COPD

1
COPD

• Tintinalli Chapter 73

2
COPD definition

• Airflow limitation that is progressive and not
  fully reversible
• Abnormal inflammatory response to noxious
  particles or gases.
• Only major cause of death that is ?
• 85 chronic bronchitis
• Productive cough for gt3 months x 2 yrs
• 15 emphysema
• Destruction of bronchioles and alveoli

3
Pathophysiology

• Airway changes 2 to noxious stimuli
• Increase in number and size of bronchial mucous
  glands
• ? secretions
• Acute and chronic airway inflammation
• ? airway resistance
• Breakdown in alveolar architecture
• Hypoxemia 2 to V/Q mismatch

4
Chronic Signs/Symptoms

• Classic signs
• Exertional dyspnea
• Cough
• Symptoms
• Tachypnea
• Accessory muscle use
• Pursed lip exhaling
• Decreased breath sounds
• Wheezing upon exhalation
• Prolonged exhalation
• Barrel chest
• Findings of right ventricular strain on EKG

5
Acute Signs/Symptoms

• Acute decompensation characterized by
• Progressive hypoxemia
• Tachypnea
• Cyanosis
• AMS
• Increased work of breathing

6
Diagnosis of chronic, compensated COPD

• PFTs
• Ratio FEV1FVC lt 70
• Indicates obstructive disease
• Value of FEV1
• Indicates severity of disease
• DLCO lt 80
• Differentiates between chronic bronchitis and
  emphysema

7
Diagnosis of acute exacerbations

• Assess hypoxemia
• Pulse ox
• Assess hypercapnea/ acid-base disturbances
• ABGs
• Bedside PFTS if available
• Often unreliable 2 to poor pt cooperation
• Assess sputum
• Look for changes in color, volume, and
  consistency
• Culture
• CXR
• Look for underlying etiology

8
Treatment

• Chronic treatment
• Lifestyle changes
• 1 smoking cessation
• Pulmonary rehab
• Oxygen
• Home O2 indicated for PaO2 lt 55
• or SaO2 lt 88
• Meds
• Do not reduce mortality, but provide symptomatic
  relief
• ?2 agonist, anticholinergics, /- steroids

9
Treatment

• Acute treatment
• Oxygen
• Maintain SaO2 gt 90
• Bronchodilator therapy
• ?2 agonist, anticholinergics, or combination
  therapy
• Aerosolized tx preferred
• When using ?2 agonist in pt with known heart
  disease, consider placing on cardiac monitor

10
Treatment (cont)

• Corticosteroids
• IV solumedrol 125mg
• PO prednisone 60mg
• Consider abx therapy if suspect infection
• Appropriate tx based on whether pt is from
  nursing home/community
• Consider NIPPV
• BiPAP/CPAP
• Indications for mechanical ventilation
• Resp muscle fatigue
• ABG signs of worsening resp acidosis
• Declining mental status 2 to hypercapnea
• Significant hypoxemia

11
Exacerbation/Mortality

• With each exacerbation pts never return to their
  baseline pulmonary ftn.
• As a consequence pt mortality rises with each
  exacerbation regardless of therapeutic
  intervention.

12
Disposition

• Pt who fail to improve adequately or continue to
  deteriorate require hospitalization.
• Pt stable for d/c to home should have the
  following
• Adequate home O2 if needed
• Bronchodilator txs
• Short course of PO steroids
• Abx if indicated
• Secure follow up with PCP