copd and pneu
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N522: Primary Care III
COPDBy
J. Patterson Johnson, Ed.D, FNP
Primary Source: Global Initiative for COPD,WWW.GOLDCOPD.COM (2009 expert panel’srecommendations)
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OVERVIEW
COPD (chr. Obstr.pulmonary disease)
4th leading cause of death & morbidity
in the U.S.
Mortality ’s with age, men > women
Symptoms manifest after significantlung tissue damage
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DEFINITION
American Thoracic Society: “Air flowobstruction caused by chronic bronchitis
or emphysema; the airflow obstructionis generally progressive,may beaccompanied by airway
hyperactivity,and may be partiallyreversible”
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DEFINITIONS [CONT]
Emphysema - Abnormal permanentstretching of the alveoli with destruction
of their walls which results in airtrapping.
Chronic bronchitis - excessive sputum
production/recurrent cough on mostdays for more that 3 mons. /yr.for atleast 2 consecutive yrs.
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DEFINITION [CONT.]
THE GOLD report defines COPD as “A disease state characterized by airflow
limitation that is not fully reversible.The airflow limitation is usually bothprogressive and associated with an
abnormal inflammatory response of thelungs to noxious particles or gases
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CAUSES OF AIRFLOWLIMITATION
IRREVERSIBLE CAUSES:
fibrosis & narrowing of the airways
Loss of elastic recoil due to alveolardestruction
Destruction of alveolar support thatmaintains patency of small airways.
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CAUSES OF AIRFLOWLIMITATION [CONT.]
Reversible:
Accumulation of inflammatory cells,
mucus, and plasma exudate in bronchi
Smooth muscle contraction in peripheraland central airways
Dynamic hyperinflation during exercise
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RISK FACTORS
Cigarette smoking (primary cause)
1 -antitrypsin deficiency -- an inherited
disorder
Occupational dusts & chemical
Infections
Socioeconomic status
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CLINICAL MANIFESTATIONS
Chronic cough, chronic sputumproduction, dyspnea, and history of
exposure to risk factors. As a rule cough is the earliest symptom
of COPD
chronic sputum production suggestCOPD regardless of the pattern
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CLINICAL MANIFESTATION[cont.]
Dyspnea that is persistent, worsensover time, and worsens with resp.
infections or exercise is alsocharacteristic of COPD.
Even patients without dyspnea, but with
a chronic cough, sputum productionand risk factors should be screenedwith pulmonary function tests
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PHYSICAL FINDINGS - Advanced Disease
Emphysema - thin, muscle wasting,increased use of accessory resp.
muscles. Reduced diaphragramaticexcursion, barrel chest diminishedbreath sounds, no clubbing no cyanosis.
Chronic bronchitis - overweight,cyanosis, copious sputum, wheezes,crackles at the bases
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DIFFERENTIAL DIAGNOSIS
Asthma, TB, congestive heart failure,bronchiectasis, obliterative bronchiolitis
Studies show that COPD is most oftenmisdiagnosed for asthma
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DIFFERENTIAL DIAGNOSISFeatures
COPD: Onset in mid-life
Symptoms slowly progressive
Long smoking history
Dyspnea during exercise
largely irreversible airflow limitation
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DIFFERENTIAL DIAGNOSISFeatures
ASTHMA: Onset early in life
Symptoms vary from day to day
Symptoms at night & early morning
Allergy, rhinitis, & or eczema alsopresent
Family history of asthma
largely reversible air flow
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DIFFERENTIAL DIAGNOSISFeatures
CHF: fine basilar crackles onauscultation
CXR shows dilated heart, pulmonaryedema
PFTs indicate volume restriction not
airflow limitation
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DIFFERENTIAL DIAGNOSISFeatures
BRONCHIECTASIS: Large volumes of purulent sputum
commonly associated with bacterialinfection
Coarse crackles on auscultation
CXR/CT shows bronchial wall thickening
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DIFFERENTIAL DIAGNOSISFeatures
TUBERCULOSIS: Onset all ages
CXR shows lung infiltrate or nodular
lesions
Microbial confirmation
High local prevalence of TB
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DIFFERENTIAL DIAGNOSISFeatures
OBLITERATIVE BRONCHIOLITIS:Onset in younger age, nonsmokers
May have history of rheumatoid arthritisor fume exposure
CT scan on expiration shows hypodense
areas
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LABORATORY STUDIES
Pulmonary function tests - spirometry,static lung volumes, and single breath
maximal diffusion capacity of carbonmonoxide (DlCOSB)
Spirometry - FEV1, FVC, FEV1 / FVC
Static lung volume - TLC, FRC, RV
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LAB. STUDIES [cont.]
