COPD Management

Treatment ,pharmacological +
follow up

Rashk kaushal
6th course,grp:37
 Goals
• Prevent disease progression
• Relieve symptoms
• Improve exercise tolerance
• Improve health status
• Prevent and treat complications
• Prevent and treat exacerbations
• Reduce mortality
• Prevent or minimize side effects from
treatment
• Cessation of cigarette smoking
Components

• Assess and monitor disease

• Reduce risk factors
• Manage stable COPD
• Manage acute exacerbations
Assess and Monitor
Disease
 Initial Visit
• Pattern of symptom development
• Exposure to risk factors
• History of exacerbations or previous
hospitalizations for respiratory disorder
• Past medical history
• Family history
• Social history
• Impact of disease on patient’s life
• Effect on family routines
• Feelings of depression or anxiety
• Social and family support available to the
patient
• Possibilities for reducing risk factors,
especially smoking cessation
 Testing
• Spirometry
• Initially and yearly
• ABG
• Obtain if FEV1 < 40% predicted OR
• Clinical signs of respiratory or right heart
failure
• Respiratory Failure
• Alpha-1 antitrypsin
• If patient <45 years old or strong family
history of COPD
Follow-Up Visits
• Discuss new or worsening symptoms
• Perform spirometry if there is a substantial
increase in symptoms OR if a complication
occurs
• ABG
• Patients with an FEV1 <40% predicted
• Early signs of respiratory failure or CHF
• Monitor pharmacotherapy
• Dosages
• Adherence
• Inhaler technique
• Effectiveness of current regimen at
controlling symptoms
• Side effects of treatment
 Follow-up Visits
• Monitor co-morbid conditions
• Bronchial carcinoma
• Tuberculosis
• Sleep apnea
• Left heart failure
• Obtain appropriate information through CXR,
ECG whenever symptoms suggest one of
these conditions
Reduce Risk
Factors
Risk Factors

• Tobacco smoke
• Occupational dusts and
chemicals
• Indoor and outdoor air
pollutants
 Smoking Cessation
• The single MOST effective and cost-effective intervention
to reduce the risk of developing COPD and to stop its
progression
• Offer this at EVERY visit to the health care provider
• Brief 3 minute period of counseling
• Three types of counseling are esp. effective:
• Practical counseling
• Social support as part of the treatment
• Social support arranged outside of the treatment
• Several effective medications are available and at least
one of these medications should be added to counseling if
necessary and if there are no contraindications
• Nicotine gum, inhaler, nasal spray, trasndermal patch,
sublingual tablet, lozenges
• Bupropion
• nortriptyline
Ask Systematically identify all tobacco users at
every visit

Advise Strongly urge all tobacco users to quit, in a

clear, strong, and personalized manner
Assess Determine willingness to make a quit
attempt.
e.g. within the next 30 days, how willing is
this person to make a quit attempt
Assist Aid the patient in quitting
e.g. quit plan, counseling, intra-treatment
social support, extra-treatment social
support, approved pharmacotherapy,
supplementary materials
Arrang Schedule a follow-up contact, either in
e person or via telephone
Smoking Prevention –
What you can do as a provider:
• Encourage comprehensive tobacco-
control policies and programs
• Work with government officials to
pass legislation to establish smoke-
free schools, public facilities, and
work environments
• Encourage patients to keep smoke-
free homes

Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians.
Occupational Exposures

• Primary prevention
• Eliminate or reduce exposures to
various substances in the
workplace
• Secondary prevention
• Surveillance and early detection
Indoor and Outdoor Air
Pollution
• Implement measures to reduce or avoid
indoor air pollution from biomass fuel
burned for cooking and heating in poorly
ventilated dwellings
• Advise patients to monitor public
announcements of air quality
• Avoid vigorous exercise outdoors or stay
indoors during pollution episodes,
depending on COPD severity
Manage Stable
COPD
 General Principles
• Determine disease • Prescribe
severity Treatment
• Implement step- • Pharmacologic
wise treatment plan
• Non-
• Educate the patient
pharmacologic
• Improve skills
• Rehabilitation
• Improve ability to
cope with illness − Exercise
• Improve health training
status − Nutrition
counseling
− education
− Oxygen therapy
• Surgical
GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention interventions
Stage Characteristics

0: Normal spirometry
At Risk Chronic symptoms (cough, sputum)

