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A presentation on pathology and management COPD final.pptx
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- 4. INTRODUCTION • Chronic obstructivepulmonary disease is defined as a group of diseases characterised by persistent slowing of airflow during expiration. • COPD is a syndrome of chronic Bronchitis and Emphysema. • COPD is a disease state characterized by airflow limitation that is not fully reversible. • Airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.
- 5. CHRONIC BRONCHITIS It isdefined as a clinical disorder charecterised by excessive mucous secretions in the bronchial tree manifested by chronic recurrent productive cough for more than 3 months in a year for 2 consecutive years. EMPHYSEMA It is defined as an anatomical alteration of the lung, charecterised by abnormal enlargement of the airspaces distal to the terminal, non-respiratory bronchioles and accompanied by destructive changes in the alveolar walls.
- 6. STRUCTURAL CHANGES INALVEOLI
- 7. AETIOLOGY 1. Smoking Major causeof COPD 2. Age Increasing age results in ventilatory impairment 3. Gender Women have at more risk than men, because of greater airway reactivity and experience faster decline of FEV1 4. Occupation Coal and gold mining, cement, cotton and farming
- 8. Aetiology … 5. Geneticfactor Deficiency of α1 antitrypsin 6. Air pollution Death rates are higher in urban areas than in rural areas 7. Socio-economic status More common in individuals of low socio-economic status 8. Airway- hyper responsiveness &allergies Smokers show high IgE & eosnophils & airway hyper responsiveness
- 9. SYMPTOMS • Chronic cough( after 20 or > cigarettes/day) • Dyspnea (during physical activity and rest) • Frequent respiratory infections • Production of purulent sputum • Bluish discoloration of lips and nail beds • Morning headaches • Wheezing • Weight loss • Pulmonary hypertension • Peripheral oedema • Hemoptysis
- 10. DIAGNOSIS • Medical history •Physical examination • Chest X-ray • Chest radiographs • CT scan • Pulmonary function tests • Measurements of O2 & Co2 in blood • Listening to faint and distant breath sounds with a stethescope • Spirometry • Oximetry
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- 12. Lung functiontests For the assessment of airflow limitation through spirometer is the standard for diagnosis and monitoring of COPD. Stage Clinical state Investigation Mild cough, little breathlessness FEV1 >80% Moderate cough, breathlessness on exertion FEV1 30-80% Severe cough, breathlessness on exertion, cyanosis, oedema FEV1 <30%
- 13. PATHOPHYSIOLOGY • Mucous hypersecretion •Airflow limitation and hyperinflation • Gas exchange abnormalities • Pulmonary hypertension • Cor pulmonale • Inflammation and skeletal muscle wasting
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- 15. CHRONIC BRONCHITIS Excessmucous secretions Inflamated lung endothelium Damaged cilia Tissue destruction Airway obstruction Decreases gas exchange Infections Hypoxemia Pulmonary hypertension Polycythemia
- 16. EMPHYSEMA Destructive enlargement Impaired gas exchange Breakdown of elastin Loss of elasticity ( centrilobular) Lack of anti trypsin (panacinar)
- 17. TREATMENT Non pharmacologicaltreatment 1. Smoking cessation 2. Pulmonary exercise training 3. Optimal medical training 4. Health education
- 18. E.D. Management ofCOPD Exacerbations ƒ For ALL Pts. : –Oxygen –Beta agonist aerosol ƒ Consider SQ terbutaline if unable to take aerosol –Anticholinergic aerosols ƒ For some pts. : –Corticosteroids –Antibiotics –Diuretics –CPAP / BiPAP / Intubation / Ventilation
- 19. Considerations for O2Therapy for COPD Exacerbations ƒ Risk of eliminating hypoxic drive (& causing further resp. acidosis / failure) is overstated –Only applies to < 5% of COPD population ƒ Venturi mask can be used to give precise regulated O2 concentrations ƒ Pts. that develop resp. acidosis with O2 Rx usually need to be intubated & ventilated anyway
