Obstructive Airway and Pulmonary Disease

8/12/2019 Obstructive Airway and Pulmonary Disease

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OBSTRUCTIVE AIRWAY AND PULMONARY

DISEASE

TABLE OF CONTENTS

1. ASTHMA BRONCHIALE

- WHAT IS KNOWN ABOUT ASTHMA

- DIAGNOSING ASTMA

- CLASSIFICATION OF ASTHMA BY LEVEL OF CONTROL

- FOUR COMPONENT OF ASTHMA

- Develop P!"e#!$Do%!o& P&!#e&'("p

- I)e#!"*+ #) Re),%e Epo',&e !o R"' F%!o&

- A''e'/T&e!/#) Mo#"!o& A'!(0

- M#eE%e&2!"o#

- SPECIAL CONSIDERATION IN MANAGING ASTHMA

3. CHRONIC OBSTRUCTIVE PULMONARY DISEASE 4COPD5

- WHAT IS CHRONIC OBSTRUCTIVE PULMONARY DISEASE 4COPD5

- RISK FACTOR6 WHAT CAUSE COPD7

- DIAGNOSING COPD

- COMPONENT OF CARE6

A COPD MANAGEMENT PROGRAM

Co0po#e#! 16 A''e' #) Mo#"!o& )"'e'e

Co0po#e#! 36 Re),%e R"' F%!o&'

Co0po#e#! 86 M#e S!2le COPD

Patient Education

Pharmacologic Treatment

Non-Pharmacologic TreatmentCo0po#e#! 96 M#e E%e&2!"o#'

How to Asses the Severity of an Exacerbation

Home Management

Hosital Management

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1. ASTHMA BRONCHIALE

WHAT IS KNOWN ABOUT ASTHMA

" Asthma is a %(&o#"% "#*l00!o&+ )"'o&)e& of the airways# $hronically inflamed airways are

(+pe&&e'po#'"ve: they become obstructed and airflow is limited %by bronchoconstriction& mucuslugs& and increased inflammation' when airways are exosed to various ris( factors#

. )efinition * Asthma is a chronic inflammatory disorder of the airways in wich many cells and

cellular elements lay a role %infiltration of mast cell&eosinofil and lymhocyte'# $hronic

inflammation causes an associated increase in airway hyerresonsiveness that leads to recurrent

eisodes of whee+ing& brethlessness,shorthness of breath& chest tighness& and coughing& symtom

varying overtime and severity articularly at night or in the early morning# These eisodes are

usually associated with widesread but variable airflow obstruction that is often reversible either

sontaneously or with treatment#

" $ommon &"' *%!o&' for asthma symtoms include exosure to allergens %such as those from

house dust mites& animals with fur& coc(roaches& ollens& and molds'& occuational irritants& tobacco

smo(e& resiratory %viral' infections& exercise& strong emotional exressions& chemical irritants& and

drugs %such as asirin and beta bloc(ers'#" A '!ep;"'e pp&o%( to harmacologic treatment to achieve and maintain control of asthma should

ta(e into account the safety of treatment& otential for adverse effects& and the cost of treatment

reuired to achieve control#

" Asthma !!%' %or exacerbations' are eisodic& but airway inflammation is chronically resent# .or

many atients& %o#!&olle& medication must be ta(en daily to revent symtoms& imrove lung

function& and revent attac(s# Rel"eve& medications may occasionally be reuired to treat acute

symtoms such as whee+ing& chest tightness& and cough#

" To reach and maintain asthma control reuires the develoment of a p&!#e&'("p between the

erson with asthma and his or her health care team#

DIAGNOSING ASTHMA

Asthma can often be diagnosed on the basis of a atient/s '+0p!o0' and

0e)"%l ("'!o&+ %F",&e 1'#

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FOUR COMPONENTS OF ASTHMA CARE