I: FEV1/FVC < 70%

Mild FEV1 >= 80% predicted
Usu. Chronic cough and sputum production
II: 50% <= FEV1 < 80% predicted
Moderate Progression of symptoms; dyspnea on exertion
III: 30%<= FEV1 < 50% predicted
Severe ↑ dyspnea; repeated exacerbations which have an
impact on patients’ quality of life

IV FEV1< 30% predicted OR

Very FEV1<50% predicted + chronic respiratory failure
severe •Quality of life is appreciably impaired
•Exacerbations may be life-threatening
 Patient Education
• Smoking cessation
• Basic information about COPD and pathophysiology
of the disease
• General approach to therapy and specific aspects
of medical treatment
• Self-management skills
• Strategies to help minimize dyspnea
• Advice about when to seek help
• Self-management and decision-making in
exacerbations
• Advance directives and end-of-life issues
 Medications
• Goals
• Prevent and control symptoms
• Reduce frequency and severity of exacerbations
• Improve health status
• Improve exercise tolerance
• No existing medications can modify the
long-term decline in lung function
• Reduction of therapy once symptom control
occurs is not normally possible
• COPD is progressive and over time will
require progressive introduction of more
treatments to attempt to limit the impact of
these changes
 Bronchodilators
• Central to symptom management
• Used in all stages of COPD severity
• Inhaled forms are preferred
• Can be prescribed as needed OR regularly
to prevent or reduce symptoms
• Long-acting inhaled bronchodilators are
more effective and convenient (but are
more expensive)
• Combining drugs with different mechanisms
and durations of action may increase the
degree of bronchodilation for equivalent or
lesser side effects
• All categories of bronchodilators have been
show to increase exercise capacity without
necessarily producing significant changes
in FEV1
 Bronchodilators
• Beta2-agonists
• Short-acting: albuterol
• Long-acting: salmeterol (Serevent™), formoterol
(Foradil™)
• Anticholinergics
• Short acting: ipratropium bromide (Atrovent™)
• Long acting: tiotropium bromide (Spiriva™)
• Methylxanthines (Theophylline™)
• Combination bronchodilators
• Fenoterol/ipratropium (Duovent™)
• Salbutamol/ipratropium (Combivent™)

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

 Glucocorticosteroids
• Use if FEV1 < 50% predicted and repeated
exacerbations, e.g. three in the last three
years
• Severe COPD and Very Severe COPD
• Does not modify the long-term decline in
FEV1 BUT does reduce the frequency of
excacerbations and improves health status
• The combination of a long-acting beta2-
agonist and an inhaled glucocorticosteroid
is more effective than the individual
components
• Long-term treatment with oral
glucocorticoids is NOT recommended
Inhaled Glucocorticoids

• Beclomethasone (Vanceril™)
• Budesonide (Pulmicort™)
• Fluticasone (Flovent™)
• Triamcinolone (Azmacort™)
 Immunizations
• Vaccines
• Influenza yearly
• Reduces serious illness and death in
COPD patients by approximately 50%
• Give once yearly: autumn OR twice
yearly: autumn and winter
• Pneumovax
• Sufficient data to support its general
use in COPD is lacking, but it is
commonly used
 Other Medications?
• Alpha-1 Antitrypsin Augmentation Therapy
• Only if this deficiency is present in an individual
should they undergo treatment
• Antibiotics
• Prophylactic use is NOT recommended
• Can be used in the treatment of infectious
exacerbations of COPD
• Mucolytic agents
• Overall benefits are small, so currently not
recommended for widespread use
• Types:
• Ambroxol
• Erdosteine (Erdostin, Mucotec)
• Carbocysteine (Mucodyne)
• Iodinated gylerol (Expigen)
• Antioxidant agents
• N-acetylcysteine (Bronkyl, Fluimucil, Mucomyst)
• Have been shown to reduce the frequency of
exacerbations and could have a role in the
treatment of patients with recurrent
exacerbations
• More studies are needed
• Immunoregulators
• Not recommended at this time
• No reproducible studies are available
• Antitussives
• Regular use is contraindicated in stable COPD
since cough has a significant protective role
• Vasodilators
• Inhaled nitric oxide
• Can worsen gas exchange because of altered hypoxic
regulation of ventilation-perfusion balance and is
contraindicated in stable COPD
• Respiratory stimulants
• Doxapram (IV)
• Almitrine bismesylate
• Not recommended in stable COPD
• Narcotics
• Oral and parenteral opioids are effective for
treating dyspnea in patients with advanced
COPD
• Use this with caution; benefits may be limited to a few
sensitive subjects
• nebulized opioids: insufficient evidence .
• Miscellaenous:
• Nedocromil
• Leukotriene modifiers
• Alternative healing methods
• None have been adequately studied in COPD patients at
this time
GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention
Stage 0: At Risk

