C O P D By Dr Sarma

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C O P D By Dr Sarma

  1. 1. CHRONIC OBSTRUCTIVE PULMONARY DISEASE Dr.Sarma RVSN, M.D., M.Sc (Canada) Consultant in Medicine and Chest, President IMA – Tiruvallur Branch JN Road, Jayanagar, Tiruvallur, TN +91 98940 60593, (4116) 260593
  2. 2. G LOBAL INITIATIVE FOR CHRONIC O BSTRUCTIVE L UNG D ISEASE GOLD NHLBI AND WHO COLLABORATIVE INITIATIVE
  3. 3. WORLD COPD DAY November 19, EVERY YEAR Raising COPD Awareness Worldwide
  4. 4. PURPOSE OF THIS TALK RELEVANCE Present the Global strategy for the Diagnosis, Management and Prevention of COPD (updated Nov 2004) BASED ON THE GOLD, NICE NAEPP, CDC, BTS, GUIDELINES <ul><li>COPD is very common </li></ul><ul><li>COPD is often covert </li></ul><ul><li>COPD is treatable </li></ul><ul><li>Culprit is smoking </li></ul><ul><li>Symptoms + DD Use spirometry </li></ul><ul><li>GP must know to Dx. Tests, Rx. and refer </li></ul><ul><li>New advances in Rx. </li></ul>
  5. 5. DEFINITIONS
  6. 6. DEFINITION OF COPD CONTENTS <ul><li>It is chronic </li></ul><ul><li>It is progressive </li></ul><ul><li>Mostly fixed airway obstruction </li></ul><ul><li>Non reversible by bronchodilators </li></ul><ul><li>Exposure to noxious agent is a must </li></ul><ul><li>Chronic obstructive lung disease (COLD) </li></ul><ul><li>Chronic obstru. airways disease (COAD) </li></ul><ul><li>Two entities in COPD – namely </li></ul><ul><ul><li>Chronic Bronchitis 2. Emphysema </li></ul></ul><ul><li>Definition - Key points </li></ul><ul><li>Epidemiology </li></ul><ul><li>Risk factors </li></ul><ul><li>Pathogenesis –Pathol </li></ul><ul><li>Clinical features </li></ul><ul><li>Diagnosis, Spirometry </li></ul><ul><li>Antismoking strateg. </li></ul><ul><li>Management Guide </li></ul><ul><li>Drug delivery options </li></ul><ul><li>Rehabilitation, Exace. </li></ul>
  7. 7. 1. CHRONIC BRONCHITIS 2. EMPHYSEMA <ul><li>Productive cough </li></ul><ul><li>For a period of 3 months </li></ul><ul><li>In each of 2 consecutive years </li></ul><ul><li>Absence of any other identifiable cause of excessive sputum production </li></ul><ul><li>Airflow limitation that is not fully reversible </li></ul><ul><li>Abnormal inflammatory response to noxious agent - like smoking </li></ul><ul><li>Alveolar wall destruction </li></ul><ul><li>Irreversible enlargement of the air spaces </li></ul><ul><li>Distal to the terminal bronchioles </li></ul><ul><li>Without evidence of fibrosis </li></ul>
  8. 8. DEFINITION OF COPD CONTENTS <ul><li>ROAD – Recurrent Obstructive Airways Disease </li></ul><ul><li>Bronchial Asthma </li></ul><ul><li>Seasonal, Recurrent </li></ul><ul><li>Sensitizing Agent, Other Atopic disorders </li></ul><ul><li>Reversible obstruction, Inflammation </li></ul><ul><li>COLD – Irreversible, Chronic, Noxious agent </li></ul><ul><li>Chronic Bronchitis </li></ul><ul><li>Emphysema </li></ul><ul><li>Combination of both </li></ul><ul><li>Definition - Key points </li></ul><ul><li>Epidemiology </li></ul><ul><li>Risk factors </li></ul><ul><li>Pathogenesis –Pathol </li></ul><ul><li>Clinical features </li></ul><ul><li>Diagnosis, Spirometry </li></ul><ul><li>Stop smoking strateg. </li></ul><ul><li>Management Guide </li></ul><ul><li>Drug delivery options </li></ul><ul><li>Rehabilitation, Exace. </li></ul>
  9. 9. OBSTRUCTIVE LUNG DISEASES ASTHMA COPD REVERSIBILITY OF AIR WAY OBSTRUTION FULL NONE ASTHMA EMPHYSEMA CHRONIC BRONCHITIS
  10. 10. EPIDEMIOLGY OF COPD
  11. 11. KEY POINTS CONTENTS <ul><li>Underestimated, often covert </li></ul><ul><li>It is not diagnosed until clinically overt </li></ul><ul><li>By that time it is moderately advanced. </li></ul><ul><li>The global burden of COPD will increase </li></ul><ul><li>Toll from ↑ tobacco use in alarming </li></ul><ul><li>Definition - Key points </li></ul><ul><li>Epidemiology </li></ul><ul><li>Risk factors </li></ul><ul><li>Pathogenesis –Pathol </li></ul><ul><li>Clinical features </li></ul><ul><li>Diagnosis, Spirometry </li></ul><ul><li>Stop smoking strateg. </li></ul><ul><li>Management Guide </li></ul><ul><li>Drug delivery options </li></ul><ul><li>Rehabilitation, Exace. </li></ul>
  12. 12. BURDEN OF ILLNESS <ul><li>COPD is the 4 th leading cause of death (next to IHD, Cancer, CVA). </li></ul><ul><li>In 2000, the WHO estimated 2.74 million COPD deaths worldwide. </li></ul><ul><li>In 1990, COPD was ranked 12 th among the burden of diseases </li></ul><ul><li>By 2020 it is projected to rank 5 th . </li></ul><ul><li>Often, COPD is covert </li></ul>MORTALITY Deaths Cause 64,574 Diabetes 94,828 Accidents 114,318 COPD 158,060 CVA 534,947 Cancer 724,269 CHD
  13. 13. COPD PREVALENCE 2000 MORTALITY TRENDS 1965 - 2000 <ul><li>Established Market Economies 6.98 </li></ul><ul><li>Formerly Socialist Economies 7.35 </li></ul><ul><li>India 4.38 </li></ul><ul><li>China 26.20 </li></ul><ul><li>Other Asia and Islands 2.89 </li></ul><ul><li>Sub-Saharan Africa 4.41 </li></ul><ul><li>Latin America and Caribbean 3.36 </li></ul><ul><li>Middle Eastern Crescent 2.69 </li></ul><ul><li>World 9.34 </li></ul><ul><li>*From Murray & Lopez, 2001 </li></ul>% Change Cause - 7% All other + 32% Accident + 163% COPD - 39% CVA - 64% Cancer - 59% CHD
  14. 14. WHAT IS WRONG ? <ul><li>Cigarette smoking is the primary cause. </li></ul><ul><li>USA - 47.2 million smoke, ♂ 28%, ♀ 23% </li></ul><ul><li>WHO estimates 1.1 B smokers in world. </li></ul><ul><li>This increases to 1.6 billion by 2025. </li></ul><ul><li>Many countries, rates are ↑ alarmingly. </li></ul><ul><li>In India, 4,00,000 premature deaths annually to use of biomass fuels, like cow dung cakes, open fires </li></ul><ul><li>Indoor air pollution, Industrial pollution are the major risk factors in our country. </li></ul>MORBIDITY Consultations Year ↑↑↑↑ 2010 13.9 million 2000 11.8 million 1995 10.1 million 1990 7.4 million 1985 6.1 million 1980
  15. 15. SMOKING - THE CULPRIT
  16. 16. RISK FACTORS FOR COPD <ul><li>Host Factors </li></ul><ul><ul><li>Genes (alpha 1 - anti-trypsin ↓ ) </li></ul></ul><ul><ul><li>Hyper responsiveness </li></ul></ul><ul><ul><li>Lung growth, low BW, Age </li></ul></ul><ul><li>Exposure </li></ul><ul><ul><li>Tobacco smoke , </li></ul></ul><ul><ul><li>Bio mass fuel smoke, open fires </li></ul></ul><ul><ul><li>Occupational dusts and chemicals </li></ul></ul><ul><ul><li>Chronic uncontrolled asthma </li></ul></ul><ul><ul><li>Infections, overcrowding, damp </li></ul></ul><ul><ul><li>Low socioeconomic status </li></ul></ul><ul><ul><li>Low dietary vegetable and fruit intake </li></ul></ul>MOST IMP RISK
  17. 17. WOMEN SMOKERS PASSIVE SMOKERS
  18. 18. TENDER AGE GROUPS COLLEGE STUDENTS INTENSE CAUSE FOR CONCERN ?