The ol o* '!(0 %&e "' !o %("eve #) 0"#!"# %o#!&ol of the clinical manifestations

of the disease for rolonged eriods# 9hen asthma is controlled& atients can revent most

attac(s& avoid troublesome symtoms day and night& and (ee hysically active#

To reach this goal& four interrelated comonents of theray are reuired*Co0po#e#! 1. )evelo atient,doctor artnershi

Co0po#e#! 3. 7dentify and reduce exosure to ris( factors

Co0po#e#! 8. Assess& treat& and monitor asthma

Co0po#e#! 9. Manage asthma exacerbations

Co0po#e#! 16 Develop P!"e#!$Do%!o& P&!#e&'("p

The effective management of asthma reuires the develoment of a artnershi between the

erson with asthma and his or her health care team#

9ith your hel& and the hel of others on the health care team& atients

can learn to*

" Avoid ris( factors" Ta(e medications correctly

" :nderstand the difference between ;controller< and ;reliever< medications

" Monitor their status using symtoms and& if relevant& PE.

" =ecogni+e signs that asthma is worsening and ta(e action

" See( medical hel as aroriate

Education should be an integral art of all interactions between health care rofessionals and

atients# :sing a variety of methods>such as discussions %with a hysician& nurse& outreach

wor(er& counselor& or educator'& demonstrations& written materials& grou classes& video or

audio taes& dramas& and atient suort grous>hels reinforce educational messages#

Co0po#e#! 36 I)e#!"*+ #) Re),%e Epo',&e !o R"' F%!o&'

To imrove control of asthma and reduce medication needs& atients should ta(e stes to

avoid the ris( factors that cause their asthma symtoms %F",&e 9'# However& many asthma

atients react to multile factors that are ubiuitous in the environment& and avoiding some

of these factors comletely is nearly imossible# Thus& medications to maintain asthma

control have an imortant role because atients are often less sensitive to these ris( factors

when their asthma is under control#

Physical activity is a common cause of asthma symtoms but atients '(o,l) #o! vo")

ee&%"'e. Symtoms can be revented by ta(ing a raid-acting inhaled ?0-agonist before

strenuous exercise %a leu(otriene modifier or cromone are alternatives'#

Patients with moderate to severe asthma should be advised to receive an "#*l,e#


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Co0po#e#! 86 A''e''/ T&e!/ #) Mo#"!o& A'!(0

A''e''"# A'!(0 Co#!&olEach atient should be assessed to establish his or her current treatment regimen& adherence to the

current regimen& and level of asthma control# A simlified scheme for recogni+ing controlled& artly

controlled& and uncontrolled asthma is rovided in F",&e 3#

T&e!"# !o A%("eve Co#!&ol

Each atient is assigned to one of five treatment ;stes#< F",&e = details the treatments ateach ste for adults and children age and over# At each treatment ste& &el"eve& 0e)"%!"o#

should be rovided for uic( relief of symtoms as needed# %However& be aware of how

much reliever medication the atient is using>regular or increased use indicates that asthma

is not well controlled#'

At Stes 0 through & atients also reuire one or more regular %o#!&olle& 0e)"%!"o#'/

which (ee symtoms and attac(s from starting# 7nhaled glucocorticosteroids %F",&e >' are

the most effective controller medications currently available#

.or most atients newly diagnosed with asthma or not yet on medication& treatment should

be started at Ste 0 %or if the atient is very symtomatic& at Ste 8'# 7f asthma is not

controlled on the current treatment regimen& treatment should be steed u until control is

achieved#I#(le) 0e)"%!"o#' are referred because they deliver drugs directly to the airways where

they are needed& resulting in otent theraeutic effects with fewer systemic side effects#

