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COPD | Jindal Chest Clinic

  1. MANAGEMENT OF COPD Goals of treatment • Symptomatic relief • Prevention of complications • Removal of risk-factors • Treatment of complications & Ac Exacerbations • Reduce the rate of decline in lung function • Prevent morbidity and mortality • Rehabilitation of patient
  2. MANAGEMENT OF COPD Steps of therapy I (Mild) Short acting BDs II (Moderate) Regular BD (one / more) III (Severe) - Bronchodilators - Inhaled corticosteroids - Rx of complications Tobacco cessation and pulmonary rehabilitation are important at all stages
  3. Guidelines on Smoking Cessation The “5A” Strategy for Physicians 1. ASK about tobacco use 2. ASSESS the status and severity of use 3. ADVISE to stop 4. ASSIST in smoking cessation 5. ARRANGE follow-up programme
  4. Bronchodilators 1. Anticholinergics Tiotropium - Long acting Ipratropium - Short acting 2. Beta-agonists Long acting – Maintenance (Salmeterol, Formoterol) Short acting – Rescue (Salbutamol) 3. Combinations (1+2) 4. Oral: Theophyllines PDE4 inhibitors (Roflumilast)
  5. Inhalational Treatment Preferred route for both controller and reliever therapy Advantages: Local effect, immediate response Minimal dosage, few side effects Available as : Dry powder (DPIs), Metered dose liquid inhalers MDIs); Nebulizers Devices: Spacers (to increase drug delivery)
  6. Side effects of inhalation drugs Local side effects: throat irritation, voice change, thrush (candida infection), vocal cord dysphonia Systemic side effects of drugs: Rare may be growth retardation in young children cataracts, other steroid effects
  7. Metered Dose Inhalers
  8. Dry powder inhalers
  9. Anticholinergics 1. Cause effective bronchodilatation 2. Reduce rate & severity of acute exacerbations 3. Improve quality of life 4. Long acting 5. Side effects: Dryness, blurred vision, urinary retention (if BPH)
  10. Corticosteroids 1. Oral/parenteral for acute exacerbations 2. Inhaled for moderate to severe COPD • Improve lung function • Reduce exacerbations • Improve symptoms & Q.O.L. • Reduce airway reactivity Side effects: • Loss of bone mineral density • Increased skin bruising
  11. Complications of COPD 1. Acute exacerbations Severe airway obstruction Acute change in baseline lung function Marked exercise tolerance Nocturnal hypoxemia 2. Pulmonary hypertension and Chronic cor pulmonale 3. Respiratory failure
  12. Symptoms of COPD Exacerbation • Increase in cough • Chest pain • Increase in breathlessness • Increase in sputum volume and change in its colour (to green, yellow, blood streaked) • Fever • Increased tiredness • Increase in oxygen requirement (for those on long-term oxygen therapy)
  13. Management of Acute Exacerbations 1. Increase the dose and/or frequency of current bronchodilator therapy 2. Add new bronchodilators 3. Bronchodilator nebulization 4. Parenteral theophyllines 5. Systemic glucocorticoids 6. Antibiotics for infections 7. Maintenance of oxygenation 8. NIV or Assisted Ventilation for refractory respiratory failure (Hypoxaemia and/ or hypercapnia)
  14. Supplemental Oxygen • Hypoxemia common in hospitalized pts. • Small increase in FiO2 - good response However, this can worsen hypercapnia due to: – Release of hypoxic vasoconstriction  Increased dead-space – Loss of hypoxic respiratory drive • Domicilliary long term-term oxygen therapy for COPD with chronic respiratory failure
  15. Assisted Respir Supports • Non-invasive ventilation (NIV) in case there is failure to respond to supportive therapy and controlled oxygen supplementation Initiate as early as possible RR > 24 and hypercapnia with acidosis (pH <7.35) are the classic indications No benefit in milder exacerbations • Intubation and Mechanical ventilation if NIV is contraindicated, has failed, or is not tolerated
  16. Chronic Cor Pulmonale Definition: Alterations in the structure and/or function of the right ventricle secondary to diseases of the lung, chest wall or lung vasculature – (which are not secondary to the diseases of the left heart or congenital heart diseases). Manifests with features of pulmonary hypertension and right heart overload/ failure: Generalized anasarca, congested liver, ascites, cyanosis, loud P-2, cardiomegaly (rt.) Diagnosis: H/O COPD CXR, ECG, ECHO
  17. Treatment of cor pulmonale 1. Long term oxygen therapy 2. Removal of fluid retention – diuretics 3. Maintenance of CO2 levels 4. Digoxin, if arterial fibrillation 5. Vasodilators - may be hazardous (Lower systemic and pulm. BP) 6. Treatment of COPD
  18. Other complications 1. Rupture of blebs/bullae: Pneumothorax, pneumomediastinum, subcutaneous emphysema 2. Polycythemia (due to chronic hypoxemia) 3. Increased coagulation problems In situ thrombosis Pulmonary thromboembolism 5. Hyperuricemia (and occasionally gout) 6. Systemic manifestations