  19. 19. COPD NH – EFFECT OF SMOKING Mortality among women smokers is on the rise globally
  20. 20. PATHOGENESIS AND PATOLOGY
  21. 21. PATHOGENESIS NOXIOUS AGENT (tobacco smoke, pollutants, occupational exposures COPD CONTENTS Genetic factors Respiratory infection Others <ul><li>Definition - Key points </li></ul><ul><li>Epidemiology </li></ul><ul><li>Risk factors </li></ul><ul><li>Pathogenesis –Pathol </li></ul><ul><li>Clinical features </li></ul><ul><li>Diagnosis, Spirometry </li></ul><ul><li>Stop smoking strateg. </li></ul><ul><li>Management Guide </li></ul><ul><li>Drug delivery options </li></ul><ul><li>Rehabilitation, Exace. </li></ul>
  22. 22. PATHOGENESIS <ul><li>Definition -key points </li></ul><ul><li>Burden of COPD </li></ul><ul><li>Classification </li></ul><ul><li>Risk factors </li></ul><ul><li>Pathogenesis, </li></ul><ul><li>Pathophysiology, </li></ul><ul><li>Management </li></ul><ul><li>Future research </li></ul>
  23. 23. PATHOGENESIS <ul><li>Definition -key points </li></ul><ul><li>Burden of COPD </li></ul><ul><li>Classification </li></ul><ul><li>Risk factors </li></ul><ul><li>Pathogenesis, </li></ul><ul><li>Pathophysiology, </li></ul><ul><li>Management </li></ul><ul><li>Future research </li></ul>ATOPY
  24. 24. SHIFT IN THE DELICATE BALANCE PROTEASES ANTI PROTEASES Nutrophil elastase Cathepsisns MMP-1, MMP- 9, MMP – 12 Granzymes Perforins Alpha 1 Anti-trypsin SLP 1 , Elastin, TIMPs COPD
  25. 25. PATHOLOGY <ul><li>Irreversible – COPD – Why ? </li></ul><ul><ul><li>Fibrosis and narrowing of the airways </li></ul></ul><ul><ul><li>Loss of elastic recoil due to alveolar destruction </li></ul></ul><ul><ul><li>Destruction of alveolar support that maintains patency of small airways </li></ul></ul><ul><li>Reversible – Bronchial Asthma </li></ul><ul><ul><li>Accumulation of inflammatory cells, mucus, and exudates in bronchi </li></ul></ul><ul><ul><li>Smooth muscle contraction in peripheral and central airways </li></ul></ul><ul><ul><li>Dynamic hyperinflation during exercise </li></ul></ul>CONTENTS <ul><li>Definition - Key points </li></ul><ul><li>Epidemiology </li></ul><ul><li>Risk factors </li></ul><ul><li>Pathogenesis –Pathol </li></ul><ul><li>Clinical features </li></ul><ul><li>Diagnosis, Spirometry </li></ul><ul><li>Stop smoking strateg. </li></ul><ul><li>Management Guide </li></ul><ul><li>Drug delivery options </li></ul><ul><li>Rehabilitation, Exace. </li></ul>
  26. 26. PATHOLOGY in COPD Normal bronchial architecture <ul><li>Mucus gland hypertrophy </li></ul><ul><li>Smooth muscle hypertrophy </li></ul><ul><li>Goblet cell hyperplasia </li></ul><ul><li>Inflammatory infiltrate </li></ul><ul><li>Excessive mucus </li></ul><ul><li>Squamous metaplasia </li></ul>COPD
  27. 27. DISSECTING MICROSCOPIC APPEARENCE Normal parenchymal architecture Emphysematous Lung architecture
  28. 28. PATHOLOGY – COPD <ul><li>Neutrophilic inflammation </li></ul><ul><li>Macrophages and CD8 T cells ↑ </li></ul><ul><li>Altered protease/antiprotiase balance </li></ul><ul><li>Tissue destruction progressive </li></ul><ul><li>Alpha 1 AT ↓- Young age emphysema </li></ul><ul><li>Goblet cell size and number ↑ in CB </li></ul><ul><li>Inflammatory mediators </li></ul><ul><li>LT B4 </li></ul><ul><li>IL 8 </li></ul><ul><li>TNF- α </li></ul>ASTHMA <ul><li>Eosinophilic inflamm. </li></ul><ul><li>CD4, Th2 Lymphocyte </li></ul><ul><li>Mast cells </li></ul><ul><li>Tissue destruct. less </li></ul><ul><li>Mainly allergic inflam. </li></ul><ul><li>Inflam. Mediators </li></ul><ul><li>LT D4 </li></ul><ul><li>IL 4 </li></ul><ul><li>IL 5 </li></ul>
  29. 29. PULMONARY HYPERTENSION IN COPD Normal Pulmonary Artery <ul><li>Duplication of elastic lamina </li></ul><ul><li>Medial hypertrophy - PH </li></ul>
  30. 30. CLINICAL FEATURES
  31. 31. CHRONIC BRONCHITIS <ul><li>Mild dyspnea </li></ul><ul><li>Cough before dyspnea starts </li></ul><ul><li>Copious, purulent sputum </li></ul><ul><li>More frequent infections </li></ul><ul><li>Repeated resp. insufficiency </li></ul><ul><li>PaCO 2 50-60 mmHg </li></ul><ul><li>PaO 2 45-60 mmHg </li></ul><ul><li>Hematocrit 50-60% </li></ul><ul><li>DLCO is not that much ↓ </li></ul><ul><li>Cor pulmonale common </li></ul>EMPHYSEMA <ul><li>Severe dyspnea </li></ul><ul><li>Cough after dyspnea </li></ul><ul><li>Scant sputum </li></ul><ul><li>Less frequent infections </li></ul><ul><li>Terminal RF </li></ul><ul><li>PaCO 2 35-40 mmHg </li></ul><ul><li>PaO 2 65-75 mmHg </li></ul><ul><li>Hematocrit 35-45% </li></ul><ul><li>DLCO is decreased </li></ul><ul><li>Cor pulmonale rare. </li></ul>
  32. 32. CHRONIC BRONCHITIS EMPHYSEMA BLUE BLOTTER PINK PUFFER
  33. 33. ALPHA 1 ANTITRYPSIN ↓ <ul><li>Specific circumstances of Alpha 1- AT ↓include . </li></ul><ul><li>Emphysema in a young individual (< 35) </li></ul><ul><li>Without obvious risk factors (smoking etc) </li></ul><ul><li>Necrotizing panniculitis, Systemic vasculitis </li></ul><ul><li>Anti-neutrophil cytoplasmic antibody (ANCA) </li></ul><ul><li>Cirrhosis of liver, Hepatocellular carcinoma </li></ul><ul><li>Bronchiectasis of undetermined etiology </li></ul><ul><li>Otherwise unexplained liver disease, or a </li></ul><ul><li>Family history of any one of these conditions </li></ul><ul><li>Especially siblings of PI*ZZ individuals. </li></ul><ul><li>Only 2% of COPD is alpha 1- AT ↓ </li></ul>EMPHYSEMA
  34. 34. ALPHA1 ANTITRYPSIN ↓ <ul><li>MM – A 1 AT 100% </li></ul><ul><li>MS – A 1 AT 75% </li></ul><ul><li>SS – A 1 AT 55% </li></ul><ul><li>MZ – A 1 AT 55% </li></ul><ul><li>SZ – A 1 AT 40% </li></ul><ul><li>ZZ – A 1 AT 8% </li></ul>A 1 AT LEVELS
  35. 35. CLINICAL SIGNS <ul><li>Physical exam may be negative </li></ul><ul><li>Hyper-inflated chest, Barrel chest </li></ul><ul><li>Wheeze or quite breathing </li></ul><ul><li>Pursed lip / accessory muscles resp. </li></ul><ul><li>Peripheral edema </li></ul><ul><li>Cyanosis, ↑ JVP </li></ul><ul><li>Cachexia </li></ul><ul><li>Cough, wheeze, dyspnea, sputum </li></ul><ul><li>Decreased FEV 1 </li></ul><ul><li>Decreased FVC </li></ul><ul><li>FEV 1 < 80% </li></ul><ul><li>FEV 1 ÷ FVC < 70% </li></ul><ul><li>Post bronchodilator – no change in FEV 1 </li></ul><ul><li>PEF is decreased </li></ul><ul><li>FET – is prolonged </li></ul><ul><li>V Max - decreased </li></ul>SPIROMETRY