7nhaled medications for asthma are available as ressuri+ed metered-dose inhalers %M)7s'&

breath-actuated M)7s& dry owder inhalers %)P7s'& and nebuli+ers# Sacer %or valved

holding-chamber' devices ma(e inhalers easier to use and reduce systemic absortion and

side effects of inhaled glucocorticosteroids#

Teach atients %and arents' how to use inhaler devices# )ifferent devices need different

inhalation techniues#

" Bive demonstrations and illustrated instructions#

" As( atients to show their techniue at every visit#

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Mo#"!o&"# !o M"#!"# Co#!&ol

Dngoing monitoring is essential to maintain control and establish the lowest ste and dose of

treatment to minimi+e cost and maximi+e safety

Adusting medication*

" 7f asthma is #o! %o#!&olle) on the current treatment regimen& '!ep ,p treatment# Benerally&

imrovement should be seen within ! month#Fut first review the atient/s medication techniue& comliance& and avoidance of ris(

factors#

" 7f asthma is p&!l+ %o#!&olle)/ %o#'")e& '!epp"# ,p treatment& deending on whether

more effective otions are available& safety and cost of ossible treatment otions& and the

atient/s satisfaction with the level of control achieved#

" 7f %o#!&ol "' 0"#!"#e) for at least 8 months& '!ep )o;# with a gradual& stewise

reduction in treatment# The goal is to decrease treatment to the least medication necessary to

maintain control#

Monitoring is still necessary even after control is achieved& as asthma is a variable diseaseG

treatment has to be adusted eriodically in resonse to loss of control as indicated by

worsening symtoms or the develoment ofan exacerbation#

Co0po#e#! 96 M#e E%e&2!"o#'

Exacerbations of asthma %asthma attac(s' are eisodes of a rogressive increase in shortness

of breath& cough& whee+ing& or chest tightness& or a combination of these symtoms#

Do #o! ,#)e&e'!"0!e !(e 'eve&"!+ o* # !!%: severe asthma attac(s may be life

threatening# Their treatment reuires close suervision

Mild attac(s& defined by a reduction in ea( flow of less than 043& nocturnal awa(ening&

and increased use of raid-acting ?0-agonists& can usually be treated at home if the atient is

reared and has a ersonal asthma management lan that includes action stes# Moderate

attac(s may reuire& and severe attac(s usually reuire& care in a clinic or hosital#

Asthma attac(s reuire p&o0p! !&e!0e#!6

" 7nhaled raid-acting ?0-agonists in adeuate doses are essential# %Fegin with 0 to @ uffs

every 04 minutes for the first hourG then mild exacerbations will reuire 0 to @ uffs every 8

to @ hours& and moderate exacerbations 5 to !4 uffs every ! to 0 hours#'

" Dral glucocorticosteroids %4# to ! mg of rednisolone,(g or euivalent during a 0@-hour

eriod' introduced early in the course of a moderate or severe attac( hel to reverse the

inflammation and seed recovery#

" Dxygen is given at health centers or hositals if the atient is hyoxemic %achieve D0

saturation of 3'#

" $ombination ?0-agonist,anticholinergic theray is associated with lower hositali+ationrates and greater imrovement in PE. and .E1!#

" Methylxanthines are not recommended if used in addition to high doses of inhaled ?0-

agonists# However& theohylline can be used if inhaled ?0-agonists are not available# 7f the

atient is already ta(ing theohylline on a daily basis& serum concentration should be

measured before adding short-acting theohylline#

Theraies #o! &e%o00e#)e) for treating asthma attac(s include*

" Sedatives %strictly avoid'

" Mucolytic drugs %may worsen cough'

" $hest hysical theray,hysiotheray %may increase atient discomfort'

" Hydration with large volumes of fluid for adults and older children %may be necessary for

younger children and infants'

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" Antibiotics %do not treat attac(s but are indicated for atients who also have neumonia or

bacterial infection such as sinusitis'

" Einehrine,adrenaline %may be indicated for acute treatment of anahylaxis and

angioedema but is not indicated for asthma attac(s'

