COPD Management in the Pulmonary Department of the University Hospital of Crete

COPD An effective COPD management includes: a) Assess and Monitor Disease b) Reduce Risk Factors c) Manage Stable COPD d) Manage Exacerbations

COPD: physical findings The physical signs in patients with COPD depend on the degree of airflow limitation, the severity of pulmonary hyperinflation, and body build. Classical signs: a) wheezing during tidal breathing b) prolonged forced expiratory time c) diminished breath sounds d) diaphragmatic excursion These signs are useful indicators of airflow limitation but of no value as guides to severity

COPD: physical findings During exacerbation, the clinical findings depend on: the degree of additional airflow limitation the severity of the underlying COPD the presence of coexisting conditions. The severity of an exacerbation is assessed crudely by: tachypnoea, tachycardia use of accessory respiratory muscles cyanosis, pursed-lip breathing evidence of respiratory muscle dysfunction or fatigue

COPD The classic signs of hypercapnia are inconsistent and unreliable The poor sensitivity of symptoms and signs emphasizes the need for objective measurements If the severity of an exacerbation is in doubt, it should always be assessed in hospital

COPD: investigations (objective measurements) Lung Function Tests : useful not only for the diagnosis but for the assessment of the severity, progression and prognosis as well The FEV1/VC ratio is a relatively sensitive index of mild COPD. In moderate to severe disease, the severity of airflow limitation is best assessed by the FEV1 in relation to reference values

COPD: investigation According to ERS consensus the severity of COPD is estimated based on FEV1. Severity FEV1 (%pred) Mild ≥70 Moderate 50-69 Severe <50

COPD: investigation Routine: FEV1 VC or FVC Bronchodilator response Chest radiograph TLco/Kco

COPD: investigation Moderate or severe: Lung volumes Blood gases Electrocardiogram Ht and Hb Purulent sputum Sputum culture and sensitivity Young patient a1-antitrypsin level Assessment of bullae CT scan

COPD: specific indications Disproportionate dyspnoea: Exercise test MIP MEP Suspected asthma: Bronchoconstrictor response Suspected OSA: Sleep studies

COPD: management/stable Aims: a) to improve symptoms and quality of life b) to reduce the decline of lung function c) to prevent and treat complications d) to increase survival with maintained quality of life e) to avoid or minimize adverse effects of treatment

COPD: management/mild stable Step One: Smoking cessation Protection from or reduction of environmental exposure Annual influenza vaccination Measure FEV1 at least yearly Short-acting bronchodilator when needed

COPD: management /mild stable Dyspnoea Consider and treat other causes of dyspnoea heart failure, muscle weakness Bronchodilators: anticholinergic or b2-agonist Ensure adequate inhaler technique Review at 4-6 weeks: symptom relief or inhaler use ≤ 4/day : review at 6-12 months symptoms persist: switch or add BD review at 4-6 week rehab or other causes

COPD: management of moderate/stable First step plus: Regular treatment with one or more bronchodilators Rehabilitation Inhaled steroids if significant symptoms and lung function response or if repeated exacerbations

COPD:management / rehab Lack of Fitness COPD Dyspnea Immobility Depression Social Isolation

COPD: severe/stable First step plus: Regular treatment with one or more bronchodilators Inhaled glucocorticosteroids if significant symptoms and lung function response or if repeated exacerbations Treatment of complications Rehabilitation Long-term O2 therapy if needed Consider surgical treatments

COPD: causes of acute exacerbation Infection of the tracheobronchial tree (viral) Pneumonia Heart failure or arrhythmias Pulmonary embolism Pneumothorax Inappropriate oxygen administration Drugs/Poor nutritional status Metabolic or other diseases (gast .bleeding)

Case I Mr DJ (69 yrs old) is referred to the emergency department by a general physician for evaluation of COPD exacerbation. The patient had a diagnosis of COPD of mild severity (FEV1 60% pred) 10 months ago and is on treatment with inhaled bronchodilators (b2-agonists) as needed. The patient is febrile (T: 37,5-38,3oC) and he has a productive cough with purulent sputum for the last 2 days. He also refers dyspnea on exertion . PEF 180L/min

COPD: measurements in the emergency room Physical Examination FEV1 Arterial Blood gases : breathing room air: on O2 therapy Chest radiograph White blood cell count Sputum stain/culture Biochemistry (gl, urea, electrolites) Electrocardiogram

Case 1 The physical examination reveals wheezing and diminished breath sounds bilaterally FEV1 :1.8L (68% of pred) ABG: (room air) PO2 67mmHg, PCO2 49mmHg, pH 7.37 Chest x-ray: lung hyperinflation WCC(mm3): 11500 Sputum stain : gram + bac