  36. 36. MRC DYSPNOEA SCALE <ul><li>No of cigarettes / day </li></ul><ul><li>No of smoker years </li></ul><ul><li>Age at starting </li></ul><ul><li>Time of 1 st cigarette </li></ul><ul><li>Desire to quit </li></ul><ul><li>Barriers to quit </li></ul><ul><li>Passive smoking </li></ul><ul><li>Occupational expo. </li></ul><ul><li>Domestic pollution </li></ul>ABOUT SMOKING Too breathless to leave house or breathless while dressing 4 Stops for breath on walking 100 m or after 2 or 3 minutes continuously 3 Walks slower than contemporaries or has to stop for breath while walking alone 2 Short of breath when walking uphill or while hurrying to catch a bus or train 1 No breathlessness except on strenuous exercise 0 Degree of breathlessness - related activity Grade
  37. 37. OXYGEN COST DIAGRAM <ul><li>Coal mining </li></ul><ul><li>Cotton dust </li></ul><ul><li>Cement dust </li></ul><ul><li>Oil fumes </li></ul><ul><li>Cadmium fumes </li></ul><ul><li>Grain dust – </li></ul><ul><li>Rice millers </li></ul><ul><li>Grain handlers </li></ul><ul><li>Flour millers </li></ul>OCCUPATIONAL Slow up hill walking Medium up hill walk Brisk walking on level 0 10 Sleeping Sitting Slow walking Light shopping Heavy shopping Medium walking Self washing Bed making Brisk up hill walk
  38. 38. PROGNOSTIC FACTORS <ul><li>Several factors affect survival in COPD. </li></ul><ul><li>Age </li></ul><ul><li>Smoking status </li></ul><ul><li>Pulmonary artery pressure </li></ul><ul><li>Resting heart rate </li></ul><ul><li>Airway responsiveness </li></ul><ul><li>Hypoxemia </li></ul><ul><li>Most importantly the level of FEV 1 </li></ul><ul><li>Use of long term oxygen therapy </li></ul><ul><li>Hypercapnic RF pts. </li></ul><ul><li>1029 patients studied </li></ul><ul><li>89% survived acute hospitalization for RF </li></ul><ul><li>Only 51% are alive at 2 years of follow-up </li></ul><ul><li>Prognostic factors are </li></ul><ul><ul><li>Severity of RF </li></ul></ul><ul><ul><li>Low BMI </li></ul></ul><ul><ul><li>Older age </li></ul></ul><ul><ul><li>Low PaO 2 /FIO 2 </li></ul></ul>‘ SUPPORT’ STUDY
  39. 39. DIFF. Dx. of COPD & ASTHMA <ul><li>Different etiology </li></ul><ul><li>Different prognosis </li></ul><ul><li>Different therapy </li></ul><ul><li>Different response to therapy </li></ul><ul><li>DD includes </li></ul><ul><li>Bronchial Asthma </li></ul><ul><li>Bronchiectasis- CSLD </li></ul><ul><li>Bronchogenic Ca. </li></ul>WHY D.D WITH ASTHMA ? Change > 15% Change < 15% Reversibility ICS IBD (Ipa+Salm) Most IMP Rx. Normal or Obstru. Obstructive Spirometry Useful ad on Rx. Not useful Anti leukotrn. Variable, static Progressive Course Episodic Persistent Dyspnea Mucoid or none Productive Sputum Nearly all Rare Age < 35 May or may not be Nearly all Smoker ASTHMA COPD Clinical
  40. 40. COPD IMAGES
  41. 41. CHEST SKIAGRAMS OF EMPHYSEMA
  42. 42. V- P MISMATCH NUCLEOTIDE IMAGING
  43. 43. CHEST SKIAGRAM OF CHRONIC BRONCHITIS
  44. 44. CHEST LATERAL VIEW CHRONIC BRONCHITIS
  45. 45. HRCT – NORMAL CHEST
  46. 46. HRCT – EMPHYSEMA
  47. 47. HRCT – EMPHYSEMA
  48. 48. ASSESSMENT OF STABLE COPD
  49. 49. MANAGEMENT OF COPD <ul><li>Assess and monitor disease </li></ul><ul><li>Reduce risk factors </li></ul><ul><li>Manage stable COPD </li></ul><ul><ul><li>Education </li></ul></ul><ul><ul><li>Pharmacologic </li></ul></ul><ul><ul><li>Non-pharmacologic </li></ul></ul><ul><li>Manage exacerbations </li></ul><ul><li>Prevent disease progression </li></ul><ul><li>Relieve symptoms </li></ul><ul><li>Improve exercise tolerance </li></ul><ul><li>Improve health status </li></ul><ul><li>Prevent and treat exacerbations </li></ul><ul><li>Prevent and treat complications </li></ul><ul><li>Reduce mortality </li></ul><ul><li>Minimize side effects from treatment </li></ul>Rx. OBJECTIVES
  50. 50. ASSESSMENT OF COPD <ul><li>Diagnosis of COPD is based on </li></ul><ul><li>H/o exposure to noxious agent </li></ul><ul><li>Presence of Air flow limitation </li></ul><ul><li>Non-reversibility of the limitation </li></ul><ul><li>Chronic productive cough </li></ul><ul><li>Copious sputum, Dyspnea +/- </li></ul>MANAGEMENT <ul><li>Definition - Key points </li></ul><ul><li>Epidemiology </li></ul><ul><li>Risk factors </li></ul><ul><li>Pathogenesis –Pathol </li></ul><ul><li>Clinical features </li></ul><ul><li>Diagnosis, Spirometry </li></ul><ul><li>Stop smoking strateg. </li></ul><ul><li>Management Guide </li></ul><ul><li>Drug delivery options </li></ul><ul><li>Rehabilitation, Exace. </li></ul>
  51. 51. ASSESSMENT OF COPD <ul><li>Assess and monitor disease </li></ul><ul><li>Reduce risk factors </li></ul><ul><li>Manage stable COPD </li></ul><ul><li>Education </li></ul><ul><li>Pharmacologic </li></ul><ul><li>Non-pharmacologic </li></ul><ul><li>Manage exacerbations </li></ul>SYMPTOMS EXPOSURE COUGH SPUTUM DYSPNEA SMOKING OCCUPATION INDOOR / OUTDOOR Air Pollution SPIROMETRY IS A MUST + or - More than one month Age 35 +
  52. 52. ASSESSMENT OF COPD <ul><li>Diagnosis of COPD </li></ul><ul><li>Spirometry is the Gold Standard </li></ul><ul><li>Every COPD suspect must get spirometry test done </li></ul><ul><li>Like ECG, Spirometry is essential </li></ul><ul><li>Arterial blood gas tensions are needed if the FEV 1 < 40% </li></ul><ul><li>Respiratory failure, Corpulmonale </li></ul>MANAGEMENT <ul><li>Definition - Key points </li></ul><ul><li>Epidemiology </li></ul><ul><li>Risk factors </li></ul><ul><li>Pathogenesis –Pathol </li></ul><ul><li>Clinical features </li></ul><ul><li>Diagnosis, Spirometry </li></ul><ul><li>Stop smoking strateg. </li></ul><ul><li>Management Guide </li></ul><ul><li>Drug delivery options </li></ul><ul><li>Rehabilitation, Exace. </li></ul>