Mo#"!o& &e'po#'e !o !&e!0e#!6

Evaluate symtoms and& as much as ossible& ea( flow# 7n the hosital& also assess oxygensaturationG consider arterial blood gas measurement in atients with susected

hyoventilation& exhaustion& severe distress& or ea( flow 84-4 ercent redicted#

Follo; ,p6

After the exacerbation is resolved& the factors that reciitated the exacerbation should be

identified and strategies for their future avoidance imlemented& and the atient/s medication

lan reviewed#

SPECIAL CONSIDERATIONS IN MANAGING ASTHMA

Secial considerations are reuired in managing asthma in relation to* P&e##%+. )uring regnancy the severity of asthma often changes& and atients may reuire close

follow-u and adustment of medications# Pregnant atients with asthma should be advised that the

greater ris( to their baby lies with oorly controlled asthma& and the safety of most modern asthma

treatments should be stressed# Acute exacerbations should be treated aggressively to avoid fetal

hyoxia#

? S,&e&+. Airway hyerresonsiveness& airflow limitation& and mucus hyersecretion

redisose atients with asthma to intraoerative and ostoerative resiratory comlications&

articularly with thoracic and uer abdominal surgeries# 6ung function should be evaluated several

days rior to surgery& and a brief course of glucocorticosteroids rescribed if .E1! is less than I43

of the atient/s ersonal best#

? R("#"!"'/ S"#,'"!"'/ #) N'l Pol+p'. =hinitis and asthma often coexist in the same atient& and

treatment of rhinitis may imrove asthma symtoms# Foth acute and chronic sinusitis can worsen

asthma& and should be treated# Nasal olys are associated with asthma and rhinitis& often with

asirin sensitivity and most freuently in adult atients# They are normally uite resonsive to toical

glucocorticosteroids#

? O%%,p!"o#l '!(0. Pharmacologic theray for occuational asthma is identical to theray for

other forms of asthma& but is not a substitute for adeuate avoidance of the relevant exosure#

$onsultation with a secialist in asthma management or occuational medicine is advisable#

? Re'p"&!o&+ "#*e%!"o#'. =esiratory infections rovo(e whee+ing and increased

asthma symtoms in many atients# Treatment of an infectious exacerbation follows the same

rinciles as treatment of other exacerbations#

? G'!&oe'op(el &e*l,. Bastroesohageal reflux is nearly three times as revalent in atients

with asthma comared to the general oulation# Medical management should be given for the reliefof reflux symtoms& although this does not consistently imrove asthma control#

? A'p"&"#-"#),%e) '!(0. : to 0I ercent of adults with asthma& but rarely children& suffer from

asthma exacerbations in resonse to asirin and other nonsteroidal anti-inflammatory drugs# The

diagnosis can only be confirmed by asirin challenge& which must be conducted in a facility with

cardioulmonary resuscitation caabilities# $omlete avoidance of the drugs that cause symtoms is

the standard management#

? A#p(+l"'. Anahylaxis is a otentially life-threatening condition that can both mimic and

comlicate severe asthma# Promt treatment is crucial and includes oxygen& intramuscular

einehrine& inectable antihistamine& intravenous hydrocortisone& and intravenous fluid


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3. CHRONIC OBSTRUCTIVE PULMONARY DISEASE 4COPD5

WHAT IS CHRONIC OBSTRUCTIVE PULMONARY DISEASE 4COPD5

)efinition* $hronic Dbstructive Pulmonary )isease %$DP)' is a reventable and treatable

disease with some significant extraulmonary effects that may contribute to the severity inindividual atients# 7ts ulmonary comonent is characteri+ed by airflow limitation that is

not fully reversible# The airflow limitation is usually rogressive and associated with an

abnormal inflammatory resonse of the lung to noxious articles or gases# This definition

does not use the terms chronic bronchitis and emhysemaJ and excludes asthma %reversible

airflow limitation'#

Symtoms of $DP) include*

" $ough

" Sutum roduction

" )ysnea on exertion

Eisodes of acute worsening of these symtoms often occur#

*Chronic bronchitis& defined as the resence of cough and sutum roduction for at least 8

months in each of 0 consecutive years& is not necessarily associated with airflow limitation#

Emphysema& defined as destruction of the alveoli& is a athological term that is sometimes

%incorrectly' used clinically and describes only one of several structural abnormalities

resent in atients with $DP)#

RISK FACTORS6 WHAT CAUSES COPD7

Wo&l);")e/ %"&e!!e '0o"# "' !(e 0o'! %o00o#l+ e#%o,#!e&e) &"' *%!o& *o& COPD.

