COPD. Chronic Obstructive Pulmonary Disease b Chronic Bronchitis b Emphysema.

COPDCOPD

Chronic Obstructive Chronic Obstructive Pulmonary DiseasePulmonary Disease

Chronic BronchitisChronic BronchitisEmphysemaEmphysema

DefinitionDefinitionA disease state characterized by A disease state characterized by airflow airflow

limitation that is not fully reversiblelimitation that is not fully reversibleConditions includeConditions include

bull Emphysema anatomically defined condition Emphysema anatomically defined condition characterized by destruction and characterized by destruction and enlargement of the lung alveolienlargement of the lung alveoli

bull Chronic bronchitis clinically defined Chronic bronchitis clinically defined condition with chronic cough and phlegmcondition with chronic cough and phlegm

bull Small-airways disease condition in which Small-airways disease condition in which small bronchioles are narrowedsmall bronchioles are narrowed

EpidemiologyEpidemiologybull bull Fourth leading cause of death in the Fourth leading cause of death in the

USUS

bull bull Affects gt 16 million persons in the USAffects gt 16 million persons in the US

bull bull Global Initiative for Chronic Obstructive Global Initiative for Chronic Obstructive Lung Disease (GOLD) estimates Lung Disease (GOLD) estimates suggest that chronic obstructive lung suggest that chronic obstructive lung disease (COLD) will increase from the disease (COLD) will increase from the sixth to the third most common cause of sixth to the third most common cause of death worldwide by 2020death worldwide by 2020

EpidemiologyEpidemiology

gt70 of COLD-related health care gt70 of COLD-related health care expenditures go to emergency expenditures go to emergency department visits and hospital care department visits and hospital care (gt$10 billion annually in the US)(gt$10 billion annually in the US)


SexSexHigher prevalence inHigher prevalence in men men probably probably

secondary to smokingsecondary to smokingPrevalence of COLD among Prevalence of COLD among

women is increasing as the gender women is increasing as the gender gap in smoking rates has gap in smoking rates has diminisheddiminished

AgeAgeHigher prevalence with increasing Higher prevalence with increasing

ageagebull Dosendashresponse relationship between Dosendashresponse relationship between

cigarette smoking intensity and cigarette smoking intensity and decreased pulmonary functiondecreased pulmonary function


Risk FactorsRisk Factors

11 Cigarette smoking is a major risk Cigarette smoking is a major risk factorfactor

22 Cigar and pipe smokingCigar and pipe smoking33 Passive (secondhand) smokingPassive (secondhand) smoking

1048707 1048707 Associated with reductions in pulmonary Associated with reductions in pulmonary functionfunction

1048707 1048707 Its status as a risk factor for COLD Its status as a risk factor for COLD remains uncertainremains uncertain

Occupational exposures to dust and Occupational exposures to dust and fumes (eg cadmium)fumes (eg cadmium)bull Likely risk factorsLikely risk factors

bull The magnitude of these effects appears The magnitude of these effects appears substantially less important than the substantially less important than the effect of cigarette smokingeffect of cigarette smoking

Ambient air pollutionAmbient air pollutionbull The relationship of air pollution to COLD The relationship of air pollution to COLD

remains unprovenremains unproven

Genetic factorsGenetic factors

bull α1 antitrypsin (α1AT) deficiencyα1 antitrypsin (α1AT) deficiencybull Common M allele normal levelsCommon M allele normal levelsbull S allele slightly reduced levelsS allele slightly reduced levelsbull Z allele markedly reduced levelsZ allele markedly reduced levelsbull Null allele absence of α1AT (rare)Null allele absence of α1AT (rare)bull Lowest levels of α1AT are associated with Lowest levels of α1AT are associated with

incidence of COLD α1AT deficiency interacts incidence of COLD α1AT deficiency interacts with cigarette smoking to increase riskwith cigarette smoking to increase risk

Distributions of forced expiratory volume in 1 s (FEV1)values Distributions of forced expiratory volume in 1 s (FEV1)values in a generalin a generalpopulation sample stratified by pack-years of smoking population sample stratified by pack-years of smoking

EtiologyEtiologyCOLDCOLD

bull Causal relationship between cigarette Causal relationship between cigarette smoking and development of COLD smoking and development of COLD has been proven however the has been proven however the response varies considerably among response varies considerably among individualsindividuals