  53. 53. OTHER INVESTIGATIONS <ul><li>Serial spirometry tests </li></ul><ul><li>Pulse Oximetry </li></ul><ul><li>Alpha 1 Anti-trypsin levels </li></ul><ul><li>T L CO </li></ul><ul><li>HRCT </li></ul><ul><li>ECG </li></ul><ul><li>ECHO </li></ul><ul><li>Sputum culture </li></ul><ul><li>Definition - Key points </li></ul><ul><li>Epidemiology </li></ul><ul><li>Risk factors </li></ul><ul><li>Pathogenesis –Pathol </li></ul><ul><li>Clinical features </li></ul><ul><li>Diagnosis, Spirometry </li></ul><ul><li>Stop smoking strateg. </li></ul><ul><li>Management Guide </li></ul><ul><li>Drug delivery options </li></ul><ul><li>Rehabilitation, Exace. </li></ul>TESTS
  54. 54. NORMAL AND COPD SPIROMETRY
  55. 55. WITH BRONCHODILATOR <ul><li>Patient must be clinically stable </li></ul><ul><li>Patient should avoid </li></ul><ul><li>Short acting β agonists for 6 hours </li></ul><ul><li>Long acting β agonists for 12 hours </li></ul><ul><li>SR Theophylline for 24 hours </li></ul><ul><li>Baseline spirometry </li></ul><ul><li>Nebulize Salbuamol 2.5 mg + Ipatropium 500mg for 15 minutes with Nacl </li></ul><ul><li>Wait for 30 minutes </li></ul><ul><li>Repeat spirometry </li></ul>REVERSIBILITY PROTOCOL <ul><li>Definition - Key points </li></ul><ul><li>Epidemiology </li></ul><ul><li>Risk factors </li></ul><ul><li>Pathogenesis –Pathol </li></ul><ul><li>Clinical features </li></ul><ul><li>Diagnosis, Spirometry </li></ul><ul><li>Stop smoking strateg. </li></ul><ul><li>Management Guide </li></ul><ul><li>Drug delivery options </li></ul><ul><li>Rehabilitation, Exace. </li></ul>
  56. 56. WITH STEROIDS <ul><li>Spirometry before and after steroid </li></ul><ul><li>Two weeks treatment with 30 mg Prednisolone daily or </li></ul><ul><li>Six weeks treatment with 800 mcg to 1000 mcg of inhaled betamethasone/day </li></ul><ul><li>Results to be interpreted. </li></ul><ul><li>Look for steroid contraindications </li></ul><ul><li>This predicts the COPD group who will benefit </li></ul><ul><li>from inhaled or systemic steroids </li></ul>REVERSIBILITY PROTOCOL <ul><li>Definition - Key points </li></ul><ul><li>Epidemiology </li></ul><ul><li>Risk factors </li></ul><ul><li>Pathogenesis –Pathol </li></ul><ul><li>Clinical features </li></ul><ul><li>Diagnosis, Spirometry </li></ul><ul><li>Stop smoking strateg. </li></ul><ul><li>Management Guide </li></ul><ul><li>Drug delivery options </li></ul><ul><li>Rehabilitation, Exace. </li></ul>
  57. 57. WHAT IS REVERSIBILITY ? <ul><li>Criteria for reversibility of obstruction </li></ul><ul><li>Spirometry is the Gold Standard </li></ul><ul><li>Every COPD suspect must get spirometry test done and reversibility assessed </li></ul><ul><li>Post bronchodilator FEV 1 must show increase of at least 200 ml ↑ </li></ul><ul><li>And the increase should be at least 15% of the baseline FEV 1 value </li></ul>TESTING <ul><li>Definition - Key points </li></ul><ul><li>Epidemiology </li></ul><ul><li>Risk factors </li></ul><ul><li>Pathogenesis –Pathol </li></ul><ul><li>Clinical features </li></ul><ul><li>Diagnosis, Spirometry </li></ul><ul><li>Stop smoking strateg. </li></ul><ul><li>Management Guide </li></ul><ul><li>Drug delivery options </li></ul><ul><li>Rehabilitation, Exace. </li></ul>
  58. 58. SEVERITY OF COPD <ul><li>STAGES OF COPD </li></ul><ul><li>Stage 0 Normal spirometry but with </li></ul><ul><li>(At risk) chronic sym. – sputum, dyspnea </li></ul><ul><li>Stage 1 FEV 1 > 80% </li></ul><ul><li>Mild FEV 1 ÷ FVC is < 70% </li></ul><ul><li>Stage 2 FEV 1 < 80% but > 50% </li></ul><ul><li>Moderate FEV 1 ÷ FVC is < 60% </li></ul><ul><li>Stage 3 FEV 1 < 50% but > 30% </li></ul><ul><li>Severe FEV 1 ÷ FVC is < 40% </li></ul><ul><li>Stage 4 FEV 1 < 30% </li></ul><ul><li>V. severe FEV 1 ÷ FVC is < 30% </li></ul><ul><li>Severity of symptoms </li></ul><ul><li>Stages of COPD </li></ul><ul><li>Frequency and severity of exacerbations </li></ul><ul><li>Presence of complications of COPD </li></ul><ul><li>Presence of respiratory insufficiency </li></ul><ul><li>Co-morbidity </li></ul><ul><li>General health status </li></ul><ul><li>Number of medications needed to manage the disease </li></ul>FACTORS
  59. 59. RISK REDUCTION STRATEGIES
  60. 60. IF ONE QUITS SMOKING <ul><li>Treatment starts with reducing risks – pack years concept* </li></ul><ul><li>Studies have shown that with smoking cessation </li></ul><ul><ul><li>The rate of decline in lung function slows </li></ul></ul><ul><ul><li>There will be definite clinical improvement in symptoms </li></ul></ul><ul><li>Assess and monitor disease </li></ul><ul><li>Reduce risk factors </li></ul><ul><li>Manage stable COPD </li></ul><ul><li>Education </li></ul><ul><li>Pharmacologic </li></ul><ul><li>Non-pharmacologic </li></ul><ul><li>Manage exacerbations </li></ul>NO TOMORROW! * Packets per day x Years of smoking = Pack Years
  61. 61. <ul><li>↓ E xposure to smoking, noxious agn </li></ul><ul><li>Smoking cessation is the single most effective - and cost effective - intervention to reduce the risk of developing COPD </li></ul><ul><li>It stops progression of COPD </li></ul>RISK FACTORS REDUCTION <ul><li>5. Withdrawal </li></ul><ul><li>4. Boredom </li></ul><ul><li>3. Sense of deprivation or depression </li></ul><ul><li>2. Emotional upset and stress </li></ul><ul><li>Alcohol abuse ! </li></ul><ul><li>One devil replaced by another devil </li></ul>5 RELAPSE TRIGGERS
  62. 62. NICOTINE REPLACEMENTS <ul><li>Helpful for physical withdrawal symptoms </li></ul><ul><li>Can be dosed according to degree of use </li></ul><ul><li>Costs the same as daily smoking habit </li></ul><ul><li>Most products of NRT - cautious use in cardiac patients </li></ul><ul><li>Bupropion may be alternative to NRT </li></ul><ul><li>Nicotex or Smoquit SR 150 b.i.d </li></ul><ul><li>Patch is more constant level, sprays & inhaler a more rapid effect </li></ul><ul><li>Antidepressant - Bupropion </li></ul><ul><li>In psychological dependence on nicotine </li></ul><ul><li>Useful in individuals with or at risk for depression– </li></ul><ul><li>Contraindicated in drug interactions or seizure disorder </li></ul>DRUG TO QUIT ?
