(copd) by irfan ds
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CHRONIC OBSTRUCTIVE
LUNG DISEASE (COPD)Irfan DS
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COPD, a common preventable and treatabledisease, is characterized by persistentairflow limitation that is usually progressiveand associated with an enhanced chronic
inflammatory response in the airways andthe lung to noxious particles or gases.
Definition of COPD
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Mechanisms Underlying
Airflow Limitation in COPD
Small Airways Disease
Airway inflammation
Airway fibrosis, luminal plugs
Increased airway resistance
Parenchymal Destruction
Loss of alveolar attachments
Decrease of elastic recoil
AIRFLOW LIMITATION 2013 Global Initiative for Chronic Obstructive Lung Disease
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Professor Peter J. Barnes, MDNational Heart and Lung Institute, London UK
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Risk Factors for COPD
Genes
Infections
Socio-economic
status
Aging Populations
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Diagnosis and Assessment: Key Points
A clinical diagnosis of COPD should beconsidered in any patient who has dyspnea,
chronic cough or sputum production, and ahistory of exposure to risk factors for thedisease.
Spirometry is requiredto make the diagnosis;the presence of a post-bronchodilator FEV1/FVC< 0.70 confirms the presence of persistent
airflow limitation and thus of COPD.
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SYMPTOMS
chronic cough
shortness of breath
EXPOSURE TO RISKFACTORS
tobaccooccupation
indoor/outdoor pollution
SPIROMETRY: Required to establishdiagnosis
Diagnosis of COPD
sputum
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Spirometry: Normal Trace ShowingFEV1and FVC
1 2 3 4 5 6
1
2
3
4
Volume,
liters
Time, sec
FVC5
1
FEV1= 4L
FVC = 5L
FEV1/FVC = 0.8
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Spirometry: Obstructive Disease
Volume,
liters
Time, seconds
5
4
3
2
1
1 2 3 4 5 6
FEV1= 1.8L
FVC = 3.2L
FEV1/FVC = 0.56
Normal
Obstructive
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Symptoms of COPD
The characteristic symptoms of COPD are chronic andprogressive dyspnea, cough, and sputum production
that can be variable from day-to-day.
Dyspnea: Progressive, persistent and characteristicallyworse with exercise.
Chronic cough: May be intermittent and may beunproductive.
Chronic sputum production: COPD patients commonlycough up sputum.
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Classification of Severity of AirflowLimitation in COPD*
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild FEV1> 80% predicted
GOLD 2: Moderate 50% < FEV1< 80% predicted
GOLD 3: Severe 30% < FEV1< 50% predicted
GOLD 4: Very Severe FEV1< 30% predicted
*Based on Post-Bronchodilator FEV1
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Asthma
Congestif Heart Failure
Bronchiectasis
Differential Diagnosis
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Differential Diagnosis:COPD and Asthma
COPD
Onset in mid-life
Symptoms slowlyprogressive
Long smoking history
ASTHMA
Onset early in life (often
childhood)
Symptoms vary from day to day
Symptoms worse at night/earlymorning
Allergy, rhinitis, and/or eczemaalso present
Family history of asthma
2013 Global Initiative for Chronic Obstructive Lung Disease
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Additional Investigations
Chest X-ray: Seldom diagnostic but valuable to excludealternative diagnoses and establish presence of significantcomorbidities.
Lung Volumes and Diffusing Capacity: Help to characterizeseverity, but not essential to patient management.
Oximetry and Arterial Blood Gases: Pulse oximetry can be
used to evaluate a patients oxygen saturation and need forsupplemental oxygen therapy.
Alpha-1 Antitrypsin Deficiency Screening: Perform when COPDdevelops in patients of Caucasian descent under 45 years or
with a strong family history of COPD.
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Therapeutic Options: Risk Reduction
Encourage comprehensive tobacco-control policies with clear,consistent, and repeated nonsmoking messages.
Emphasize primary prevention, best achieved by elimination or
reduction of exposures in the workplace. Secondaryprevention, achieved through surveillance and early detection,is also important.
Reduce or avoid indoor air pollutionfrom biomass fuel, burned
for cooking and heating in poorly ventilated dwellings.
Advise patients to monitor public announcements of air qualityand, depending on the severity of their disease, avoid vigorousexercise outdoors or stay indoors during pollution episodes.