• Avoid risk factors

• Offer influenza vaccination
 Stage I: Mild COPD

• Avoid risk
I: FEV1/FVC < 70%
Mild
factors FEV1 >= 80%
• Offer predicted
vaccination Usu. Chronic
• Use short-acting cough and
bronchodilators sputum
as needed production
 Stage II: Moderate
COPD II: 50% <= FEV 1 <
• Avoid risk factors Modera 80% predicted
• Offer influenza te Progression of
vaccine symptoms;
• Add short-acting dyspnea on
bronchodilators exertion
when needed
• Add regular
treatment with 1
or more long-
acting
bronchodilators
• Add rehabilitation
 Stage III: Severe COPD
• Avoid risk factors III: 30%<= FEV1
• Offer influenza vaccine Sever
• Add short-acting <50% predicted
bronchodilators when e ↑ dyspnea;
needed
• Add regular treatment repeated
with 1 or more long- exacerbations
acting bronchodilators which have an
• Add rehabilitation
• Add inhaled
impact on
glucocorticoids if patients’ quality
repeated exacerbations of life
Stage IV: Very Severe COPD
• Avoid risk factors IV FEV1< 30%
• Offer influenza predicted OR
vaccination Very
FEV1<50%
• Add short-acting severe
bronchodilators as predicted +
needed chronic
• Add rehabilitation respiratory
• Add inhaled failure
glucocorticoids if •Quality of life is
repeated exacerbations appreciably
• Add long-term oxygen if impaired
chronic respiratory •Exacerbations
failure may be life-
• Consider surgical threatening
treatments
Non-
Pharmacologic
Therapy
 Rehabilitation
• COPD patients at all stages of severity benefit from exercise
training programs
• Improves both exercise tolerance and symptoms of dyspnea and
fatigue
• Goals
• Reduce symptoms
• Improve quality of life
• Increase physical and emotional participation in everyday activities
• Comprehensive program should include several types of
health professionals:
• Exercise training
• Nutrition counseling
• Education
• Minimum effective length of time = 2 months
• Setting: inpatient OR outpatient OR home
• Baseline and outcome assessments of each participant
should be made to quantify individual gains and target areas
for improvement
• Measurement of spirometry before and after a bronchodilator drug
• Assessment of exercise capacity
• Assessment of inspiratory and expiratory muscle strength and lower limb
strength
 Oxygen Therapy
• Stage IV - Severe COPD who have
• PaO2 at or below 55 mm Hg or SaO2 at or below
88% with or without hypercapnia OR
• PaO2 between 55-60 mm Hg or SaO2 88% IF
pulmonary hypertension, peripheral edema
suggesting congestive heart failure, or
polycythemia (Hct > 55%)
• Based on awake PaO2 values
• GOAL
• Increase baseline PaO2 to at least 60 mm Hg at
sea level and rest and/or produce SaO2 at least
90%
• Need to use at least 15 hours per day in patients with
chronic respiratory failure to improve survival
• Can have a beneficial impact on hemodynamics,
hematologic characteristics, exercise capacity, lung
mechanics and mental state
 Surgical Treatment
• Bullectomy
• Effective in reducing dyspnea and improving lung
function in appropriately selected patient
• Lung volume reduction surgery
• Parts of the lung are resected to reduce
hyperinflation
• Does not improve life expectancy
• Does improve exercise capacity in patients with
predominantly upper lobe emphysema and a low
post-rehabilitation exercise capacity
• May improve global health status in patients
with heterogeneous emphysema
• High hospital costs; still experimental/palliative
Surgical Treatment
• Lung transplantation
• Improves quality of life and
functional capacity in
appropriately selected
patient
• Criteria for referral:
• FEV1 < 35% predicted
• PaO2 < 55-60 mm Hg
• PaCO2 > 50 mm Hg
• Secondary pulmonary
hypertension
• All four criteria must be present
COPD Patients and
Surgery
• Increased risk of post-operative
pulmonary complications
• Risk of complications increases as
the incision approaches the
diaphragm
• Epidural and spinal anesthesia have a
lower risk than general anesthesia
• Postpone surgery if the patient has a
COPD exacerbation
Manage Exacerbations
 General Points
• Most common causes of exacerbations are:
• Infection of the tracheobronchial tree
• Air pollution
• In 1/3 of severe exacerbations a cause cannot be identified
• Inhaled bronchodilators, theophylline, and systemic
(preferably oral) glucocorticosteroids are effective
treatments
• Patients with clinical signs of airway infection may benefit
from antibiotic treatment
• Increased volume of sputum
• Change in color of sputum
• Fever
• Non-invasive intermittent positive pressure ventilation
(NIPPV) in exacerbations is helpful:
• Improves blood gases and pH
• Reduces in-hospital mortality
• Decreases the need for invasive mechanical ventilation and
intubation
• Decreases the length of hospital stay
Diagnosis and
Assessment of Severity