  63. 63. COPD MANAGEMENT LATEST GUIDELINES
  64. 64. <ul><li>Prevent disease progression </li></ul><ul><li>Relieve symptoms </li></ul><ul><li>Improve exercise tolerance </li></ul><ul><li>Improve health status </li></ul><ul><li>Prevent and treat complications </li></ul><ul><li>Prevent and treat exacerbations </li></ul><ul><li>Reduce mortality </li></ul>GOALS OF MANAGEMENT MANAGEMENT <ul><li>Stable COPD </li></ul><ul><li>Exacerbations </li></ul><ul><li>Respiratory failure </li></ul><ul><li>Cardiac failure </li></ul>
  65. 65. <ul><li>Spirometric assessment </li></ul><ul><li>Walking distance </li></ul><ul><li>Dyspnea indices </li></ul><ul><li>Symptom scores </li></ul><ul><li>Exacerbation rates </li></ul>OUTCOME MEASURES HOW TO ASSESS? <ul><li>Assess and monitor disease </li></ul><ul><li>Reduce risk factors </li></ul><ul><li>Manage stable COPD </li></ul><ul><li>Education </li></ul><ul><li>Pharmacologic </li></ul><ul><li>Non-pharmacologic </li></ul><ul><li>Manage exacerbations </li></ul>
  66. 66. <ul><li>IBD are the main stay </li></ul><ul><li>As when needed basis </li></ul><ul><li>The main drugs are </li></ul><ul><ul><li>β 2 - Agonists (Salbutamol group) </li></ul></ul><ul><ul><li>Anticholinergics (Ipatropium group) </li></ul></ul><ul><ul><li>Their combination </li></ul></ul><ul><ul><li>?? Theophylline </li></ul></ul>MANAGEMENT - IBD BRONCHO- DILATORS <ul><li>Assess and monitor disease </li></ul><ul><li>Reduce risk factors </li></ul><ul><li>Manage stable COPD </li></ul><ul><li>Education </li></ul><ul><li>Pharmacologic </li></ul><ul><li>Non-pharmacologic </li></ul><ul><li>Manage exacerbations </li></ul>
  67. 67. <ul><li>IBD do not alter the pathology </li></ul><ul><li>Drug Rx. is to improve </li></ul><ul><ul><li>symptoms and ↓ complications. </li></ul></ul><ul><li>But stopping smoking will halt </li></ul><ul><li>COPD </li></ul>BUT UNFORTUNATELY MANAGEMENT <ul><li>Assess and monitor disease </li></ul><ul><li>Reduce risk factors </li></ul><ul><li>Manage stable COPD </li></ul><ul><li>Education </li></ul><ul><li>Pharmacologic </li></ul><ul><li>Non-pharmacologic </li></ul><ul><li>Manage exacerbations </li></ul>
  68. 68. <ul><li>NO systemic steroids in stable COPD </li></ul><ul><li>Inhalation treatment is BEST </li></ul><ul><li>Salmeterol is the FIRST choice </li></ul><ul><li>Ipatropium is the SECOND choice </li></ul><ul><li>Salbutamol for short bursts </li></ul><ul><li>Inhaled steroids THIRD choice </li></ul><ul><li>Combination Ipa + Salmet inhalers beneficial </li></ul><ul><li>Oral β 2 Agonists FOURTH choice </li></ul><ul><li>Theophyllins ? role – LA preps. No injectables </li></ul><ul><li>Oxygen therapy for exacerbations and RF </li></ul>MANAGEMENT RULES THE RULES <ul><li>Assess and monitor disease </li></ul><ul><li>Reduce risk factors </li></ul><ul><li>Manage stable COPD </li></ul><ul><li>Education </li></ul><ul><li>Pharmacologic </li></ul><ul><li>Non-pharmacologic </li></ul><ul><li>Manage exacerbations </li></ul>
  69. 69. <ul><li>Bronchodilators in COPD have been shown to be ineffective in modifying the long-term decline in lung function which is the hallmark of this disease (Class 1). </li></ul><ul><li>There will be no ↑ in FEV 1 or FEV1 ÷ FVC </li></ul><ul><li>But, ↑ in exercise capacity demonstrated. Ipratropium and Salmeterol have been shown to improve COPD clinical status </li></ul>IS IT A PARADOX ? BRONCHO DILATORS <ul><li>Assess and monitor disease </li></ul><ul><li>Reduce risk factors </li></ul><ul><li>Manage stable COPD </li></ul><ul><li>Education </li></ul><ul><li>Pharmacologic </li></ul><ul><li>Non-pharmacologic </li></ul><ul><li>Manage exacerbations </li></ul>
  70. 70. BRONCHODILATION SYNERGISM IPATROPIUM SABA and LABA
  71. 71. <ul><li>Direct action on the beta 2 receptors in the bronchial smooth muscle – relaxation </li></ul><ul><li>Salbutamol most widely used </li></ul><ul><li>In COPD 1 mg is the maximum dose </li></ul><ul><li>Short acting – every 4 to 6 hours </li></ul><ul><li>Salmeterol is long acting – 12 hours </li></ul><ul><li>Slow onset, dose 50 μ g b.i.d </li></ul><ul><li>Formoterol still longer -12 μ g b.i.d </li></ul><ul><li>Side effects – tremors, tachycardia etc., </li></ul>BRONCHODILATORS ß AGONISTS <ul><li>Selective ß agonists </li></ul><ul><li>Short acting drugs </li></ul><ul><li>Long acting drugs </li></ul><ul><li>Oral medication </li></ul><ul><li>Inhaled form </li></ul>
  72. 72. <ul><li>↑ Cholinergic drive is in the bronchii </li></ul><ul><li>Anti-cholinergics ↓ resting bronchial tone </li></ul><ul><li>Three muscarinic receptors M1, M2, M3 </li></ul><ul><li>Ipatropium, Oxitropium – onset slower than ß agonists – but more effective </li></ul><ul><li>Sustained broncho-dilatation – up to 8 h </li></ul><ul><li>Have influence on sleep quality in COPD </li></ul><ul><li>Ipatropium optimal dose 80 μ g as inhaler </li></ul><ul><li>Tiotropium – selective to M1, M3 receptors </li></ul><ul><li>It is long acting – once a day – dose 40 μ g </li></ul>BRONCHODILATORS ANTI ACH <ul><li>Anti-cholinergics </li></ul><ul><li>Short acting drugs </li></ul><ul><li>Long acting drugs </li></ul><ul><li>Inhaled forms </li></ul><ul><li>Combination with beta agonists </li></ul>
  73. 73. <ul><li>Inhaled Glucocorticoids </li></ul><ul><li>In stage I and II COPD – no role to play </li></ul><ul><li>Betamethasone, Budisonide, Fluticasone </li></ul><ul><li>Inhaled steroids are preferable and they reduce the # of episodes of exacerbation </li></ul><ul><li>To be used in stage III and stage IV COPD </li></ul><ul><li>They are useful in short bursts in acute exacerbations </li></ul><ul><li>In people with significant asthma component they are found useful </li></ul><ul><li>No role for long acting steroid injections </li></ul>CORTICOSTEROIDS ORAL STEROIDS <ul><li>Asthmatic component </li></ul><ul><li>Quick recovery from acute exacerbations </li></ul><ul><li>Delays next exacerb. </li></ul><ul><li>Only small number of patients sustained improvement </li></ul><ul><li>Similar to asthmatics </li></ul><ul><li>Significant risk of side effects </li></ul>
  74. 74. <ul><li>Assumed to relax the airway smooth muscle </li></ul><ul><li>At therapeutic concentration NO direct action on the bronchial smooth muscle </li></ul><ul><li>Toxicity – Many drug interactions </li></ul><ul><li>Low therapeutic index - Poor safety window </li></ul><ul><li>Need to monitor blood levels frequently </li></ul><ul><li>Adverse effects on liver and in elderly </li></ul><ul><li>Their use is at best questionable </li></ul><ul><li>Never injectable – in may countries banned </li></ul><ul><li>SR prep has some add on value </li></ul>BRONCHODILATORS THEOPHYLLINE <ul><li>Deriphyllin group </li></ul><ul><li>Nausea, tachycardia </li></ul><ul><li>Fatal arrhythmias </li></ul><ul><li>Interactions with drugs - Macrolides </li></ul><ul><li>Smokers have higher theophylline toxicity </li></ul><ul><li>Already tachycardiac </li></ul><ul><li>Only oral - if at all </li></ul>
