copd
DESCRIPTION
COPD. Chronic Obstructive Pulmonary Disease. Chronic Bronchitis Emphysema. Definition. A disease state characterized by airflow limitation that is not fully reversible Conditions include: - PowerPoint PPT PresentationTRANSCRIPT
COPDCOPD
Chronic Obstructive Chronic Obstructive Pulmonary DiseasePulmonary Disease
Chronic BronchitisChronic BronchitisEmphysemaEmphysema
DefinitionDefinitionA disease state characterized by A disease state characterized by airflow airflow
limitation that is not fully reversiblelimitation that is not fully reversibleConditions includeConditions include
bull Emphysema anatomically defined condition Emphysema anatomically defined condition characterized by destruction and characterized by destruction and enlargement of the lung alveolienlargement of the lung alveoli
bull Chronic bronchitis clinically defined Chronic bronchitis clinically defined condition with chronic cough and phlegmcondition with chronic cough and phlegm
bull Small-airways disease condition in which Small-airways disease condition in which small bronchioles are narrowedsmall bronchioles are narrowed
EpidemiologyEpidemiologybull bull Fourth leading cause of death in the Fourth leading cause of death in the
USUS
bull bull Affects gt 16 million persons in the USAffects gt 16 million persons in the US
bull bull Global Initiative for Chronic Obstructive Global Initiative for Chronic Obstructive Lung Disease (GOLD) estimates Lung Disease (GOLD) estimates suggest that chronic obstructive lung suggest that chronic obstructive lung disease (COLD) will increase from the disease (COLD) will increase from the sixth to the third most common cause of sixth to the third most common cause of death worldwide by 2020death worldwide by 2020
EpidemiologyEpidemiology
gt70 of COLD-related health care gt70 of COLD-related health care expenditures go to emergency expenditures go to emergency department visits and hospital care department visits and hospital care (gt$10 billion annually in the US)(gt$10 billion annually in the US)
EpidemiologyEpidemiology
SexSexHigher prevalence inHigher prevalence in men men probably probably
secondary to smokingsecondary to smokingPrevalence of COLD among Prevalence of COLD among
women is increasing as the gender women is increasing as the gender gap in smoking rates has gap in smoking rates has diminisheddiminished
AgeAgeHigher prevalence with increasing Higher prevalence with increasing
ageagebull Dosendashresponse relationship between Dosendashresponse relationship between
cigarette smoking intensity and cigarette smoking intensity and decreased pulmonary functiondecreased pulmonary function
EpidemiologyEpidemiology
Risk FactorsRisk Factors
11 Cigarette smoking is a major risk Cigarette smoking is a major risk factorfactor
22 Cigar and pipe smokingCigar and pipe smoking33 Passive (secondhand) smokingPassive (secondhand) smoking
1048707 1048707 Associated with reductions in pulmonary Associated with reductions in pulmonary functionfunction
1048707 1048707 Its status as a risk factor for COLD Its status as a risk factor for COLD remains uncertainremains uncertain
Occupational exposures to dust and Occupational exposures to dust and fumes (eg cadmium)fumes (eg cadmium)bull Likely risk factorsLikely risk factors
bull The magnitude of these effects appears The magnitude of these effects appears substantially less important than the substantially less important than the effect of cigarette smokingeffect of cigarette smoking
Ambient air pollutionAmbient air pollutionbull The relationship of air pollution to COLD The relationship of air pollution to COLD
remains unprovenremains unproven
Genetic factorsGenetic factors
bull α1 antitrypsin (α1AT) deficiencyα1 antitrypsin (α1AT) deficiencybull Common M allele normal levelsCommon M allele normal levelsbull S allele slightly reduced levelsS allele slightly reduced levelsbull Z allele markedly reduced levelsZ allele markedly reduced levelsbull Null allele absence of α1AT (rare)Null allele absence of α1AT (rare)bull Lowest levels of α1AT are associated with Lowest levels of α1AT are associated with
incidence of COLD α1AT deficiency interacts incidence of COLD α1AT deficiency interacts with cigarette smoking to increase riskwith cigarette smoking to increase risk
Distributions of forced expiratory volume in 1 s (FEV1)values Distributions of forced expiratory volume in 1 s (FEV1)values in a generalin a generalpopulation sample stratified by pack-years of smoking population sample stratified by pack-years of smoking
EtiologyEtiologyCOLDCOLD
bull Causal relationship between cigarette Causal relationship between cigarette smoking and development of COLD smoking and development of COLD has been proven however the has been proven however the response varies considerably among response varies considerably among individualsindividuals
COLD exacerbationCOLD exacerbation
bull Bacterial infectionsBacterial infections1048707 1048707 Streptococcus pneumoniaeStreptococcus pneumoniae
1048707 1048707 Haemophilus influenzaeHaemophilus influenzae
