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End of Life
New Definition
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state characterised by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects the lungs, it also produces significant systemic consequences.
ATS/ERS 2004
chronic bronchitis
chronic productive cough for 3 months during each of 2 consecutive years permanent enlargement of the air spaces distal to the terminal bronchioles, without obvious fibrosis
emphysema
introduction
COPD
Little research (? neglect) Few advances in therapy
Revolution in therapy
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines define COPD as a disease state characterized by
Airflow limitation that is not fully reversible, is usually progressive, and Associated with an abnormal inflammatory response of the lungs to inhaled noxious particles or gases
introduction
1 5
2 4
3 6
8 7
9 10
Histopathology of chronic bronchitis showing hyperplasia of mucous glands and infiltration of the airway wall with inflammatory cells
Gross pathology of advanced emphysema. Large bullae are present on the surface of the lung.
At high magnification, loss of alveolar walls and dilatation of airspaces in emphysema can be seen.
Etiology I/II
Immunodeficiency syndromes
Independent risk
Vasculitis syndrome
Hypocomplementemic vasculitis urticaria syndrome (HVUS)
Salla disease
Autosomal recessive storage disorder , sialic acid
Etiology II/II
Prognosis
Pathophysiological changes
At risk
Mild COPD
>0.7
<0.7
>80
>80
Moderate COPD
Severe COPD Very severe COPD
<0.7
<0.7 <0.7
50-80
30-50 <30
SPIROMETRY is not to substitute for clinical judgment in the evaluation of the severity of disease in individual patients.
Characteristic i/ii
Typically combination of signs and symptoms of chronic bronchitis, emphysema, and reactive airway disease.
Systemic manifestations
decreased fat-free mass impaired systemic muscle function Osteoporosis Anemia Depression pulmonary hypertension cor pulmonale left-sided heart failure
Cough worsening dyspnea progressive exercise intolerance sputum production alteration in mental status Productive cough or acute chest illness Breathlessness Wheezing
Hx of more than 40 pack-yrs of smoking was the best single predictor of airflow obstruction
If all 3 signs are absent, airflow obstruction can be nearly ruled out
Self-reported smoking Hx of > 55 pack-yrs Wheezing on auscultation Self-reported wheezing
Characteristic ii/ii
Hyperinflation (barrel chest) Wheezing Frequently heard on forced and unforced expiration Diffusely decreased breath sounds Hyperresonance on percussion
Physical Examination
Emphysema(pink puffers)
thin with a barrel chest little or no cough Breathing may be assisted by pursed lips patients may adopt the tripod sitting position hyperresonant, and wheezing may be heard Distant Heart sounds
Pulmonary Embolism
Differentials diagnosis
ABG
Hypoxemia / hypercapnia Acidosis
Serum Chemistries
Retain sodium /Lower potassium levels /bicarbonate
Chronic respiratory acidosis leads to compensatory metabolic alkalosis
Investigation i/ii
CBC
Secondary polycythemia
Hct>52% in men or 47% in women
Alpha1-Antitrypsin
all patients < 40 yrs or Fm Hx of emphysema at early age
Sputum Evaluation
Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Pseudomonas aeruginosa
Investigation ii/ii
COPD: Hyperinflation, depressed diaphragm, increased retrosternal space, and hypovascularity of lung parenchyma are demonstrated.
Emphysema : increased AP diameter, increased retrosternal airspace, and flattened diaphragm on lateral chest radiograph.
A lung with emphysema shows increased anteroposterior (AP) diameter, increased retrosternal airspace, and flattened diaphragm on posteroanterior chest radiograph
A computed tomography (CT) scan shows hyperlucency due to diffuse hypovascularity and bullae formation, predominantly in the upper lobes.
Severe bullous disease as seen on a computed tomography (CT) scan in a patient with chronic obstructive pulmonary disease (COPD).
treatment
Severity evaluate
Mild to moderate
Hemodynamic stable
bronchodilator
Acute exacerbation
Moderate to severe
Risk for respiratory failure
Accessory muscle used: paradoxical chest/abd motion SpO2 < 90% or PaO2 < 60 mmHg PaCO2 > 45 mmHg or pH < 7.35
Treatment
Treatment
ACUTE EXACERBATION
treatment
Treatment
Acute exacerbation : 1-3 wk onset
Bronchodilator
Beta2-agonist Anticholinergic Methylxantine
Corticosteroid
Systemic corticosteroids
Oxygen
Antibiotic
Cover Streptococcus pneumoniae, Hemophilus influenza, Morexella catarrhalis, Klebsiella pneumoniae ; Pseudomonas aeruginosa
Machanical ventilation
Non-invasive positive pressure ventilation: NIPPV Invasive mechanical ventilation
Short acting Beta2-agonist is first line but recommended combine of SABA and Anticholinergic for limited S/E (palpitation, tachycardia, tremor)
Fenoterol/Ipratropium bromide Every 15-20 min in 1st hour then 4-6 hr interval Addition SABA every 1-2 hr
Treatment
Medication Beta2agonist
type Short
drug Salbutamol(ventolin) Terbutaline Fenoterol Procaterol Salmeterol Formoterol Ipratopium bromide Tiotropium (Spiriva) Theophylline Aminophylline
8-12 Long Anticholinergic Short Long 30-45 10-15 5 > 12 6-8 >24
Methylxanthine
bronchodilator
Systemic corticosteroid
Treatment
Oxygen
All pt with SpO2 < 90% keep SpO2 9094%
Treatment
Machanical ventilation
Indication of NIV
accessory muscle with abd paradox Acidosis pH 7.25-7.35 and/or PaCO2 > 45 mmHg RR > 24 / min
C/I of NIV
Uncooperation Cardiovascular instability Life-threatening hypoxemia Severe acidosis : pH < 7.25
Treatment
Mechanical ventilation
Indication of Invasive mechanical ventilation
Respiratory failure
with
C/I for NIV Fail NIV
Treatment
STABLE COPD
treatment
Treatment
Stable COPD : base on severity
Bronchodilator
Beta2-agonist Anticholinergic Methylxantine
Corticosteroid
inhaled corticosteroids
Vaccination
Annual influenza vaccine Pneumococcal vaccination
Pulmonary rehabilitation
Improve quality of life
Oxygen therapy
Short term Long term
surgery
Treatment
Medication Beta2agonist
type Short
drug Salbutamol(ventolin) Terbutaline Fenoterol Procaterol Salmeterol Formoterol Ipratopium bromide Tiotropium (Spiriva) Theophylline Aminophylline
8-12 Long Anticholinergic Short Long 30-45 10-15 5 > 12 6-8 >24
Methylxanthine
bronchodilator
Pulmonary rehabilitation
Oxygen therapy
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