  75. 75. <ul><li>IBD is the preferred drugs </li></ul><ul><li>LABA + Tiotropium is best </li></ul><ul><li>LABA + TIO + ICS for Stage III, IV </li></ul><ul><li>Combination is better than increasing individual drugs </li></ul>MANAGEMENT INHALED Rx. <ul><li>Assess and monitor disease </li></ul><ul><li>Reduce risk factors </li></ul><ul><li>Manage stable COPD </li></ul><ul><li>Education </li></ul><ul><li>Pharmacologic </li></ul><ul><li>Non-pharmacologic </li></ul><ul><li>Manage exacerbations </li></ul>
  76. 76. <ul><li>No systemic steroids because of </li></ul><ul><li>unfavorable benefit-to-risk ratio </li></ul><ul><li>Exercise training programs , </li></ul><ul><li>LTOT > 15 hours per day for RF </li></ul><ul><li>LTOT increases survival </li></ul>MANAGEMENT NO SYSTEMIC STEROIDS <ul><li>Assess and monitor disease </li></ul><ul><li>Reduce risk factors </li></ul><ul><li>Manage stable COPD </li></ul><ul><li>Education </li></ul><ul><li>Pharmacologic </li></ul><ul><li>Non-pharmacologic </li></ul><ul><li>Manage exacerbations </li></ul>
  77. 77. MANGEMENT AS PER STAGING
  78. 78. <ul><li>Avoidance of risk factors </li></ul><ul><li>Stop smoking </li></ul><ul><li>Influenza vaccine </li></ul><ul><li>Regular follow up spirometry </li></ul>MANAGEMENT - STAGE 0 AT RISK <ul><li>Chronic symptoms </li></ul><ul><li>Cough </li></ul><ul><li>Phlegm </li></ul><ul><li>Dyspnea </li></ul><ul><li>H/o smoking </li></ul><ul><li>Spirometry Normal </li></ul>
  79. 79. <ul><li>Avoidance of risk factors </li></ul><ul><li>Stop smoking </li></ul><ul><li>Influenza vaccine </li></ul><ul><li>Regular follow up spirometry + </li></ul><ul><li>SABA + IPATROP </li></ul><ul><li>Inhaled route </li></ul>MANAGEMENT – STAGE I MILD COPD <ul><li>Chronic symptoms </li></ul><ul><li>Cough </li></ul><ul><li>Phlegm </li></ul><ul><li>Dyspnea </li></ul><ul><li>H/o smoking </li></ul><ul><li>Spirometry abnormal </li></ul><ul><li>FEV1 > 80% but </li></ul><ul><li>FEV1 / FVC < 70% </li></ul>
  80. 80. <ul><li>Avoidance of risk factors </li></ul><ul><li>Stop smoking </li></ul><ul><li>Influenza vaccine </li></ul><ul><li>Regular follow up spirometry </li></ul><ul><li>SABA + IPA inhalations + </li></ul><ul><li>LABA or TIOTROP or BOTH in inhaled </li></ul><ul><li>Pulmonary Rehabilitation </li></ul>MANAGEMENT – STAGE II MODERATE COPD <ul><li>Chronic symptoms </li></ul><ul><li>Cough </li></ul><ul><li>Phlegm </li></ul><ul><li>Dyspnea </li></ul><ul><li>H/o smoking </li></ul><ul><li>Spirometry abnormal </li></ul><ul><li>FEV1 < 80% but > 50% </li></ul><ul><li>FEV1 / FVC < 60% </li></ul>
  81. 81. <ul><li>Avoidance of risk factors </li></ul><ul><li>Stop smoking </li></ul><ul><li>Influenza vaccine </li></ul><ul><li>Regular follow up spirometry </li></ul><ul><li>SABA + IPA inhalations + </li></ul><ul><li>LABA or TIOTROP or BOTH inhaled </li></ul><ul><li>Pulmonary Rehabilitation </li></ul><ul><li>ICS – Budesonide </li></ul><ul><li>LTOT at least 15 hours per day </li></ul>MANAGEMENT – STAGE III SEVERE COPD <ul><li>Chronic symptoms </li></ul><ul><li>Cough </li></ul><ul><li>Phlegm </li></ul><ul><li>Dyspnea </li></ul><ul><li>H/o smoking </li></ul><ul><li>Spirometry abnormal </li></ul><ul><li>FEV1 < 50% but > 30% </li></ul><ul><li>FEV1 / FVC < 40% </li></ul>
  82. 82. <ul><li>Avoidance of risk factors </li></ul><ul><li>Stop smoking </li></ul><ul><li>Influenza vaccine </li></ul><ul><li>Regular follow up spirometry </li></ul><ul><li>SABA + IPA inhalations + </li></ul><ul><li>LABA or TIOTROP or BOTH inhaled </li></ul><ul><li>Pulmonary Rehabilitation </li></ul><ul><li>ICS – Budesonide </li></ul><ul><li>LTOT at least 15 hours per day </li></ul><ul><li>Oral steroids in short bursts </li></ul><ul><li>Surgical treatments </li></ul>MANAGEMENT – STAGE IV V. SEVERE COPD <ul><li>Chronic symptoms </li></ul><ul><li>Cough </li></ul><ul><li>Phlegm </li></ul><ul><li>Dyspnea </li></ul><ul><li>H/o smoking </li></ul><ul><li>Spirometry abnormal </li></ul><ul><li>FEV1 < 30% </li></ul><ul><li>FEV1 / FVC < 30% </li></ul><ul><li>Chronic Resp. Failure </li></ul>
  83. 83. DRUG DELIVERY SYSTEMS - OPTIONS
  84. 84. <ul><li>MDI – Metered Dose Inhalers </li></ul><ul><li>Rotahalers, Diskhalers </li></ul><ul><li>Spacehalers </li></ul><ul><li>Nebulizers </li></ul><ul><li>Oxygen mixed delivery </li></ul><ul><li>Oral tablets, syrups ?? </li></ul><ul><li>Parenteral – I.M or I.V use ???? </li></ul>DRUG DELIVERY - OPTIONS DRUG DELIVERY <ul><li>Dexterity </li></ul><ul><li>Hand grip strength </li></ul><ul><li>Co-ordination </li></ul><ul><li>Severity of COPD </li></ul><ul><li>Educational level </li></ul><ul><li>Age of the patient </li></ul><ul><li>Ability to inhale and synchronize </li></ul>
  85. 85. NEBULISED THERAPY <ul><li>Severe breathlessness despite using inhalers </li></ul><ul><li>Assessment should be done for improvement </li></ul><ul><li>Choice between a facemask or mouth piece </li></ul><ul><li>Equipment servicing and support are essential </li></ul><ul><li>Dosage 0.5 ml of Ipatropium + </li></ul><ul><li>0.5 ml of Salbutamol + 5 ml of NaCl (not DW) </li></ul><ul><li>If decided to use ICS (FEV1 < 50%) – </li></ul><ul><li>0.5 ml of Budusonide is added to the above </li></ul><ul><li>15 minutes and slow or moderate flow rate </li></ul><ul><li>Can be repeated 2 to 3 times a day – Mouth Wash </li></ul>
  86. 86. EDUCATION AND REHABILITATION
  87. 87. REHABILITATION For the lungs to get more air PURSED-LIP BREATHING (like breathing out slowly into a straw) INHALE EXHALE
  88. 88. REHABILITATION For the lungs to get more air DIAPHRAGMATIC BREATHING Sit comfortably and relax your shoulders Put one hand on your abdomen. Now inhale slowly through your nose. (Push your abdomen out while you breathe in) Then push in your abdominal muscles and breathe out using the pursed-lip technique Note: • Repeat the above maneuver three times and then take a little rest. • This exercise can be done many times a day. 3. Then push in your abdominal muscles and breathe out using the pursed-lip technique. (You should feel your abdomen go down) 2. Put one hand on your abdomen. Now inhale slowly through your nose. (Push your abdomen out while you breathe in) 1. Sit comfortably and relax your shoulders.
