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

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

3. 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

4. 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

5. 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

6. 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

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

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

9. 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

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

11. 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

12. 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

13. 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

14. 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

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

16. 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

17. 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)

18. 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

19. 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

20. 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

21. 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)

22. 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

23. 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

24. 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

25. CaseII
Does the patient meet the criteria for admission;

26. 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

27. 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

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

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

30. 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

31. Case II
Does the patient meet the criteria for NIPPV;

32. 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

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

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

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

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

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

38. 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 days

39. 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

40. 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

41. 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

42. 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