The genetic ris( factor that is best documented is a severe hereditary deficiency of alha-!antitrysin# 7t rovides a model for how other genetic ris( factors are thought to contribute to $DP)#

$DP) ris( is related to the total burden of inhaled articles a erson encounters over their lifetime*

" To2%%o '0oe& including cigarette& ie& cigar& and other tyes of tobacco smo(ing oular in

many countries& as well as environmental tobacco smo(e %ETS'

" O%%,p!"o#l ),'!' #) %(e0"%l' %vaors& irritants& and fumes' when the exosures are

sufficiently intense or rolonged " I#)oo& "& poll,!"o# from biomass fuel used for coo(ing and

heating in oorly vented dwellings& a ris( factor that articularly affects women in develoing

countries

" O,!)oo& "& poll,!"o# also contributes to the lungs/ total burden of inhaled articles& although it

aears to have a relatively small effect in causing $DP)# 7n addition& any factor that affects lung

growth during gestation and childhood %low birth weight& resiratory infections& etc#' has the

otential for increasing an individual/s ris( of develoing $DP)#

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DIAGNOSING COPD

A diagnosis of $DP) should be considered in any atient who has dysnea& chronic cough or sutum

roduction& and,or a history of exosure to ris( factors for the disease& esecially cigarette smo(ing

%F",&e 1'#

J9here sirometry is unavailable& the diagnosis of $DP) should be made using all available tools#

$linical symtoms and signs %abnormal shortness of breath and increased forced exiratory time' can

be used to hel with the diagnosis# A low ea( flow is consistent with $DP) but has oor secificity

since it can be caused by other lung diseases and by oor erformance# 7n the interest of imroving

the accuracy of a diagnosis of $DP)& every effort should be made to rovide access to standardi+ed

sirometry#

Spirometry is as important for the diagnosis of COPD as bloodpressure measurements are for the

diagnosis of hypertension. Spirometry should be available to all health care professionals.

Sirometry measurements used for diagnosis of $DP) include %see .igure 0& age '*

" FVC %forced vital caacity'* maximum volume of air that can be exhaled during a forced maneuver#

" FEV! %forced exired volume in one second'* volume exired in the first second of maximalexiration after a maximal insiration#

This is a measure of how uic(ly the lungs can be emtied#

" FEV!$FVC6 .E1! exressed as a ercentage of the .1$& gives a clinically useful index of airflow

limitation#

The ratio .E1!,.1$ is between C43 and I43 in normal adultsG a value less than C43 indicates

airflow limitation and the ossibility of $DP)# .E1! is influenced by the age& sex& height and

ethnicity& and is best considered as a ercentage of the redicted normal value# There is a vast

literature on normal valuesG those aroriate for local oulations should be used

9hen erforming sirometry& measure*

" Forced Vital Caacity %FVC' and

" Forced Exiratory Volume in one second %FEV1'#

$alculate the .E1!,.1$ ratio#

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Sirometric results are exressed as ? P&e)"%!e) using aroriate normal values for the

erson/s sex& age& and height#

P!"e#!' ;"!( COPD !+p"%ll+ '(o; )e%&e'e "# 2o!( FEV1 #) FEV1$FVC. T(e)e&ee o* 'p"&o0e!&"% 2#o&0l"!+ e#e&ll+ &e*le%!' !(e 'eve&"!+ o* COPD. Ho;eve&/