  89. 89. HEALTH EDUCATION – TEAM WORK
  90. 90. EXACERBATIONS RESP. FAILURE
  91. 91. <ul><li>Diagnosis uncertain </li></ul><ul><li>Disproportionate symptoms </li></ul><ul><li>Persistent symptoms </li></ul><ul><li>Development of lung cancer </li></ul><ul><li>Pulmonary rehabilitation </li></ul><ul><li>Nebulizer assessment </li></ul><ul><li>Oxygen assessment </li></ul>MANAGEMENT – REFERRAL OXIGENERATOR
  92. 92. <ul><li>Pulmonary embolism </li></ul><ul><li>Pneumothorax – rupture of bullae </li></ul><ul><li>Myocardial infarction </li></ul><ul><li>Left ventricular failure </li></ul><ul><li>Acute pneumonia </li></ul><ul><li>Bronchogenic carcinoma </li></ul>D.D. of EXACERBATIONS WHEN SUSPECT? <ul><li>↑ in symptoms </li></ul><ul><li>↑ in sp purulence </li></ul><ul><li>↑ in sp volume </li></ul><ul><li>Fever, chills </li></ul><ul><li>Ankle edema </li></ul><ul><li>Cyanosis </li></ul><ul><li>↓ Consciousness </li></ul>
  93. 93. <ul><li>Exacerbations of symptoms requiring Rx. are important clinically in COPD. </li></ul><ul><li>The most common causes of exacerbation are </li></ul><ul><ul><ul><li>Infection of the bronchial tree and </li></ul></ul></ul><ul><ul><ul><li>Air pollution and ↑ in smoking </li></ul></ul></ul><ul><ul><ul><li>In 35% of cases cause is not known </li></ul></ul></ul><ul><li>Systemic corticosteroids – oral better </li></ul><ul><li>Antibiotics in short bursts – what to give </li></ul><ul><li>NIPPV – Non invasive intermittent positive pressure ventilation - Home </li></ul>MANAGE EXACERBATIONS WHAT EXTRA ? <ul><li>Oxygen therapy </li></ul><ul><li>NIPPV mostly or </li></ul><ul><li>Macha. Ventilation </li></ul><ul><li>Ipatropium inhalation </li></ul><ul><li>SA - Beta agonists </li></ul><ul><li>No theophylline group </li></ul><ul><li>Narrow spectrum antibiotics – 2 wks </li></ul><ul><li>Oral steroids for 2 wk </li></ul><ul><li>Diuretics may help </li></ul>
  94. 94. LONG TERM OXYGEN THERAPY <ul><li>Pulse oximetry to know PaO 2 </li></ul><ul><li>Arterial blood gas saturation monthly </li></ul><ul><li>Review LTOT every year </li></ul><ul><li>Oxygen concentrators - oxygen cylinders </li></ul><ul><li>Fire warning – smoking </li></ul><ul><li>Ambulatory oxygen therapy – O 2 cylinders, liquid oxygen </li></ul><ul><li>SBOT - Short burst OT – Exacerbations. </li></ul><ul><li>NIPPV in patients with ↓ respiratory drive </li></ul>INDICATIONS <ul><li>FEV 1 < 30% must </li></ul><ul><li>Consider if < 50% </li></ul><ul><li>PaO 2 < 90% </li></ul><ul><li>PaCO 2 > 60% </li></ul><ul><li>Cyanosis </li></ul><ul><li>↑ JVP, Pedal edema </li></ul><ul><li>Pulmonary HT </li></ul><ul><li>Polycythemia </li></ul>
  95. 95. CORPULMONALE <ul><li>LTOT </li></ul><ul><li>Diuretics, Sodium restriction </li></ul><ul><li>ACEi </li></ul><ul><li>Alpha blockers </li></ul><ul><li>Digoxin </li></ul><ul><li>Heart failure management </li></ul>FEATURES <ul><li>Increasing dyspnea </li></ul><ul><li>Peripheral oedema </li></ul><ul><li>↑ venous pressure </li></ul><ul><li>Parasternal heave </li></ul><ul><li>Loud pulmonary second heart sound </li></ul><ul><li>ECG changes of RVH and PH </li></ul><ul><li>Echo evidence </li></ul>
  96. 96. <ul><li>Pulmonary hypertension </li></ul><ul><li>Right ventricular hypertrophy </li></ul><ul><li>Right ventricular diastolic dys. function </li></ul><ul><li>Right ventricular systolic dysfunction </li></ul><ul><li>Corpulmonale – Right heart failure </li></ul><ul><li>Acute respiratory insufficiency </li></ul><ul><li>Life threatening respiratory failure </li></ul><ul><li>Hypercapnia, Severe hypoxia </li></ul><ul><li>Intubation and IPPV </li></ul><ul><li>Managing RVF and RF – ICU care </li></ul>RESPIRATORY FAILURE RESP. FAILURE <ul><li>Assess and monitor disease </li></ul><ul><li>Reduce risk factors </li></ul><ul><li>Manage stable COPD </li></ul><ul><li>Education </li></ul><ul><li>Pharmacologic </li></ul><ul><li>Non-pharmacologic </li></ul><ul><li>Management of exacerbations </li></ul>
  97. 97. <ul><li>Increasing dyspnea </li></ul><ul><li>Single large emphysematous bulla </li></ul><ul><li>Severe - FEV1 < 35% but > 20% </li></ul><ul><li>Upper lobe emphysema </li></ul><ul><li>PaCo 2 not more than 55% </li></ul><ul><li>T L CO must be at least 20% </li></ul><ul><li>Age less than 65 </li></ul><ul><li>Severe pulmonary hypertension </li></ul>LUNG RESECTION SURGERY <ul><li>Bullectomy </li></ul><ul><li>LVRS - Lung volume reduction surgery </li></ul><ul><li>Single lung transplant </li></ul>
  98. 98. <ul><li>Pneumococcal vaccine may be given </li></ul><ul><li>Early initiation of O 2 shown to ↑ survival </li></ul><ul><li>Prolonged use of inhaled steroids – long acting better – 2 weeks duration </li></ul><ul><li>Alpha 1 anti-trypsin (Prolastin, Aralast) </li></ul><ul><li>Antibiotics in short bursts for exacerbations </li></ul><ul><li>N-Acetyl cysteine (NAC) is shown useful </li></ul><ul><li>Immuno-modulators are under trial </li></ul><ul><li>Calcium and vitamin D supplementation </li></ul>WHAT ELSE WE CAN GIVE WHAT NOT ! <ul><li>No Anti-tussives </li></ul><ul><li>Mucolytics ?? </li></ul><ul><li>No prophylactic antibiotics </li></ul><ul><li>No long term antibiotics </li></ul><ul><li>No systemic steroids </li></ul><ul><li>No narcotics </li></ul><ul><li>No vigorous exercise </li></ul><ul><li>No with holding the benefits of Oxygen </li></ul>
  99. 99. COPD - FUTURE DEVELOPMENTS
  100. 100. <ul><li>Emphasis on early diagnosis </li></ul><ul><li>Effective anti smoking services </li></ul><ul><li>COPD will be primary care issue by GP </li></ul><ul><li>New drug development for COPD perse </li></ul><ul><li>Tiotropium takes a center stage </li></ul><ul><li>New M1 and M3 blockers are in line </li></ul><ul><li>PDE4 inhibitors – for bronchodilatation </li></ul><ul><li>Drugs to ↓ Neutrophilic inflammation </li></ul><ul><li>Mediator antagonists - ↓ inflammation </li></ul>FUTURE DEVELOPMENTS NEXT DECADE <ul><li>COPD will increase </li></ul><ul><li>Mortality will increase </li></ul><ul><li>Dx. facilities increase </li></ul><ul><li>Quit smoking a must </li></ul><ul><li>Industrial pollution ↑ </li></ul><ul><li>Newer drugs </li></ul><ul><li>New drug delivery </li></ul><ul><li>Oxygen Therapy ↑ </li></ul>
  101. 101. <ul><li>COPD is no more a specialists concern – it is ours ! </li></ul><ul><li>It is alarmingly increasing – It is preventable </li></ul><ul><li>Please differentiate Asthma and COPD </li></ul><ul><li>Use spirometry, peak flow meter - just as ECG </li></ul><ul><li>Don’t embark on Deri + Bet iv for all breathlessness </li></ul><ul><li>Don’t use Theophylline as far as possible </li></ul><ul><li>Inhalation therapy is the best – Drug delivery choices </li></ul><ul><li>Don’t spare any body from early oxygen therapy </li></ul><ul><li>And finally, motivate smokers to quit smoking </li></ul>TAKE HOME MESSAGES
  102. 102. SELF SCREENING
  103. 103. Do you know what COPD is ? This chronic lung disease is a major cause of illness. Many people have it and yet don’t know it. If you answer these questions, it will help you find out if you could have COPD.   1. Do you cough several times most days? Yes ___ No ___   2. Do you bring up phlegm or mucus most days? Yes ___ No ___   3. Do you get out of breath more easily than others your age? Yes ___ No ___   4. Are you older than 40 years? Yes ___ No ___   5. Are you a current smoker or an ex-smoker? Yes ___ No ___ If you answered yes to three or more of these questions, ask your doctor if you might have COPD and should have a simple breathing test. If COPD is found early, there are steps you can take to prevent further lung damage and make you feel better.   Take time to think about your lungs……Learn about COPD ! Could it be COPD?
