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COPD with acute exacerbation bronchitis

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					COPD with acute
exacerbation
What is COPD?
 COPD is a chronic slowly progressive
 disorder characterized by airflow
 obstruction (FEV1 < 80% predicted and
 FEV1/FVC ratio < 70%) which does not
 change markedly over several months.

 It encompasses three clinical entities :
 EMPHYSEMA
 CHRONIC BRONCHITIS
 SMALL AIRWAYS DISEAES
DEFINITIONS
CHRONIC BRONCHITIS : It is defined as
cough with sputum on most days for at least
three consecutive months for more than two
successive years.

EMPHYSEMA : It is defined as permanent
destructive enlargement of the air spaces
distal to the terminal bronchioles.

SMALL AIRWAYS DISEASE : A condition in
which small bronchioles are narrowed.
RISK FACTORS
 SMOKING: studies have shown accelerated
 decline in FEV1 in a dose response relationship to
 the intensity of cigarette smoking which is
 expressed as pack years.

 AIR WAY RESPONSIVENESS: Increased air way
 responsiveness is a significant predictor of
 subsequent decline in pulmonary function.

 RESPIRATORY INFECTIONS: Though respiratory
 infections are an important cause of exacerbation
 of COPD , their association to the development
 and progression of COPD remains to be proven.
RISK FACTORS contd..
 OCCUPATIONAL EXPOSURE: Including coal
 mine , gold mining and cotton textile dust have
 been suggested as risk factors.

 AMBIENT AIR POLLUTION: with high rates of
 COPD in non smoking women in developing
 countries indoor air pollution associated with
 cooking has been suggested as potential
 contributor.

 ALPHA 1 ANTI TRYPSIN DEFICIENCY: Cigarette
 smokers with alpha 1 anti-trypsin deficiency are
 more likely to develop COPD at early ages.
CLINICAL PRESENTATION
  HISTORY: three most common symptoms of
  COPD are cough, sputum production and
  exertional dyspnea.

  As disease progresses dyspnea occurs with mild
  activity and in severe cases at rest.

  Hallmark of COPD is frequent exacerbation of
  illness.

  Pneumonia , pulmonary HTN , cor pulmonale
  and chronic respiratory failure characterize the
  late stages of the disease.
SIGNS OF COPD
Nicotine staining of finger nails.
Pursed lip breathing.
Characteristic tripod position.
Use of accessory muscles.
Barrel shaped chest.
Excavation of suprasternal and
supraclavicular fossae during respiration.
Cyanosis.
Weight loss , bitemporal wasting.
Hoover’s sign : paradoxical inward
movement of rib cage during inspiration.
SIGNS OF COPD contd..
 Tracheal tug
 Loss of cardiac dullness
 Prolonged expiratory phase with wheezing
 Signs of hypercapnia i.e bounding pulse, warm
 extremities and flapping tremors

 Signs of cor pulmonale namely elevated JVP ,
 right ventricular heave , loud P2 , S3 , hepatic
 congestion , ascities . Peripheral edema

 Clubbing is not a sign of COPD ; CA lung is the
 most likely explanation for clubbing in COPD.
INVESTIGATIONS
     PFTs: Reduction in FEV1 and FEV1/FVC ratio.

     ABGs: Indicated if
1.   Hypoxemia or hypercapnia is suspected.
2.   FEV1 is less than 40% of predicted.
3.   Clinical signs of heart failure.

     SPUTUM EXAMINATION for micro organisms in acute
     exacerbation

     ECG may show sinus tachycardia , signs of RVH and
     Supraventricular arrythmias.

     HAEMATOLOGY may show polycythemia.
INVESTIGATIONS contd..
 CXR may show hyperinflation with flattening of
 diaphragm or peripheral arterial deficiency ,
 parenchymal bullae and enlargement of central
 pulmonary arteries.

 CT SCAN is the current definitive test for the
 establishing the presence or absence of
 emphysema.

 ALPHA 1 ANTI TRYPSIN LEVEL in patients
 presenting with age < 50 yrs, strong family history
 , predominant basilar disease or with minimal
 smoking history.