Case 1 The physician decides that the patient does not meet the criteria for hospital admission. He/she prescribes increases the doses of b2-agonists and adds anticholinergics an antibiotic (amoxycillin/ clavulanic acid) rehabilitation of respiratory system Furthermore he/she advises him to visit the Outpatient Hospital department in two weeks for re-evaluation.(of the progression of the disease)

Case II Mr JR, 72 yrs old, arrives to the emergency department with shortness of breath of three days duration and increased sputum production. The patient had a previous diagnosis of COPD of moderate severity (FEV1 67% pred) and is on regular therapy with inhaled bronchodilators. He has a smoking history of 40 pack years and quit smoking 5 years ago. The resident on call evaluates the patient

COPD: measurements in the emergency room FEV1 Arterial Blood gases : breathing room air: on O2 therapy Chest radiograph White blood cell count Sputum stain/culture Biochemistry (gl, urea, electrolites) Electrocardiogram

Case II RR :26 br/min HR: 115b/min Use of accessory resp muscles Bilateral basal crackles. Wheezing FEV1 0.8 L (30% of predicted) ABG: PaO2 45 mmHg, PaCO2 50 mmHg (21%) On O2 (FIO2 28%) PaO2 57 mmHg, PaCO2 54 mmHg, pH 7.33 X-ray “dirty lungs” WBC: 12000 ECG: atrial fibrillation

CaseII Does the patient meet the criteria for admission;

COPD: indications for admission ↑ in intensity of symptoms Severe background COPD New physical signs (cyanosis, edema) Failure of exacerbation to respond to initial medical management Significant comorbidities Arrhythmias (newly occurring) Diagnostic uncertainty Older age Insufficient home support

COPD: hospital management Goals: a) to evaluate the severity, including life-threatening conditions b) to identify the cause of the exacerbation c) to provide controlled oxygenation d)to return the patient to the best previous condition

Case II Does the patient meet the criteria for severe exacerbetion;

COPD: management in the department Administer controlled O2 therapy Bronchodilators: Antibiotics Steroids Consider noninvasive mechanical ventilation Rehabilitation

COPD: management O2 therapy: low inspired O2: Venturi mask Nasal cannula Reassess with blood gas mesurement after 30 min: Increase FIO2 stepwise Use of NIMV

Case II Does the patient meet the criteria for NIPPV;

COPD: criteria for severe exacerbation History: Previous condition Symptoms: Cough / Sputum Dyspnea at rest Sighs: T>38.8’C, RR>25br/min, HR>110beats/min, Edema Worsening cyanosis Use of accessory muscles Loss of alertness Measurement: PEF<100L/min

COPD: management Criteria for NIPPV: Respiratory asidosis (pH:7.25-7.35, PaCO2> 50-60 mmHg) Moderate to severe dyspnea with use of accessory muscles and paradoxical abdominal motion RR > 25 br/min

COPD: management In addition to standard medical treatment the patients should receive NIPPV on general ward (Plant et al. Lancet 2000 )

COPD: management Bronchodilators: Increase dose or frequency. Combine b2-agonists and anticholinergics. Use spacers or air-driven nebulizers. Consider adding intravenous aminophylline.

COPD: management Antibiotics: Use of Anthonisen’s criteria: increased dyspnoea increased cough increased sputum volume increased sputum purulence

COPD: pathogens/antibiotics viruses streptococcus pneumoniae haemophilus influenzae moraxella catarrhalis Antibiotics: amoxycillin or amoxycillin/clavulanic acid cephalosporines, macrolides quinolones

COPD: management Corticosteroids: Systemic glucorticosteroids are beneficial in the management of acute exacerbations. They shorten recovery time and help to restore lung function more quickly They should be considered in addition to bronchodilators if FEV1<50% pred We use 30-40mg of prednisolone /day for 10-14 days

COPD: management At all times: a) Monitor fluid balance and nutrition b) Consider subcutaneous heparine c) Identify and treat associated conditions: heart failure arrhythmias Closely monitor condition of the patient

COPD: discharge criteria Bronchodilators no more than every 4h Patient is able to eat and sleep without frequent awakening by dyspnea. Patient has been clinically stable for 12-24h Arterial blood gases have been stable for 12-24h Patient (or home caregiver) fully understands correct use of medications

COPD: conclusions I Exacerbations of respiratory symptoms requiring medical intervention are important clinical events in COPD The most common causes are infections and air pollution

COPD: conclusions II Inhaled bronchodilators, systemic steroids and if there is an evidence antibiotics are effective for treatments for acute exacerbations NIPPV in acute exacerbations improves blood gases and pH, reduces in-hospital mortality, decreases the need for IMV and decreases the length of hospital stay