DLCOSB -measures the rate at which cois taken up by hemoglobin in the
pulmonary capillaries CXR -excludes other diagnoses and
helps diagnosis if bullous disease
ABG’S Alpha-1 antitrypsin deficiency screening
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CLASSIFICATIONPost-Bronchodilator
Stage I: Mild -FEV1/FVC < 0.70; FEV1 ≥ 80%predicted
Stage II: Moderate – FEV1/FVC <0.70; 50%≤ FEV1 < 80% predicted
Stage III: Severe - FEV1/FVC < 0.70; 30% ≤FEV1 <50% predicted
Stage IV: Very severe – FEV1/FVC < 0.70;FEV1 < 30% predicted or FEV1 <50%predicted, plus chronic resp. failure
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DISEASE MANAGEMENT
Treatment modalities - Education,pharmacotherapy, rehabilitation,and
oxygen administration. Education - smoking cessation,
reduction of risk factors, use of
medication, recognition of exacerbation,and reduction of dyspnea
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DISEASE MANAGEMENT
Education in the last stage of COPDshould include instruction on: disease
complication, oxygen therapy, and endof life decisions (advanced directives)
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KEY POINTS: STRATEGIES TOHELP PT. QUIT
systematically identify all tobacco usersat every visit
strongly urge all tobacco users to quit
determine willingness to make quitattempt
Aid the patient in quitting
Schedule follow-up contact
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DISEASE MANAGEMENT[cont]
Pharmacotherapy -
Note: Studies show that none of the
existing meds for COPD serve to modifythe long term decline in lung functionthat is the hallmark of the disease.
Pharmacotherapy is used to decreasesymptoms and or/complications
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DISEASE MANAGEMENT[cont.]
Medications - Bronchodilators arecentral to the symptomatic
management of COPD. They are givenon an as needed basis or on a regularbasis to prevent or reduce symptoms.
Principal bronchodilator treatments arebeta2 -agonists, anticholinergics,theophylline, and combo of these drugs
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DISEASE MANAGEMENT[cont.]
Inhalation is the preferred route of bronchodilators
To improve delivery, breath-activateddevices or spacers should be used
Routine use of nebulizers for medication
administration is discouraged becauseof the added cost.
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DISEASE MANAGEMENT[cont.]
The long-acting beta2-agonistsalmeterol significantly improves health
status and is more convenient than theshort-acting eg. Albuterol
the anticholinergic ipratropium
(atrovent) also improves health statusbut requires frequent dosing
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DISEASE MANAGEMENT[cont.]
Combination therapy using a fixed ratioof short-acting beta2-agonist and
ipratropium have been shown to haveenhanced effects.
Theophylline although effective is no
longer considered a first-line drug. Thisis due the higher rate of adversereaction and toxicity.
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DISEASE MANAGEMENT[cont.]
Steroid use is controversial.Glococorticosteroids may be helpful
during exacerbation but less effectivefor routine management.
Glucocorticosteroid Reversibility Testing
glucocorticosteroid be added tobronchodilator for a 6-12 week trial
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DISEASE MANAGEMENT[cont.]
Determine benefit of steroid bycomparing FEV1 at end of trial with
baseline. Positive response = FEV1 increase of
200ml and 15% above bronchodilator
baseline
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DISEASE MANAGEMENT[cont.]
Other Meds - antibiotics (prophylacticantibiotics use is not supported in Lit.),
vaccines, alpha1- antitrypsinaugmentation.
Rehabilitation; recommended for all
stages. Components - exercise training,counseling, and education.
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DISEASE MANAGEMENT[cont.]
Oxygen therapy has been found toimprove survival as well as mental and
physical status. Should be reserved for patients with
severe COPD.
Indication is by waking PaO2 ordesaturation during activity.
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DISEASE MANAGEMENT[cont.]
Indication for O2 -
PaO2 < 55 mm Hg or SaO2 < 88% at
rest; PaO2 < 55 mm Hg or SaO2 <89%with exercise or during sleep; PaO2 bet.55- 60 mm Hg or SaO2 < 89% with
evidence of pulmonary hypertension orcor pulmonale
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DISEASE MANAGEMENT[cont.]
Surgical Intervention: Lung volumereduction surgery. A large US trial (the
national Emphysema Treatment)started in 1996 and scheduled to end in2003 is in progress.
Lung transplantation may provideopportunity for survival.
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DISEASE MANAGEMENT[cont.]
Exacerbation - Common causes includeresp. infection and air pollution
Signs of exacerbation - accessorymuscle use, worsening or new onset of central cyanosis, dev. Of peripheral
edama, hemodynamic instability, rightheart failure, decreased level of alertness
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DISEASE MANAGEMENT[cont.]
Managing Exacerbation
Increase bronchodilators, initiate
antibiotics if indicated (increasedsputum amount and purulence). Pt.Should be assessed hours after initial
treatment adaptation. If not adequatelyimproved add oral corticosteroid. If noimprovement or worsening, hospitalize
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