2o!( '+0p!o0' #) 'p"&o0e!&+ '(o,l) 2e %o#'")e&e) ;(e# )evelop"# #

"#)"v"),l"


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D"**e&e#!"l D"#o'"'6 A maor differential diagnosis is asthma# 7n some atients with chronic

asthma& a clear distinction from $DP) is not ossible using current imaging and hysiological

testing techniues# 7n these atients& current management is similar to that of asthma# Dther otential

diagnoses are usually easier to distinguish from $DP) %F",&e 8'#

COMPONENTS OF CARE6 A COPD MANAGEMENT PROGRAM

The goals of $DP) management include*

" =elieve symtoms

" Prevent disease rogression

" 7mrove exercise tolerance

" 7mrove health status

" Prevent and treat comlications

" Prevent and treat exacerbations

" =educe mortality

" Prevent or minimi+e side effects from treatment#$essation of cigarette smo(ing should be included as a goal throughout the management rogram#

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THESE GOALS CAN BE ACHIEVED THROUGH IMPLEMENTATION OF A

COPD MANAGEMENT PROGRAM WITH FOUR COMPONENTS6

1. A''e'' #) Mo#"!o& D"'e'e

3. Re),%e R"' F%!o&'

8. M#e S!2le COPD9. M#e E%e&2!"o#'

Co0po#e#! 16 A''e'' #) Mo#"!o& D"'e'e

A )e!"le) 0e)"%l ("'!o&+ of a new atient (nown or thought to have $DP) should assess*

@ Exosure to ris( factors& including intensity and duration#

@ Past medical history& including asthma& allergy& sinusitis or nasal olys& resiratory

infections in childhood& and other resiratory diseases

@ .amily history of $DP) or other chronic resiratory disease#

@ Pattern of symtom develoment#

@ History of exacerbations or revious hositali+ations for resiratory disorder#

@ Presence of comorbidities& such as heart disease& malignancies& osteoorosis& andmusculos(eletal disorders& which may also contribute to restriction of activity#

@ Aroriateness of current medical treatments#

@ 7mact of disease on atient/s life& including limitation of activityG missed wor( and

economic imactG effect on family routinesG and feelings of deression or anxiety#

@ Social and family suort available to the atient#

@ Possibilities for reducing ris( factors& esecially smo(ing cessation#

7n addition to 'p"&o0e!&+& the following o!(e& !e'!' should be underta(en for the assessment

of a atient withModerate (Stage !" Severe(Stage !" and #ery Severe (Stage #! COPD#

@ B&o#%(o)"l!o& &eve&'"2"l"!+ !e'!"#6 To rule out a diagnosis of asthma& articularly in

atients with an atyical history %e#g#& asthma in childhood and regular night wa(ing with

cough and whee+e'#

@ C(e'! -&+6 Seldom diagnostic in $DP) but valuable to exclude alternative diagnoses

such as ulmonary tuberculosis& and identify comorbidities such as cardiac failure#

@ A&!e&"l 2loo) ' 0e',&e0e#!6 Perform in atients with .E1! K 43 redicted or with

clinical signs suggestive of resiratory failure or right heart failure# The maor clinical sign

of resiratory failure is cyanosis# $linical signs of right heart failure include an(le edema

and an increase in the ugular venous ressure# =esiratory failure is indicated by PaD0 K I#4

(Pa %54 mm Hg'& with or without Pa$D0 5#C (Pa %4 mm Hg' while breathing air at sea

level#

@ Alp(-1 #!"!&+p'"# )e*"%"e#%+ '%&ee#"#6 Perform when $DP) develos in atients of$aucasian descent under @ years or with a strong family history of $DP)#

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Co0po#e#! 36 Re),%e R"' F%!o&'

Smoking cessation: is the single most effective>and costeffective>intervention to reduce

the ris( of develoing$DP) and slow its rogression#

Smoking Prevention: Encourage comrehensive tobacco-control olicies and rograms with

clear& consistent& and reeated nonsmo(ing messages# 9or( with government officials to

ass legislation to establish smo(e-free schools& ublic facilities& and wor( environments andencourage atients to (ee smo(e-free homes#

