 noxious particles or gases, primarily caused
 by cigarette smoking.
CLASSIFICATION OF COPD
CHIEF COMPLAINT: SHORTNESS OF BREATH
          COPD VS ASTHMA?
CHIEF COMPLAINT: SHORTNESS OF BREATH
        DIFFERENTIAL DIAGNOSIS
   CAUSES OF COPD EXACERBATIONS

Exacerbations of COPD can be caused by
 many factors, including environmental
 irritants, heart failure or noncompliance
 with medication use
Most often, however, exacerbations are the
 result of bacterial or viral infection.
 Bacterial infection is a factor in 70 to 75
 percent of exacerbations.
    TREATMENT OPTIONS FOR COPD
          EXACERBATION

Oxygenation
Bronchodilators
Anticholingerics
Antibiotics
Corticosteroids
 OXYGENATION IN COPD EXACERBATION

Initial therapy should focus on maintaining
 oxygen saturation at 90 percent or higher.
Oxygen supplementation by nasal cannula
 or face mask is frequently required.
With more severe exacerbations, intubation
 or a positive-pressure mask ventilation
 method (e.g., continuous positive airway
 pressure [CPAP]) is often necessary to
 provide adequate oxygenation.
        BRONCHODILATORS IN COPD
            EXACERBATIONS

Inhaled beta2 agonists should be
 administered as soon as possible during an
 acute exacerbation of COPD.
 Albuterol (Ventolin) nebulizers from continuous to
  Q6hrs either standing or PRN depending on
  severity of exacerbation.
 Salmeterol (Serevent), a long-acting beta2
  agonist, has been shown to relieve symptoms in
  patients with COPD. Twice-daily dosing is an
  added benefit and may be convenient for many
  patients.
        ANTICHOLINGERICS IN COPD
             EXACERBATIONS

 Compared with beta2 agonists, inhaled
  anticholinergics such as ipratropium (Atrovent)
  provide the same or greater bronchodilation.
   Dosing: Ipratropium 500mcg/2.5ml Nebs from
    continuous to Q6hrs Standing or PRN depending
    on severity disease
 Use of a combination product such as
  ipratropium-albuterol (Combivent, DuoNebs) may
  simplify the medication regimen, thereby
  improving compliance
   MOST COMMON INFECTIOUS CAUSES OF
          COPD EXACERBATIONS

Mild to moderate exacerbations
 Streptococcus pneumoniae
 Haemophilus influenzae
 Moraxella catarrhalis
 Chlamydia pneumoniae
 Mycoplasma pneumoniae
 Viruses
Severe exacerbations
 Pseudomonas species
 Other gram-negative enteric bacilli
           ANTIBIOTIC CHOICES FOR COPD
                  EXACERBATIONS
Mild to moderate exacerbations
 First-line antibiotics
   Doxycycline (Vibramycin), 100 mg twice daily
   Trimethoprim-sulfamethoxazole (Bactrim DS, Septra DS), one tablet twice
    daily
   Amoxicillin-clavulanate potassium (Augmentin), one 500 mg/125 mg
    tablet three times daily or one 875 mg/125 mg tablet twice daily
 Alternative antibiotics
   Macrolides
      Clarithromycin (Biaxin), 500 mg twice daily
      Azithromycin (Zithromax), 500 mg initially, then 250 mg daily
   Fluoroquinolones
      Levofloxacin (Levaquin), 500 mg daily
      Gatifloxacin (Tequin), 400 mg daily
      Moxifloxacin (Avelox), 400 mg daily
          ANTIBIOTIC CHOICES FOR COPD
                 EXACERBATIONS
Moderate to severe exacerbations: Recommend IV antibiotics
 Cephalosporins
   Ceftriaxone (Rocephin), 1 to 2 g IV daily
   Cefotaxime (Claforan), 1 g IV every 8 to 12 hours
   Ceftazidime (Fortaz), 1 to 2 g IV every 8 to 12 hours
 Antipseudomonal penicillins
   Piperacillin-tazobactam (Zosyn), 3.375 g IV every 6 hours
   Ticarcillin-clavulanate potassium (Timentin), 3.1 g IV every 4 to 6 hours
 Fluoroquinolones
   Levofloxacin, 500 mg IV daily
   Gatifloxacin, 400 mg IV daily
 Aminoglycoside
   Tobramycin (Tobrex), 1 mg per kg IV every 8 to 12 hours, or 5 mg per kg
    IV daily
CORTICOSTEROIDS IN COPD EXACERBATIONS

 For severe exacerbations of COPD requiring
  inpatient therapy, methylprednisolone sodium
  succinate (Solu-Medrol) is commonly used
  initially.
   Dosage: Commonly 60mg or 125mg every six to twelve
   hours depending on severity of exacerbations
  After two to three days of intravenous therapy, the patient
   can be switched to orally administered prednisone in a
   starting dosage of 60 mg daily for a total of two weeks of
   therapy.
         SUMMARY TREATMENT OPTIONS

 Treatment of the obstruction
     Bronchodilators
     Anticholinergics
     Intravenous or oral corticosteroids
     Intravenous or oral antibiotics
 Assess for hyoxemia
   Consider supplemental O2 is PaO2 < 55mgHg or nocturnal saturation
    is less than 88%
   Consider positive pressure ventilation, CPAP or intubation, if
    necessary
 Encourage nonpharmacologic interventions
   Smoking cessation, patient education, nutrition, influenza and
    pneumococcal vaccines
                         REFERENCES

 Saint S, Bent S, Vittinghof f E, Grady D. Antibioticsin chronic
  obstructive pulmonar y disease exacerbations. A meta -
  analysis. JAMA. 1995;273:957 –60.
 Niewoehner DE, Erbland ML, Deupree RH, Collins D, Gross NJ,
  Light RW, et al. Ef fect of systemic glucocor ticoids on exacerbations of
  chronic obstructive pulmonar y disease. Depar tment of Veterans Af fair s
  Cooperative Study Group. N Engl J Med. 1999;340:1941–7.
 Continuous or nocturnal oxygen therapy in hypoxemic chronic
  obstructive lung disease: a clinical trial. Nocturnal Oxygen Therapy Trial
  Group. Ann Intern Med . 1990;93:391–8.
 Sethi S. Infectious etiology of acute exacerbations of chronic
  bronchitis. Chest. 2000;117(5 suppl 2):S380–5.
 Fein A , Fein AM. Management of acute exacerbations in chronic
  obstructive pulmonar y disease. Curr Opin Pulm Med. 2000;6:1 22–6.
 Voelkel NF, Tuder R. COPD: exacerbation. Chest. 2000;117(5 suppl
  2):S376–9.

				
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