1048707 1048707 Moraxella catarrhalisMoraxella catarrhalis
1048707 1048707 Mycoplasma pneumoniae Mycoplasma pneumoniae or or Chlamydia Chlamydia pneumoniae pneumoniae (5ndash10 of exacerbations)(5ndash10 of exacerbations)
bull Viral infections (one-third)Viral infections (one-third)bull No specific precipitant identified (20ndash35)No specific precipitant identified (20ndash35)
Symptoms amp SignsSymptoms amp Signs
bull bull 3 most common3 most commonbull CoughCough
bull Sputum productionSputum production
bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Chronic Obstructive Chronic Obstructive Pulmonary DiseasePulmonary Disease
Chronic BronchitisChronic BronchitisEmphysemaEmphysema
DefinitionDefinitionA disease state characterized by A disease state characterized by airflow airflow
limitation that is not fully reversiblelimitation that is not fully reversibleConditions includeConditions include
bull Emphysema anatomically defined condition Emphysema anatomically defined condition characterized by destruction and characterized by destruction and enlargement of the lung alveolienlargement of the lung alveoli
bull Chronic bronchitis clinically defined Chronic bronchitis clinically defined condition with chronic cough and phlegmcondition with chronic cough and phlegm
bull Small-airways disease condition in which Small-airways disease condition in which small bronchioles are narrowedsmall bronchioles are narrowed
EpidemiologyEpidemiologybull bull Fourth leading cause of death in the Fourth leading cause of death in the
USUS
bull bull Affects gt 16 million persons in the USAffects gt 16 million persons in the US
bull bull Global Initiative for Chronic Obstructive Global Initiative for Chronic Obstructive Lung Disease (GOLD) estimates Lung Disease (GOLD) estimates suggest that chronic obstructive lung suggest that chronic obstructive lung disease (COLD) will increase from the disease (COLD) will increase from the sixth to the third most common cause of sixth to the third most common cause of death worldwide by 2020death worldwide by 2020
EpidemiologyEpidemiology
gt70 of COLD-related health care gt70 of COLD-related health care expenditures go to emergency expenditures go to emergency department visits and hospital care department visits and hospital care (gt$10 billion annually in the US)(gt$10 billion annually in the US)
EpidemiologyEpidemiology
SexSexHigher prevalence inHigher prevalence in men men probably probably
secondary to smokingsecondary to smokingPrevalence of COLD among Prevalence of COLD among
women is increasing as the gender women is increasing as the gender gap in smoking rates has gap in smoking rates has diminisheddiminished
AgeAgeHigher prevalence with increasing Higher prevalence with increasing
ageagebull Dosendashresponse relationship between Dosendashresponse relationship between
cigarette smoking intensity and cigarette smoking intensity and decreased pulmonary functiondecreased pulmonary function
EpidemiologyEpidemiology
Risk FactorsRisk Factors
11 Cigarette smoking is a major risk Cigarette smoking is a major risk factorfactor
22 Cigar and pipe smokingCigar and pipe smoking33 Passive (secondhand) smokingPassive (secondhand) smoking
1048707 1048707 Associated with reductions in pulmonary Associated with reductions in pulmonary functionfunction
1048707 1048707 Its status as a risk factor for COLD Its status as a risk factor for COLD remains uncertainremains uncertain
Occupational exposures to dust and Occupational exposures to dust and fumes (eg cadmium)fumes (eg cadmium)bull Likely risk factorsLikely risk factors
bull The magnitude of these effects appears The magnitude of these effects appears substantially less important than the substantially less important than the effect of cigarette smokingeffect of cigarette smoking
Ambient air pollutionAmbient air pollutionbull The relationship of air pollution to COLD The relationship of air pollution to COLD
remains unprovenremains unproven
Genetic factorsGenetic factors
bull α1 antitrypsin (α1AT) deficiencyα1 antitrypsin (α1AT) deficiencybull Common M allele normal levelsCommon M allele normal levelsbull S allele slightly reduced levelsS allele slightly reduced levelsbull Z allele markedly reduced levelsZ allele markedly reduced levelsbull Null allele absence of α1AT (rare)Null allele absence of α1AT (rare)bull Lowest levels of α1AT are associated with Lowest levels of α1AT are associated with
incidence of COLD α1AT deficiency interacts incidence of COLD α1AT deficiency interacts with cigarette smoking to increase riskwith cigarette smoking to increase risk
Distributions of forced expiratory volume in 1 s (FEV1)values Distributions of forced expiratory volume in 1 s (FEV1)values in a generalin a generalpopulation sample stratified by pack-years of smoking population sample stratified by pack-years of smoking
EtiologyEtiologyCOLDCOLD
bull Causal relationship between cigarette Causal relationship between cigarette smoking and development of COLD smoking and development of COLD has been proven however the has been proven however the response varies considerably among response varies considerably among individualsindividuals