COLD exacerbationCOLD exacerbation

bull Bacterial infectionsBacterial infections1048707 1048707 Streptococcus pneumoniaeStreptococcus pneumoniae

1048707 1048707 Haemophilus influenzaeHaemophilus influenzae

1048707 1048707 Moraxella catarrhalisMoraxella catarrhalis

1048707 1048707 Mycoplasma pneumoniae Mycoplasma pneumoniae or or Chlamydia Chlamydia pneumoniae pneumoniae (5ndash10 of exacerbations)(5ndash10 of exacerbations)

bull Viral infections (one-third)Viral infections (one-third)bull No specific precipitant identified (20ndash35)No specific precipitant identified (20ndash35)

Symptoms amp SignsSymptoms amp Signs

bull bull 3 most common3 most commonbull CoughCough

bull Sputum productionSputum production

bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration

signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing

on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion

as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the

actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles

Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds

Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue

Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration

(Hoovers sign) in some patients(Hoovers sign) in some patients

Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds

Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each

Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale

1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention

1048707 1048707 Right ventricular heaveRight ventricular heave

1048707 1048707 Third heart sound Third heart sound

1048707 1048707 Hepatic congestionHepatic congestion

1048707 1048707 AscitesAscites

1048707 1048707 Peripheral edemaPeripheral edema

Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism

ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow

obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow

obstruction is not COLDobstruction is not COLD

22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second

(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common

1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction

33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen

44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of

COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing

ConsiderationsConsiderations

Chronic BronchitisChronic Bronchitis

Chronic lower airway inflammationChronic lower airway inflammation

bull Increased bronchial mucus Increased bronchial mucus productionproduction

bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old


Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022

CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema

Blue Bloater

EmphysemaEmphysema

Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old

EmphysemaEmphysema

Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22

CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips

Pink Puffer

COPD ManagementCOPD Management

OxygenOxygenbull Monitor carefullyMonitor carefully

bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen

Assist ventilations as neededAssist ventilations as needed

Diagnostic ApproachDiagnostic Approach

Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp

Symptoms)Symptoms)

22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction

33 Radiographic studiesRadiographic studies

Assessment of exacerbationAssessment of exacerbation11 HistoryHistory

1048707 1048707 FeverFever

1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum

1048707 1048707 ill contactsill contacts

1048707 1048707 Associated symptomsAssociated symptoms

1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations

Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination

1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination

1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles

1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status

33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia

atelectasis)atelectasis)

44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia

55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful

observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment

ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may

demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information

about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg

acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate

10487071048707

Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some

patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type

determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects

thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare

PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles

(M S(M Sand Z)and Z)

33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)

ImagingImagingbull bull Chest radiographyChest radiography

bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency

bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm

ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes

bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the

diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis

Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry

bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD

seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common

bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total

lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the

disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients

with emphysemawith emphysema

ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph

ClassificationClassification

GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic

typetype

GOLD stageGOLD stage00

1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal

II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted

IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted

IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted

IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry

FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure

Treatment Approach Treatment Approach GeneralGeneral

bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation

1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients

bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations

bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment

Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy

BronchodilatorsBronchodilators

bull Used to treat symptomsUsed to treat symptoms

bull The inhaled route is preferredThe inhaled route is preferred

bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery

bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels


Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in

symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement

in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)

(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2

inhalations qidinhalations qid


Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per

inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as

salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents


Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects

1048707 1048707 TremorTremor

1048707 1048707 TachycardiaTachycardia

Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h

Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h

Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer

solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded

Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in

nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid


Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of

inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1

bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators

bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis

1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density


bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid

bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid

bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440

μg inhaled bidμg inhaled bid

bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray

100ndash400 μg inhaled bid100ndash400 μg inhaled bid


OxygenOxygen

11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality

22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality

33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is

physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated







Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects

1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection

Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function

On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn

TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory

flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD

Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)



Other agentsOther agents

11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant

(current clinical trials) properties(current clinical trials) properties

22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency

33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating

antibiotics are not beneficialantibiotics are not beneficial

Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy

Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit

and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation

Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers

considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication

Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies

General medical careGeneral medical care

11 Annual influenza vaccineAnnual influenza vaccine

22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive


Pulmonary rehabilitationPulmonary rehabilitation

bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity

bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months


Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in

selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement

ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic

pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed

emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)


Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates

1048707 le1048707 le65 years65 years

1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy

1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease

1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications

Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred


exacerbation of COPDexacerbation of COPD

The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the

exacerbation exacerbation

Administer controlled Administer controlled oxygen therapy oxygen therapy

correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent

Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state

B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD

CORTICOSTEROIDSCORTICOSTEROIDS

short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common

adverse effectadverse effect

ANTIBIOTICSANTIBIOTICS

All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum

benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations

Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and

Moraxella catarrhalisMoraxella catarrhalis

duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )

METHYLXANTHINESMETHYLXANTHINES

theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy

has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels

The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited

therapeutic range is narrowtherapeutic range is narrow

IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL

In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x

volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL

IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h

lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )

raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers

Summary for ED Summary for ED Management Management

Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas

bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia

Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by

nebulization or MDI with spacernebulization or MDI with spacer

Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed

Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics

bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation

Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed

At all times hellip At all times hellip

Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin

(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions

(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient

Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation

Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion

Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm

Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia

(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension

shock heart failure)shock heart failure) NIPPV failureNIPPV failure

Indications for ICUIndications for ICU

Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy

Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia

PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia

PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis

(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV

Indications for Hospital Indications for Hospital Admission Admission

Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea

Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral

edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical

managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support

discharge to homedischarge to home

(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded

(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment

(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids

(4)(4) a follow-up with their physician a follow-up with their physician

Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers

Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation

bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat

PreventionPrevention

bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations

bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial

bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component

bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection

Chronic Obstructive Chronic Obstructive Pulmonary DiseasePulmonary Disease

Chronic BronchitisChronic BronchitisEmphysemaEmphysema







USUS









































































Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years


















































































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Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years













































































USUS









































































Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years


















































































































































Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































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Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







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1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































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Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years








































































































































Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































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Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years































































































































Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































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Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































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EmphysemaEmphysema


EmphysemaEmphysema



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Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































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EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years



















































































































Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years















































































































Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































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Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years





































































































Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years






























































































Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years





























































































Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































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EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years



















































































Blue Bloater

EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































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EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







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1048707 1048707 FeverFever


















10487071048707
























typetype





















































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1048707 le1048707 le65 years65 years












































































EmphysemaEmphysema


EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years












































































EmphysemaEmphysema



Pink Puffer







Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years


















































































Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years














































































Symptoms)Symptoms)




1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years













































































1048707 1048707 FeverFever


















10487071048707
























typetype





















































OxygenOxygen















































1048707 le1048707 le65 years65 years

























































































10487071048707
























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OxygenOxygen















































1048707 le1048707 le65 years65 years





















































































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1048707 le1048707 le65 years65 years




























































































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1048707 le1048707 le65 years65 years






















































































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1048707 le1048707 le65 years65 years














































































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1048707 le1048707 le65 years65 years

























































































































OxygenOxygen















































1048707 le1048707 le65 years65 years




















































































































OxygenOxygen















































1048707 le1048707 le65 years65 years














































































































OxygenOxygen















































1048707 le1048707 le65 years65 years








































































































OxygenOxygen















































1048707 le1048707 le65 years65 years




































































































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1048707 le1048707 le65 years65 years






























































































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1048707 le1048707 le65 years65 years

























































































OxygenOxygen















































1048707 le1048707 le65 years65 years



















































































OxygenOxygen















































1048707 le1048707 le65 years65 years












































































OxygenOxygen















































1048707 le1048707 le65 years65 years






















































































































1048707 le1048707 le65 years65 years
















































































































1048707 le1048707 le65 years65 years












































































































1048707 le1048707 le65 years65 years







































































































1048707 le1048707 le65 years65 years
































































































1048707 le1048707 le65 years65 years



























































































1048707 le1048707 le65 years65 years























































































1048707 le1048707 le65 years65 years



















































































1048707 le1048707 le65 years65 years













































































1048707 le1048707 le65 years65 years

















































































































































































































































































































































































































































































































































































































































































































































































Date post:	24-Dec-2015
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COPD. Chronic Obstructive Pulmonary Disease b Chronic Bronchitis b Emphysema.

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