COPD | Jindal Chest Clinic

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MANAGEMENT OF COPDGoals 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

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MANAGEMENT OF COPDSteps 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

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Guidelines on Smoking CessationThe 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

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Bronchodilators

• Anticholinergics
• Tiotropium - Long acting
• Ipratropium - Short acting
• Beta-agonists
• Long acting Maintenance
• (Salmeterol,
  Formoterol)
• Short acting Rescue
• (Salbutamol)
• Combinations (12)
• Oral Theophyllines
• PDE4 inhibitors (Roflumilast)

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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)

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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

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Metered Dose Inhalers
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Dry powder inhalers
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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)

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Corticosteroids

• Oral/parenteral for acute exacerbations
• 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

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Complications of COPD

• 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

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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)

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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)

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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

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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 gt 24 and hypercapnia with
  acidosis
• (pH lt7.35) are the classic
  indications
• No benefit in milder exacerbations
• Intubation and Mechanical ventilation if NIV is
  contraindicated, has failed, or is not tolerated

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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

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Treatment of cor pulmonale

• Long term oxygen therapy
• Removal of fluid retention diuretics
• Maintenance of CO2 levels
• Digoxin, if arterial fibrillation
• Vasodilators - may be hazardous (Lower systemic
  and pulm. BP)
• Treatment of COPD

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Other complications

• Rupture of blebs/bullae Pneumothorax,
  pneumomediastinum, subcutaneous emphysema
• Polycythemia (due to chronic hypoxemia)
• Increased coagulation problems
• In situ thrombosis
• Pulmonary thromboembolism
• 5. Hyperuricemia (and occasionally gout)
• 6. Systemic manifestations

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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

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• 4. Endocrinal
• Diabetes,
• Metabolic syndrome
• Dysfunction of pituitary,
• thyroid, gonads and
  adrenals
• 5. Neuropsychiatric
• Depression
• Disordered sleep
• Anxiety
• Cognitive function decline

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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)

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Pulmonary Rehabilitation

• Structured, multi-disciplinary programme tailored
  to ones 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

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Pulmonary Eosinophilic Disorders

• Normal E counts Differential 5, AEC
  0.5109/l
• Eosinophilia
• Mild AEC 0.5-1.5109/l
• Moderate AEC 1.5-5.0109/l
• Severe AEC gt5.0109/l
• Hyper Eosinophilic Syndrome (HES)
• AEC gt1.5109/l lasting for 6 months
• Lack of evidence for known causes of
  eosinophilia
• Signs and symptoms of organ
• involvement/dysfunction

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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

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C. Secondary pulmonary eosinophilia

• 1. Infections Parasitic infestations  
• Transient passage (Löfflers 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

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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.

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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 Wegeners granulomatosis, polyarteritis
  nodosa,
• tuberculosis, fungal infections,
• allergic bronchopulmonary aspergillosis,
• Tmt. Corticosteroids and cytotoxic medications

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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)

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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 Farmers 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

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