Occupational Exposures: Emhasi+e rimary revention& which is best achieved by

elimination or reduction of exosures to various substances in the wor(lace# Secondary

revention& achieved through surveillance and early detection& is also imortant#

Indoor and Outdoor ir Pollution: 7mlement measures to reduce

or avoid indoor air ollution from biomass fuel& burned for coo(ing and heating in oorly

ventilated dwellings# Advise atients to monitor ublic announcements of air uality and&

deending on the severity of their disease& avoid vigorous exercise outdoors or stay indoors

altogether during ollution eisodes#

Co0po#e#! 86 M#e S!2le COPD M#e0e#! o* '!2le COPD '(o,l) 2e ,")e)2+ !(e *ollo;"# e#e&l p&"#%"ple'6

P!"e#! e),%!"o# can hel imrove s(ills& ability to coe with illness& and health status# 7t is

an effective way to accomlish smo(ing cessation& initiate discussions and understanding of

advance directives and end-oflife issues& and imrove resonses to acute exacerbations#

P(&0%olo"% !&e!0e#! %F",&e =' can control and revent symtoms& reduce the

freuency and severity of exacerbations& imrove health status& and imrove exercise

tolerance#

!ronc"odilators: These medications are central to symtom management in $DP)#

" 7nhaled theray is referred#

" Bive ;as needed< to relieve intermittent or worsening symtoms& and on a regular basis to

revent or reduce ersistent symtoms#

" The choice between ?0-agonists& anticholinergics& methylxanthines& and combination

theray deends on the availability of medications and each atient/s individual resonse in

terms of both symtom relief and side effects#

" =egular treatment with long-acting bronchodilators is more effective and convenient than

treatment with short-acting bronchodilators#

" $ombining bronchodilators may imrove efficacy and decrease the ris( of side effects

comared to increasing the dose of a single bronchodilator#

#lucocorticosteroids: =egular treatment with inhaled glucocorticosteroids is only

aroriate for atients with an .E1! K 43 redicted and reeated exacerbations %for

examle& 8 in the last three years'# This treatment has been shown to reduce the freuency ofexacerbations and thus imrove health status& but does not modify the long-term decline in

.E1!# The dose-resonse relationshis and long-term safety of inhaled

glucocorticosteroids in $DP) are not (nown# 6ong-term treatment with

oral glucocorticosteroids is not recommended#

Vaccines: nfluen$a vaccines reduce serious ilness and death in $DP) atients by 43#

1accines containing (illed or live& inactivated viruses are recommended& and should be

given once each year# Pneumococcal polysaccharide vaccine is recommended for $DP)

atients 5 years and older& and has been shown to reduce community-acuired neumonia

in those under age 5 with .E1! K @43 redicted#

nti$iotics6 Not recommended excet for treatment of infectious exacerbations and other

bacterial infections#

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Mucolytic %Mucokinetic& Mucoregulator' gents: Patients with viscous sutum may benefit

from mucolytics& but overall benefits are very small# :se is not recommended#

ntitussives: =egular use contraindicated in stable $DP)#

No#-P(&0%olo"% T&e!0e#! includes rehabilitation& oxygen theray& and surgical

interventions#(e"a$ilitationrograms should include& at a minimum*

" Exercise training

" Nutrition counseling

" Education

Patients at all stages of disease benefit from exercise training rograms& with imrovements

in exercise tolerance and symtoms of dysnea and fatigue# Fenefits can be sustained evenafter a single ulmonary rehabilitation rogram# The minimum length of an effective

rehabilitation rogram is 5 wee(sG the longer the rogram continues& the more effective the

results# Fenefit does wane after a rehabilitation rogram

ends& but if exercise training is maintained at home the atientOs health status remains above