COLD exacerbationCOLD exacerbation
bull Bacterial infectionsBacterial infections1048707 1048707 Streptococcus pneumoniaeStreptococcus pneumoniae
1048707 1048707 Haemophilus influenzaeHaemophilus influenzae
1048707 1048707 Moraxella catarrhalisMoraxella catarrhalis
1048707 1048707 Mycoplasma pneumoniae Mycoplasma pneumoniae or or Chlamydia Chlamydia pneumoniae pneumoniae (5ndash10 of exacerbations)(5ndash10 of exacerbations)
bull Viral infections (one-third)Viral infections (one-third)bull No specific precipitant identified (20ndash35)No specific precipitant identified (20ndash35)
Symptoms amp SignsSymptoms amp Signs
bull bull 3 most common3 most commonbull CoughCough
bull Sputum productionSputum production
bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
DefinitionDefinitionA disease state characterized by A disease state characterized by airflow airflow
limitation that is not fully reversiblelimitation that is not fully reversibleConditions includeConditions include
bull Emphysema anatomically defined condition Emphysema anatomically defined condition characterized by destruction and characterized by destruction and enlargement of the lung alveolienlargement of the lung alveoli
bull Chronic bronchitis clinically defined Chronic bronchitis clinically defined condition with chronic cough and phlegmcondition with chronic cough and phlegm
bull Small-airways disease condition in which Small-airways disease condition in which small bronchioles are narrowedsmall bronchioles are narrowed
EpidemiologyEpidemiologybull bull Fourth leading cause of death in the Fourth leading cause of death in the
USUS
bull bull Affects gt 16 million persons in the USAffects gt 16 million persons in the US
bull bull Global Initiative for Chronic Obstructive Global Initiative for Chronic Obstructive Lung Disease (GOLD) estimates Lung Disease (GOLD) estimates suggest that chronic obstructive lung suggest that chronic obstructive lung disease (COLD) will increase from the disease (COLD) will increase from the sixth to the third most common cause of sixth to the third most common cause of death worldwide by 2020death worldwide by 2020
EpidemiologyEpidemiology
gt70 of COLD-related health care gt70 of COLD-related health care expenditures go to emergency expenditures go to emergency department visits and hospital care department visits and hospital care (gt$10 billion annually in the US)(gt$10 billion annually in the US)
EpidemiologyEpidemiology
SexSexHigher prevalence inHigher prevalence in men men probably probably
secondary to smokingsecondary to smokingPrevalence of COLD among Prevalence of COLD among
women is increasing as the gender women is increasing as the gender gap in smoking rates has gap in smoking rates has diminisheddiminished
AgeAgeHigher prevalence with increasing Higher prevalence with increasing
ageagebull Dosendashresponse relationship between Dosendashresponse relationship between
cigarette smoking intensity and cigarette smoking intensity and decreased pulmonary functiondecreased pulmonary function
EpidemiologyEpidemiology
Risk FactorsRisk Factors
11 Cigarette smoking is a major risk Cigarette smoking is a major risk factorfactor
22 Cigar and pipe smokingCigar and pipe smoking33 Passive (secondhand) smokingPassive (secondhand) smoking
1048707 1048707 Associated with reductions in pulmonary Associated with reductions in pulmonary functionfunction
1048707 1048707 Its status as a risk factor for COLD Its status as a risk factor for COLD remains uncertainremains uncertain
Occupational exposures to dust and Occupational exposures to dust and fumes (eg cadmium)fumes (eg cadmium)bull Likely risk factorsLikely risk factors
bull The magnitude of these effects appears The magnitude of these effects appears substantially less important than the substantially less important than the effect of cigarette smokingeffect of cigarette smoking
Ambient air pollutionAmbient air pollutionbull The relationship of air pollution to COLD The relationship of air pollution to COLD
remains unprovenremains unproven
Genetic factorsGenetic factors
bull α1 antitrypsin (α1AT) deficiencyα1 antitrypsin (α1AT) deficiencybull Common M allele normal levelsCommon M allele normal levelsbull S allele slightly reduced levelsS allele slightly reduced levelsbull Z allele markedly reduced levelsZ allele markedly reduced levelsbull Null allele absence of α1AT (rare)Null allele absence of α1AT (rare)bull Lowest levels of α1AT are associated with Lowest levels of α1AT are associated with
incidence of COLD α1AT deficiency interacts incidence of COLD α1AT deficiency interacts with cigarette smoking to increase riskwith cigarette smoking to increase risk
Distributions of forced expiratory volume in 1 s (FEV1)values Distributions of forced expiratory volume in 1 s (FEV1)values in a generalin a generalpopulation sample stratified by pack-years of smoking population sample stratified by pack-years of smoking
EtiologyEtiologyCOLDCOLD