• History
• Increased breathlessness
• Chest tightness
• Increased cough and sputum
• Change of color and/or tenacity of
sputum
• Fever
• Non-specific:
• Malaise, insomnia, sleepiness,
fatigue, depression, or
confusion
 Assessment of Severity
• Lung Function Tests • ECG
• Right ventricular
• PEF < 100 L/min. or FEV1
hypertrophy
< 1 L = severe
exacerbation • Arrhythmias
• Ischemia
• Arterial Blood Gas
• Sputum
• PaO2 < 60 mmHg and/or
SaO2 < 90% with or • Culture/sensitivity
without PaCO2 < 50 • Comprehensive
mmHg when breathing Metabolic Profile
room air = respiratory
• Assess for electrolyte
failure
disturbances, diabetes
• Chest x-ray • Albumin to assess
• Look for complications nutrition
• Pneumonia
• Alternative diagnoses
PLACE OF RX

• Home?
• Hospital admission?
• Floor?
• ICU?

GOLD Pocket Guide to COPD Diagnosis, Management, and Prevention

 Indications for Hospital
Admission
• Marked increase in intensity of symptoms such as
sudden development of resting dyspnea
• Severe background COPD
• Onset of new physical signs
• Cyanosis, peripheral edema
• Failure of exacerbation to respond to initial
medical management
• Significant co-morbidities
• Newly occurring arrhythmias
• Diagnostic uncertainty
• Older age
• Insufficient home support
Indications for ICU
Admission
• Severe dyspnea that responds inadequately to
initial emergency therapy
• Confusion, lethargy, coma
• Persistent or worsening hypoxemia (PaO2 < 40
mm Hg) and/or
• Severe/worsening hypercapnia (PaCO2 > 60
mm Hg) and/or
• Severe/worsening respiratory acidosis (pH <
7.25) despite supplemental oxygen and NIPPV

• NIPPV = non-invasive positive pressure ventilation

Management of
Exacerbations
• Risk of dying from an
exacerbation is closely related
to:
• Development of respiratory
acidosis
• Presence of significant co-
morbidities
• Need for ventilatory support
 Severe Exacerbation,
Non Life Threatening
• Assess severity of symptoms
• Obtain arterial blood gas and chest x-ray
• Administer controlled oxygen therapy
• Repeat ABG after 30 minutes
• Bronchodilators
• Glucocorticosteroids
• Consider antibiotics
• Consider non-invasive mechanical
ventilation
• Monitor fluid balance and nutrition
• Consider subcutaneous heparin therapy
• Identify and treat associated conditions
(CHF, arrhythmias)
 Management of COPD
Exacerbations
• Controlled oxygen therapy
• Administer enough to maintain PaO2 > 60 mmHG
or SaO2 > 90%
• Monitor patient closely for CO2 retention or
acidosis
• Bronchodilators (inhaled)
• Increase doses or frequency
• Combine ß2 agonists and anticholinergics
• Use spacers or air-driven nebulizers
• Consider adding IV methylxanthine
(aminophylline) if needed
 Management of COPD
Exacerbations
• Glucocorticosteroids (oral or IV)
• Recommended as an addition to bronchodilator therapy
• If baseline FEV1 < 50% predicted
• 30-40 mg oral prednisolone x 7-10 days OR nebulized
budesonide (Pulmicort™)
• Antibiotics
• IF breathlessness and cough are increased AND sputum
is purulent and increased in volume
• Choice of antibiotics should reflect local antibiotic
sensitivity for the following microbes:
• S. pneumoniae
• H. influenzae
• M. catarrhalis
Management of COPD
Exacerbations