re-rehabilitation levels#

Oxygen )"erapy: The long-term administration of oxygen %! hours er day' to atients

with chronic resiratory failure increases survival and has a beneficial imact on ulmonary

hemodynamics& hematologic characteristics& exercise caacity& lung mechanics& and mental

state#

7nitiate oxygen theray for atients with Stage #% #ery Severe COPD if*

" PaD0 is at or below C#8 (Pa % mm Hg' or SaD0 is at or below II3& with or without

hyercaniaG or

" PD0 is between C#8 (Pa % mm Hg' and I#4 (Pa %54 mm Hg' or SaD0 is II3& if there is

evidence of ulmonary hyertension& eriheral edema suggesting congestive heart failure&

or olycythemia %hematocrit 3'#

Surgical )reatments: Fullectomy and lung translantation may be considered in carefullyselected atients with Stage #% #ery SevereCOPD# There is currently no sufficient evidence

that would suort the widesread use of lung volume reduction surgery %61=S'#

)"ere is no convincing evidence t"at mec"anical ventilatory

support "as a role in t"e routine management o* sta$le COPO

!5


17/18

A summary of characteristics and recommended treatment at each stage

of $DP) is shown in F",&e >#

Co0po#e#! 96 M#e E%e&2!"o#'An exacerbation of $DP) is defined as an event in t"e naturalcourse o* t"e disease c"aracteri+ed

$y a c"ange in t"e patient,s $aseline dyspnea& coug"& andor sputum t"at is $eyond normal day-to-

day variations& is acute in onset&and may .arrant a c"ange in regular medication in a patient .it"

underlying COPD/The most common causes of an exacerbation are infection of the tracheobronchial tree and air

ollution& but the cause of about one-third of severe exacerbations cannot be identified#

Ho; !o A''e'' !(e Seve&"!+ o* # E%e&2!"o#

&rterial blood gas measurements (in hospital!%

" PaD0 K I#4 (Pa %54 mm Hg' and,or SaD0 K 43 with or without Pa$D0 5#C (Pa& %4 mmHg'

when breathing room air indicates resiratory failure#

" Moderate-to-severe acidosis %H K C#85' lus hyercania %Pa$D0 5-I (Pa& @-54 mm Hg' in a

atient with resiratory failure is an indication for mechanical ventilation#

Chest 'ray% $hest radiograhs %osterior,anterior lus lateral' identify alternative diagnoses that can

mimic the symtoms of an exacerbation#

EC)% Aids in the diagnosis of right ventricular hyertrohy& arrhythmias& and ischemic eisodes#

!C


18/18

Other laboratory tests%

" Sutum culture and antibiogram to identify infection if there is no resonse to initial

antibiotic treatment# " Fiochemical tests to detect electrolyte disturbances& diabetes&

and oor nutrition#

" 9hole blood count can identify olycythemia or bleeding#

Ho0e M#e0e#!!ronc"odilators: 7ncrease dose and,or freuency of existing shortacting bronchodilator

theray& referably with ?0-agonists# 7f not already used& add anticholinergics until

symtoms imrove#

#lucocorticosteroids: 7f baseline .E1! K 43 redicted& add 84-@4 mg oral rednisolone

er day for C-!4 days to the bronchodilator regimen# Nebuli+ed budesonide may be an

alternative to oral glucocorticosteroids in the treatment of nonacidotic exacerbations#

Ho'p"!l M#e0e#!

Patients with the characteristics listed in F",&e should be hositali+ed# 7ndications for

referral and the management of exacerbations of $DP) in the hosital deend on local

resources and the facilities of the local hosital#

nti$iotics: Antibiotics should be given to atients*

" 9ith the following three cardinal symtoms* increased dysnea& increased sutum volume&

increased sutum urulence " 9ith increased sutum urulence and one other cardinal

symtom

" 9ho reuire mechanical ventilation

!I

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Obstructive Airway and Pulmonary Disease

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