2013 Global Initiative for Chronic Obstructive Lung Disease
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Therapeutic Options: COPD Medications
Beta2-agonists
Short-acting beta2-agonists
Long-acting beta2-agonists
Anticholinergics
Short-acting anticholinergics
Long-acting anticholinergics
Combination short-acting beta2-agonists + anticholinergic in one inhaler
Methylxanthines
Inhaled corticosteroids
Combination long-acting beta2-agonists + corticosteroids in one inhaler
Systemic corticosteroids
Phosphodiesterase-4 inhibitors
2013 Global Initiative for Chronic Obstructive Lung Disease
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Identification and reduction of exposure to risk factors
are important steps in prevention and treatment.
All COPD patients benefit from rehabilitation andmaintenance of physical activity.
Pharmacologic therapy is used to reduce symptoms,reduce frequency and severity of exacerbations, andimprove health status and exercise tolerance.
Manage Stable COPD: Key Points
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Long-acting formulations of beta2-agonists andanticholinergics are preferred over short-actingformulations. Based on efficacy and side effects,
inhaled bronchodilators are preferred over oralbronchodilators.
Long-term treatment with inhaled corticosteroids added
to long-acting bronchodilators is recommended forpatients with high risk of exacerbations.
Long-term monotherapy with oral or inhaled
corticosteroids is not recommended in COPD.
Manage Stable COPD: Key Points
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An exacerbation of COPD is:
an acute event characterized by aworsening of the patients respiratory
symptoms that is beyond normal day-to-day variations and leads to achange in medication.
Manage Exacerbations
2013 Global Initiative for Chronic Obstructive Lung Disease
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The most common causes of COPD exacerbationsare viral upper respiratory tract infections andinfection of the tracheobronchial tree.
Diagnosis relies exclusively on the clinicalpresentation of the patient complaining of an acutechange of symptoms that is beyond normal day-to-day variation.
The goal of treatment is to minimize the impact ofthe current exacerbation and to prevent thedevelopment of subsequent exacerbations.
Manage Exacerbations: Key Points
2013 Global Initiative for Chronic Obstructive Lung Disease
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Short-acting inhaled beta2-agonists with or withoutshort-acting anticholinergics are usually thepreferred bronchodilators for treatment of an
exacerbation.
Systemic corticosteroids and antibiotics can shortenrecovery time, improve lung function (FEV1) and
arterial hypoxemia (PaO2),
and reduce the risk ofearly relapse, treatment failure, and length ofhospital stay.
COPD exacerbations can often be prevented.
Manage Exacerbations: Key Points
2013 Global Initiative for Chronic Obstructive Lung Disease
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Arterial blood gas measurements (in hospital): PaO2< 8.0 kPawith or without PaCO2> 6.7 kPa when breathing room airindicates respiratory failure.
Chest radiographs: useful to exclude alternative diagnoses.
ECG: may aid in the diagnosis of coexisting cardiac problems.
Whole blood count: identify polycythemia, anemia or bleeding.
Purulent sputumduring an exacerbation: indication to begin
empirical antibiotic treatment.
Biochemical tests: detect electrolyte disturbances, diabetes, andpoor nutrition.
Spirometric tests: not recommended during an exacerbation.
Manage Exacerbations: Assessments
2013 Global Initiative for Chronic Obstructive Lung Disease
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Oxygen: titrate to improve the patients hypoxemia with a target
saturation of 88-92%.
Bronchodilators:Short-acting inhaled beta2-agonists with orwithout short-acting anticholinergics are preferred.
Systemic Corticosteroids: Shorten recovery time, improve lungfunction (FEV1) and arterial hypoxemia (PaO2), and reduce therisk of early relapse, treatment failure, and length of hospitalstay. A dose of 30-40 mg prednisolone per day for 10-14 days is
recommended.
Manage Exacerbations: Treatment Options
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Antibioticsshould be given to patients with:
Three cardinal symptoms: increaseddyspnea, increased sputum volume, and
increased sputum purulence.
Who require mechanical ventilation.
Manage Exacerbations: Treatment Options
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Marked increase in intensity of symptoms
Severe underlying COPD
Onset of new physical signs
Failure of an exacerbation to respond to initialmedical management
Presence of serious comorbidities
Frequent exacerbations
Older age
Insufficient home support
Manage Exacerbations: Indications for
Hospital Admission
2013 Global Initiative for Chronic Obstructive Lung Disease
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2013 Global Initiative for Chronic Obstructive Lung Disease
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