• Manual or mechanical chest

percussion and postural
drainage may be beneficial in
patients producing > 25 mL
sputum per day OR with lobar
atelectasis.
 Management of COPD
Exacerbations
• Ventilatory Support
• Decrease mortality and morbidity
• Relieve symptoms
• Used most commonly in Stage IV, Very
Severe COPD
• Forms:
• Non-invasive using negative or positive
pressure devices
• invasive/mechanical with oro- or naso-tracheal
tube OR tracheostomy
NIPPV

• Success rates of 80-85%

• Increases pH, reduces PaCO2,
reduces severity of
breathlessness
• Decreases length of hospital stay
• Decreases mortality/intubation
rate
NIPPV (C-PAP, Bi-PAP)

• Selection criteria
• Moderate to severe dyspnea with
use of accessory muscles and
paradoxical abdominal motion
• Moderate to severe acidosis (pH <
7.35) and hypercapnia (PaCO2 > 45
mmHg)
• Respiratory frequency > 25
breaths/minute
 NIPPV
• Exclusion criteria
• Respiratory arrest
• Cardiovascular instability
• Hypotension
• Arrhythmias
• Myocardial infarction
• Somnolence, impaired mental status, lack
of cooperation
• High aspiration risk – viscous/copius
secretions
• Recent facial or gastroesophageal surgery
• Cranio-facial trauma, fixed nasopharyngeal
abnormalities
• Extreme obesity
 Indications for Invasive
Mechanical Ventilation
• Severe dyspnea with use of accessory muscles and
paradoxical abdominal motion
• Respiratory rate > 35 breaths/minute
• Life-threatening hypoxemia: PaO2 < 40 mm Hg
• Severe acidosis (pH < 7.25) and hypercapnia
(PaCO2 > 60 mm Hg)
• Respiratory arrest
• Somnolence, impaired mental status
• Cardiovascular complications
• Hypotension/shock/heart failure
• Other complications
• Metabolic abnormalities/sepsis/pneumonia/pulmonary
embolism/barotrauma/massive pleural effusion
• NIPPV failure
 Use of Invasive Ventilation
in End-Stage COPD
• Hazards:
• Ventilator-acquired pneumonia
• Increased prevalence of multi-resistant organisms
• Barotrauma
• Failure to wean to spontaneous ventilation
• Mortality among COPD patients with
respiratory failure is no greater than
mortality among patients ventilated for non-
COPD reasons
 Discharge Criteria
• Inhaled Beta2-agonist use is at most every 4 hours
• Patient is able to walk across the room
• Patient is able to eat and sleep without frequent
awakening
• Patient has been clinically stable for 12-24 hours
• ABGs are stable for 12-24 hours
• Patient/home caregiver fully understands correct
use of medications
• Follow-up and home care arrangements have been
completed
• Patient, family, and physician are confident that
patient can manage successfully
 Follow-Up Assessment
after Hospital Discharge
• 4-6 weeks after discharge
• Assess:
• Ability to cope in usual environment
• Inhaler technique
• Understanding of recommended treatment
regimen
• Measure FEV1
• Determine need for long-term oxygen
therapy and/or home nebulizer (for
patients with very severe COPD, Stage
IV)
THANK YOU
REFERENCES
• National Heart, Lung, and Blood Institute Data
Fact Sheet for Chronic Obstructive Pulmonary
Disease
• GOLD (Global Initiative for Chronic Obstructive
Lung Disease) Executive Summary, April 2001
• GOLD Pocket Guide to COPD Diagnosis,
Management, and Prevention. A Guide for Health
Care Professionals. Updated July 2005.
www.goldcopd.org – Accessed August 21, 2006.
• Fiore MC, Bailey WC, Cohen SJ, et. al. Treating
Tobacco Use and Dependence. Quick Reference
Guide for Clinicians. Rockville, MD: U.S.
Department of Health and Human Services. Public
Health Service. October 2000.