  19. Systemic manifestations of COPD 1. General Wasting, weight loss, Nutritional anomalies, anemia 2. Musculoskeletal Skeletal muscle dysfunction, Osteoporosis Reduced exercise tolerance, performance 3.Cardiovascular Ischemic heart disease Cardiac failure, Stroke
  20. 4. Endocrinal Diabetes, Metabolic syndrome Dysfunction of pituitary, thyroid, gonads and adrenals 5. Neuropsychiatric Depression Disordered sleep Anxiety Cognitive function decline
  21. Long term Maintenance and Prophylaxis Treatment • Keep off smoking • Bronchodilators • Inhaled corticosteroids • Use/avoidance of other drugs (e.g. antibiotics, mucolytics ,sedatives) • Prophylactic vaccination (influenza) • Pulmonary rehabilitation (multidisciplinary supports and management)
  22. Pulmonary Rehabilitation • Structured, multi-disciplinary programme tailored to one’s needs to improve quality of life, lung function and reduce breathlessness Components • Exercise training • Nutritional counseling • Education on lung disease or condition and how to manage it • Energy-conserving techniques • Breathing strategies • Psychological counseling and/or group support
  23. Pulmonary Eosinophilic Disorders Normal E counts: Differential: ≤5%, AEC: ≤0.5×109/l Eosinophilia: • Mild: AEC 0.5-1.5×109/l • Moderate: AEC 1.5-5.0×109/l • Severe: AEC >5.0×109/l • Hyper Eosinophilic Syndrome (HES): AEC: >1.5×109/l lasting for 6 months Lack of evidence for known causes of eosinophilia Signs and symptoms of organ involvement/dysfunction
  24. Pulm eosinophilic disorders: Classification A. Primary pulmonary eosinophilia Predominant involving lung. Acute eosinophilic pneumonia Chronic eosinophilic pneumonia Systemic disease with lung disease Churg-Strauss syndrome Idiopathic hypereosinophilic syndrome B. Lung disorders with associated eosinophilia 1. Interstitial lung disease, Sarcoidosis, Langerhans cell histiocytosis, Connective tissue disease 2. Asthma 3. Bronchiolitis obliterans-organizing pneumonia 4. Neoplasms:, Hematological malignancies, Solid organ tumors
  25. C. Secondary pulmonary eosinophilia 1. Infections: Parasitic infestations Transient passage (Löffler’s syndrome) Ancylostoma, ascaris, strongyloides paragonimiasis, echinococcosis Trichinella, Visceral larva migrans Disseminated strongyloidiasis Schistosomiasis • Fungal infections: Coccidiomycosis, Histoplasmosis • Other infections: Tuberculosis, Brucellosis 3. Tropical pulmonary eosinophilia 4. Allergic bronchopulmonary aspergillosis 5. Hypersensitivity pneumonia 6. Drugs, toxins and radiation
  26. Drugs causing eosinophilic lung disease 1. Antimicrobials: Para-amino salicyclic acid, Nitrofurantoin Penicillin, Tetracycline, Streptomycin, Isoniazid Sulfonamide,Tetracycline, Minocycline,Dapsone + pyrimethamine 2. Antineoplastic and immunosuppressives Bleomycin, Methotrexate, Melphalan, Gold salts Azathioprine, Penicillamine, Beclomethasone 3. Nonsteroidal anti-inflammatory drugs (NSAIDs): Aspirin, Naproxen, Piroxicam, Nimesulide, Phenylbutazone 4. Cardiovascular and antidiabetics: Amiodarone, Hydralazine, Thiazides, Clofibrate, Sulfonylureas 5. Miscellaneous: Carbamazepine, Phenytoin, Dantrolene, Methylphenidate, Imipramine, Cocaine or heroin exposure Iodinated contrast media, L-tryptophan.
  27. Churg Strauss Syndrome Now known as Allergic Granulomatosis with Angiitis Include i) asthma, ii) paranasal sinusitis, iii) monoarthropathy or polyarthropathy, iv) migratory or transient pulmonary infiltrates, v) peripheral blood eosinophilia greater than 10%, and vi) extravascular eosinophils in a blood vessel on a biopsy specimen. D/D: Wegener’s granulomatosis, polyarteritis nodosa, tuberculosis, fungal infections, allergic bronchopulmonary aspergillosis, Tmt.: Corticosteroids and cytotoxic medications
  28. Tropical Pulmonary Eosinophilia • Immunological hyper-responsiveness to human filarial parasite- W. bancrofti & Brugia malayi • Transmitted through mosquito bites • Symptoms: Cough, breathlessness, wheeze, usually nocturnal symptoms. Systemic organ involvement. • Diagnosis: Absolute eosinophil count – more than 3000/cmm; demonstration of parasites • Chest X-ray: Reticulo-nodular shadow • Elevated serum IgE and anti-falarial antibodies • Tmt: Diethylcarbamazine (6mg/kg per day for 3 weeks)
  29. Hypersensitivity Pneumonias • Type 3 immunological response to sensitizing antigens (Cf. type 1 for asthma) • Presentation delayed 4-6 hrs or more after exposure • Symptoms: Cough, fever, breathlessness, malaise etc • Types: Farmer’s lung, Byssinosis, Baggasosis Psittacosis, Pigeon breeder lung, Grain lung, Air-conditioner lung, compost lung etc Diagnosis: History of exposure-symptom relationship CXR; Non-specific. Eosinophilia, Antibodies Tmt: Removal of offending antigens Symptomatic and anti-inflammatory treatment