  104. 104. ASTHMA V/s COPD Take HOME GUIDE
  105. 105. ASTHMA V/s COPD ETIOLOGICAL BASIS Smoking is the noxious ag. No noxious external agent Any body may be effected Innate Atopy is essential Chronic exposure -Noxious Sensitizing trigger needed COPD ASTHMA
  106. 106. ASTHMA V/s COPD PATHOLOGY Disease of alveloli, bronchi Small airways - bronchioles Alveolar destruc. Br fibrosis No destruction or fibrosis Primary ↑ in bronchial tone Secondary bronchospasm Destructive Inflammation Primarily Allergic Inflamm. COPD ASTHMA
  107. 107. ASTHMA V/s COPD PATHOGENESIS CD 8 T, MF, Neutrophils CD4 T, Mast cells, Eosino LT B4, IL 8, TNF- α LT D4, IL 4, IL 5, - Th2 ↑ Proteases, ↓ in antiprote. ↑↑ IgE + other atopic disea. Emphysema, Bronchial fibr. Airway remodeling occurs Progressive destr. inflamm. Recurrent allergic inflamm. COPD ASTHMA
  108. 108. ASTHMA V/s COPD CLINICAL FEATURES Progressive dyspn, Hr. Gr. Episodic dyspnea – moder. Perennial symptoms Seasonal symptoms Sputum purulent & copious Sputum mucoid or none Chronic, progressive, Exaca Episodic, recurrent, normal Age always > 35 yrs, smoke Young subjects, any age COPD ASTHMA
  109. 109. ASTHMA V/s COPD SPIROMETRY Irreversible - < 15 % ↑ Reversible - > 15 % ↑ Resp. failure,Corpulmonale Resp. failure rare FEV 1 ÷ FVC < 60% FEV 1 ÷ FVC < 70% FEV 1 < 70% may be < 40% FEV 1 < 80% but > 60% Always obstructive pattern Normal or obstructive COPD ASTHMA
  110. 110. Treatment ASTHMA V/s COPD. - Rx. LTA have no role at all LTA are very useful Cromolyn, Ketotifen no use Mast cell stabilizers useful LTOT must in stage III and IV LTOT not needed mostly Ipatrop., Tiotrop. are first line Ipatropium add on only SR Theophylline contraindic. SR Theophylline?? some role Oral steroids in stage III & IV Oral steroids have little role SABA not much, ICS useful SABA for acute attacks LABA + Antibiotics – Ac. exa ICS are the main stay Quitting of smoking crucial Relievers and Preventers COPD ASTHMA
  111. 111. “ The old order changeth yielding place to new; Lest, one good custom should corrupt the world.” This is most pertinent today to Asthma and COPD Tennyson Sir Lord, Alfred Holm and Harris & NEJM
  112. 112. PREVENT COPD
  113. 113. THE DEADLIEST DEVIL
  114. 114. SURE TO GRAVE
  115. 115. AND FINALLY Tell me what harm smoking does not cause ??
  116. 116. <ul><li>IHD, MI, ↑ Restenosis </li></ul><ul><li>Atherosclerosis – PVD, IR, ↑ DM </li></ul><ul><li>Oxidation of LDL, ↑ LDL, ↓ HDL, ↑ TG </li></ul><ul><li>COPD, Lung Cancer </li></ul><ul><li>Tremors, Peripheral neuritis </li></ul><ul><li>APD, NUD, Oro-pharyngeal Cancers </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Poor fetal development </li></ul><ul><li>Nicotine dependence </li></ul><ul><li>Wasteful expenditure </li></ul>PROVEN DISASTERS TELL ME THE ORGAN SPARED <ul><li>The Heart </li></ul><ul><li>Blood vessels </li></ul><ul><li>Metabolic effects </li></ul><ul><li>Lungs </li></ul><ul><li>Nervous system </li></ul><ul><li>G I tract </li></ul><ul><li>Bones </li></ul><ul><li>Fetus in utero </li></ul><ul><li>The psyche </li></ul><ul><li>The Purse </li></ul>
  117. 117. Most of these effects have dose-response relationship. Most of them are reversible if smoking is stopped early. Reducing the # reduces the risk – inverse response. If we are a smoker, let us quit smoking – set an example. Let us motivate every month at least one person to quit. What right we have, to make others passive smokers? The Onus here is on us
  118. 118. Pledge to stop smoking
  119. 119. WHAT CAN WE DO ??
  120. 120. <ul><li>If, in patients I treat, I have </li></ul><ul><li>Not controlled his DM </li></ul><ul><li>Not evaluated for IHD </li></ul><ul><li>Not kept BP to goal </li></ul><ul><li>Not controlled lipids </li></ul><ul><li>Not advised the obese </li></ul><ul><li>Not persuaded a smoker </li></ul><ul><li>Not prevented OS </li></ul><ul><li>Not health educated and </li></ul><ul><li>I have not updated my K </li></ul><ul><li>Not shared what I have </li></ul>MY SINS SINS PUNYAS IF CARE NOT TO DO THESE – THEN ALL
  121. 121. <ul><li>My possessions </li></ul><ul><li>My positions </li></ul><ul><li>My achievements </li></ul><ul><li>My abilities </li></ul><ul><li>My privileges </li></ul><ul><li>My prayers </li></ul><ul><li>My visits to temples </li></ul><ul><li>My scriptural K </li></ul><ul><li>My rituals </li></ul>MY GAINS HAVE NO MEANING & ARE MERELY FUTILE SINS PUNYAS
  122. 122. REMEMBER, WE ARE BLESSED WITH THE OPPORTUNITY
  123. 123. Om Asatho maa sad gamaya Om Tamaso maa jyothir gamaya Om Mrityor maa amritam gamaya Om Sarveshaam swasthir bhavathu Om Sarveshaam shaantir bhavathu Om Shaantihi Shaantihi Shaantihi ||
  124. 124. A CD format of today’s presentation is ready 1. COPD, Asthma and basics of spirometry In addition it, also contains 2. ECG workshop presented earlier 3. Guidelines on Hypertension treatment This can be used in Computer & DVD player Important Announcement
  125. 125. <ul><li>ACCP www.chestnet.org </li></ul><ul><li>ATS www.thoracic.org </li></ul><ul><li>BTS www.brit-thoracic.org.uk </li></ul><ul><li>COPD profess. www.copdprofessional.com </li></ul><ul><li>GOLD www.goldcopd.com </li></ul><ul><li>NICE www.nice.uk.org </li></ul><ul><li>Chest Net www.chestnet.net </li></ul><ul><li>CDC www.cdc.nih.gov </li></ul><ul><li>NAEPP www.naepp.nhlbi.org </li></ul><ul><li>COPD Rapid series by ELSEVIER </li></ul>Resources for COPD and Asthma
  126. 126. Dr.Sarma RVSN, M.D., M.Sc (Canada) JN Road, Jayanagar, Tiruvallur, TN +91 98940 60593, (4116) 260593 PLEASE CONTACT US Dr. Kumaran.M, B.Sc., M.B.B.S., 10 North Raja St, Tiruvallur, TN +91 98941 10450, (4116) 260288 WE WILL MEET AGAIN SOON
  127. 127. NANRI, VANAKKAM

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