- 20. Anticholinergic Med Choices& Doses for COPD Exacerbations Medication Dose Ipratropium 0.5 mg Atropine 1 to 2 mg (0.025 mg/kg) Glycopyrrolate 0.2 to 1.0 mg Ipratropium preferred because of less side effects such as tachycardia
- 21. Considerations in Useof Corticosteroids for Rx of COPD Exacerbation ƒ Not of benefit to all pts. with COPD ƒ Should be considered if : –Pt. on chronic steroid Rx –Wheezing component is prominent –Allergic trigger –Prior response to steroids –IV versus PO is equivalent
- 22. Considerations in Useof Antibiotics for COPD Exacerbation ƒ Not indicated for all pts. ƒ Usually indicated for COPD exacerbation with : – Fever / chills – Increased sputum production – Change in color of sputum – Persistent increased cough – Atelectasis or infiltrate on CXR ƒ Most common pathogens : – Strep pneumoniae (with increasing rates of PCN resistance) – Hemophilus influenzae – Moraxella (Branhamella) catarrhalis
- 23. Antibiotic Choices forCOPD Exacerbation ƒ Best first line agents : –Azithromycin –Cefuroxime –Trimethoprim - sulfa –? levofloxacin ƒ Problems with other choices : –Doxycycline, amoxicillin : resistance –Erythromycin : no H. flu coverage –Amoxil / clavulanate : cost, side effects –Clarithromycin : cost, drug interactions, taste
- 24. Ventilatory Assistance Considerations forCOPD Exacerbation ƒ 3% of COPD pts. require ETT & ventilation for resp. failure ƒ Indications & complications same as for asthma ƒ Need to be careful to avoid barotrauma ƒ Intubated COPD pts. have higher mortality & longer time on ventilator than asthma pts. ƒ CPAP or BiPAP can be tried prior to ETT
- 25. Disposition Considerations for COPDExacerbation ƒ Indications for hospital admission : –Persistent hypoxemia (O2 sat. < 90%) –Persistent hypercarbia / resp. acidosis –Persistent dyspnea –Overt resp. failure –Altered mental status –Usually if associated pneumonia –Pneumothorax ƒ "Borderline " admission candidate may be considered for observation unit first
- 26. Suggested E.D. Management ofCOPD Exacerbation ƒ Immediate O2 & beta 2 aerosol ƒ Rapid CXR to R/O CHF or pneumothorax ƒ Evaluate for cardiac ischemia (EKG) ƒ Consider other Dx tests ƒ Early PEFR & repeat after each Rx ƒ Continued Rx (aerosols, +/- steroids, +/- antibiotics, etc.) ƒ Monitor for response : – ETT / ventilation if worsening – Admission if not improving satisfactorily
- 27. Adjunctive Treatments toConsider for COPD Exacerbations ƒ Phosphodiesterase-4 Inhibitors ƒ Reduce inflammation via macrophages and lymphocytes ƒ Cilomilast 15 mg PO bid ƒ Mucolytic agents ƒ N-acetycysteine ƒ Efficacy debatable ƒ Referral for surgical bullectomy, lung volume reduction surgery, or lung transplantation
- 28. Web Sites withUseful Clinical Guidelines for Asthma and COPD ƒ Expert Panel Report 3 Summary Report 2007 ƒ 440 pages ; summary is 74 pages ƒ http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm ƒ http://www.medscape.com/viewarticle/564670 , and 564654 ƒ emedicine.com has 4 nice articles under both “emergency medicine” and “pulmonology” : ƒ http://www.emedicine.com/med/topic177.htm , & 373 ƒ http://www.emedicine.com/emerg/topic43.htm , & 99
- 29. PATIENT COUNSELLING • Adviceand support on stop smoking • Nutritional assessment • Aerobic exercise training • Breathing training with closed lips to improve ventilatory pattern and gas exchange. • Relaxation techniques • Education about medicines, nutrition, self- management of disease and lifestyle issues • Psychological support
- 30. Follow the 5AStrategy • ASK (about tobacco use) • ASSESS (the status and severity of use) • ADVISE (to stop) • ASSIST (in smoking cessation) • ARRANGE (follow-up programme)
- 31. ASTHMA • Reversible • Immunologicallymediated • Will show effect on bronchodilators • Bronchioles are involved COPD • Irreversible • Bacteriologically mediated • BD effect only in mild cases • Mainly alveoli involved