 ECHO for suspected pulmonary HTN,
GOLD CRITERIA FOR COPD SEVERITY
Gold    severity      symptoms                      spirometry
stage

0       At risk       Ch cough,sputum production    normal



I       mild          With or without ch cough or   FEV1/FVC<0.7
                      sputum production             AND FEV1>80
                                                    %
II      moderate      As above                      FEV1/FVC<0.7
                                                    AND
                                                    50%<FEV1<80%
III     severe        As above                      FEV1/FVC<0.7
                                                    AND
                                                    30%<FEV1<50%
IV      Very severe   As above                      FEV1/FVC<0.7
                                                    AND FEV1<30%
     TREATMENT
      STABLE PHASE COPD:

1.    Smoking cessation is one of the two interventions that
      influence the natural history of patients with COPD. Nicotine
      transdermal patch, nicotine gum and bupropion increase
      cessation rates in motivated smokers.

2.    Oxygen therapy also influence natural history of disease in
      patients with resting hypoxemia. Survival in hypoxemic
      patients with COPD is directly proportionate to the no. of hrs
      / day oxygen is administered.

ABG analysis is prefered over oximetry to guide initial oxygen
    therapy. Oxygen by nasal prongs must be given for at least
    15 hrs a day.Transtracheal oxygen is alternative method of
    delivery in pts. who require high flows of oxygen than can be
    deliverd by nasal prongs.
BRONCHODILATORS
     Anticholinergic agents like ipratropium bromide is first line
     agent because of its longer duration of action and absence
     of sympathomimetic side effects. Dose 2 puffs every 6 hrs.

     Beta agonists
1.   Short acting: like salbutamol are less expensive, have
     rapid duration of action and have bronchodilator effect
     equal to ipratropium bromide but may cause tachycardia,
     tremor and hypokalemia.

2.   Long acting: like salmeterol appear to achieve
     bronchodilation that is equivalent or superior to
     ipratropium but their role in stable COPD is under
     research.
THEOPHYLLINE
 Theophylline is third line agents in COPD patients
 who fail to achieve adequate symptoms with
 anticholinergics and beta 2 agonists.

 SR theophylline improve arterial oxygen Hb
 saturation during sleep in COPD pts and is a first
 line agent for those with sleep related breathing
 disorders.

 Its benefits may result from anti inflammatory
 properties and extra pulmonary effects on
 diaphragm strength , myocardial activity and renal
 function.
CORTICOSTEROIDS
 Apart from acute exacerbation , COPD is
 not generally steroid responsive disease.

 A trial of inhaled glucocorticoids should be
 considered in pts with frequent
 exacerbations defined as 2 or more per
 year, and in pts who demonstrate a
 significant amount of acute reversibility in
 response to inhaled bronchodilators.

 Chronic use of oral glucocorticoids for
 treatment of COPD is not recommended.
OTHER AGENTS
 N ACETYL CYSTEINE: has been used in
 pts of COPD for its mucolytic and anti
 oxidant properties.

 ALPHA 1 ANTI TRYPSIN THERAPY for
 severe anti trypsin deficiency.

 Pts over 18 years of age with air flow
 obstruction on spirometry and level less
 than 11 umol/l are candidates for
 replacement therapy.
NON PHARMACOLOGICAL
THERAPIES
 General medical care : influenza vaccine annually.
 Pneumococcal vaccine is also recommended.

 Pulmonary rehabilitation: graded aerobic physical
 exercise programs

   walking 20 mins at least thrice weekly,
    bicycling are helpful for preventing deterioration of physical
   condition and to improve patient’s ability to carry out daily
   activities.
   Pursed lip respiration to slow the rate of breathing and
   abdominal breathing exercises to relieve fatigue of accessory
   muscles of respiration may reduce dyspnea in some pts.
   Adequate systemic hydration and cough training methods for
   mobilization of secretions in pts with ch bronchitis.
SURGICAL TREATMENT
1.   LUNG TRANSPLANTATION: for pts with FEV1
     less than 25% and severe limitation in quality of
     life esp with hypercapnia and hypoxemia.It is
     not an option for elderly pts.

2.   BULLECTOMY: Is considered in pts with COPD
     and dyspnea in whom a bulla or bullae occupy
     50% of hemithorax.

3.   LUNG VOLUME REDUCTION SURGERY: In
     highly selected pts with severe COPD due to
     emphysema.
ACUTE EXACERBATION
 Exacerbations are commonly considered to
 be episodes of increased dyspnea and
 cough and change in amount and
 character of sputum.

 It may or may not be accompanied by
 fever, myalgias and sore throat.

 Approach to the pt includes assesment of
 severity , identification of the precipitating
 factor and institution of therapy.
PRECIPITATING CAUSES
 Bacterial infections play a role in
 many episodes.
 (H.influenzae,S.pneomoniae,M.catarr
 halis and Mycoplasma)

 Viral infections are involved in 1/3 rd
 of cases. (Influenza and Adenovirus)

 In 20 – 35% no specific precipitant
 can be identified.
PATIENT ASSESMENT
 History include degree of dyspnea , by asking
 about breathlessness during activities , ask about
 fever , change in character of sputum and
 associated symptoms as nausea , vomiting ,
 diarrhea , myalgias and chills.

 Inquire about frequency and severity of previous
 exacerbations.

 Physical examination : process degree of distress.

 CXR and ABGs
INSTITUTION OF THERAPY
     OXYGEN to achieve and maintain PaO2 > 55-60 mm Hg
     and to keep arterial saturation > 90%. Hypoxic respiratory
     drive plays a small role in pts of COPD.

     INHALED BRONCHODILATORS

1.   Short acting beta agonists are first line agents as albuterol
     has reduced duration of action in acute exacerbation
     allowing a treatment frequency of every 30 – 60 mins as
     tolerated. Subsequent treatment can be reduced to 2- 4
     puffs every 4 hrs.

2.   Anticholinergic agents are equally effective to short acting
     beta 2 agonists. Dose : 2 puffs QID can be increased to 4-
     6 puffs every 4-6 hrs.

3.   Combination therapy has synergistic bronchodilation ,
     rapid onset of action and fewer S/E.
Contd..
 GLUCOCORTICOIDS: GOLD guidelines
 recommend 30 – 40 mg of oral prednisolone over
 10 – 14 days. They reduce hospital stay , hasten
 recovery and reduce the chance of subsequent
 exacerbation or relapse for a period upto 6 mths.

 ANTIBIOTICS: First line antibiotic regimes are
 Septran (160/800 mg every 12 hrs) , Amoxycillin (
 500mg tds) Doxycycline (100mg bd) for 7-10 days.

 For severe exacerbation recommended antibiotics
 include Azithromycin , Clarithromycin ,
 Levofloxacin and Gatifloxacin.
Contd..

 PSYCHOACTIVE DRUGS :low dose
 anxiolytics may reduce anxiety .
 Buspirone 5-10 mg tds is usually
 tolerated well.
INDICATIONS FOR ICU
ADMISSION
  SEVER DYSPNEA
  MENTAL STATUS CHANGES
  PERSISTENT WORSENING
  HYPOXEMIA
  HYPERCAPNIA
  RESPIRATORY ACIDOSIS ALL
  DESPITE MEDICAL THERAPY.
MECHANICAL VENTILATORY
SUPPORT
 Non Invasive positive pressure pressure
 ventilation (NIPPV) in pts with respiratory
 failure , defined as Pco2 > 45 mm Hg
 results in significant reduction in mortality,
 need for intubation , complication of
 therapy and duration of hospital stay.

 IPPV with ETT is indicated for pts with
 severe respiratory distress despite initial
 therapy , life threatening hypoxemia ,
 severe hypercapnia and/or acidosis ,
 impaired mental status , respiratory arrest
 and hemodynamic instability.
DISCHARGE CRITERIA

  Use of inhaled bronchodilators less
 frequently than every 4 hrs.

 Clinical and ABG stability for at least
 12 – 24 hrs and

 Acceptable ability to eat , sleep and
 ambulate.
THANK YOU !
SCENARIO
 50 years oil male presented in
 emergency department with history of
 severe shortness of breath associated
 with productive cough with yellow
 color sputum and fever.
 He has past history of cigarette
 smoking 2 pack year for last 35 years.

 What physical signs you can suspect
 in this case ?
SCENARIO

 BP 100/60mmHg
 Pulse 110 beats/min
 R/R 34/min
 Temp 101 F

Pt is cyanosed a
SCENARIO
SCENARIO
SCENARIO

				
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