bull Causal relationship between cigarette Causal relationship between cigarette smoking and development of COLD smoking and development of COLD has been proven however the has been proven however the response varies considerably among response varies considerably among individualsindividuals
COLD exacerbationCOLD exacerbation
bull Bacterial infectionsBacterial infections1048707 1048707 Streptococcus pneumoniaeStreptococcus pneumoniae
1048707 1048707 Haemophilus influenzaeHaemophilus influenzae
1048707 1048707 Moraxella catarrhalisMoraxella catarrhalis
1048707 1048707 Mycoplasma pneumoniae Mycoplasma pneumoniae or or Chlamydia Chlamydia pneumoniae pneumoniae (5ndash10 of exacerbations)(5ndash10 of exacerbations)
bull Viral infections (one-third)Viral infections (one-third)bull No specific precipitant identified (20ndash35)No specific precipitant identified (20ndash35)
Symptoms amp SignsSymptoms amp Signs
bull bull 3 most common3 most commonbull CoughCough
bull Sputum productionSputum production
bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
EpidemiologyEpidemiologybull bull Fourth leading cause of death in the Fourth leading cause of death in the
USUS
bull bull Affects gt 16 million persons in the USAffects gt 16 million persons in the US
bull bull Global Initiative for Chronic Obstructive Global Initiative for Chronic Obstructive Lung Disease (GOLD) estimates Lung Disease (GOLD) estimates suggest that chronic obstructive lung suggest that chronic obstructive lung disease (COLD) will increase from the disease (COLD) will increase from the sixth to the third most common cause of sixth to the third most common cause of death worldwide by 2020death worldwide by 2020
EpidemiologyEpidemiology
gt70 of COLD-related health care gt70 of COLD-related health care expenditures go to emergency expenditures go to emergency department visits and hospital care department visits and hospital care (gt$10 billion annually in the US)(gt$10 billion annually in the US)
EpidemiologyEpidemiology
SexSexHigher prevalence inHigher prevalence in men men probably probably
secondary to smokingsecondary to smokingPrevalence of COLD among Prevalence of COLD among
women is increasing as the gender women is increasing as the gender gap in smoking rates has gap in smoking rates has diminisheddiminished
AgeAgeHigher prevalence with increasing Higher prevalence with increasing
ageagebull Dosendashresponse relationship between Dosendashresponse relationship between
cigarette smoking intensity and cigarette smoking intensity and decreased pulmonary functiondecreased pulmonary function
EpidemiologyEpidemiology
Risk FactorsRisk Factors
11 Cigarette smoking is a major risk Cigarette smoking is a major risk factorfactor
22 Cigar and pipe smokingCigar and pipe smoking33 Passive (secondhand) smokingPassive (secondhand) smoking
1048707 1048707 Associated with reductions in pulmonary Associated with reductions in pulmonary functionfunction
1048707 1048707 Its status as a risk factor for COLD Its status as a risk factor for COLD remains uncertainremains uncertain
Occupational exposures to dust and Occupational exposures to dust and fumes (eg cadmium)fumes (eg cadmium)bull Likely risk factorsLikely risk factors
bull The magnitude of these effects appears The magnitude of these effects appears substantially less important than the substantially less important than the effect of cigarette smokingeffect of cigarette smoking
Ambient air pollutionAmbient air pollutionbull The relationship of air pollution to COLD The relationship of air pollution to COLD
remains unprovenremains unproven
Genetic factorsGenetic factors
bull α1 antitrypsin (α1AT) deficiencyα1 antitrypsin (α1AT) deficiencybull Common M allele normal levelsCommon M allele normal levelsbull S allele slightly reduced levelsS allele slightly reduced levelsbull Z allele markedly reduced levelsZ allele markedly reduced levelsbull Null allele absence of α1AT (rare)Null allele absence of α1AT (rare)bull Lowest levels of α1AT are associated with Lowest levels of α1AT are associated with
incidence of COLD α1AT deficiency interacts incidence of COLD α1AT deficiency interacts with cigarette smoking to increase riskwith cigarette smoking to increase risk
Distributions of forced expiratory volume in 1 s (FEV1)values Distributions of forced expiratory volume in 1 s (FEV1)values in a generalin a generalpopulation sample stratified by pack-years of smoking population sample stratified by pack-years of smoking
EtiologyEtiologyCOLDCOLD
bull Causal relationship between cigarette Causal relationship between cigarette smoking and development of COLD smoking and development of COLD has been proven however the has been proven however the response varies considerably among response varies considerably among individualsindividuals
COLD exacerbationCOLD exacerbation
bull Bacterial infectionsBacterial infections1048707 1048707 Streptococcus pneumoniaeStreptococcus pneumoniae
1048707 1048707 Haemophilus influenzaeHaemophilus influenzae
1048707 1048707 Moraxella catarrhalisMoraxella catarrhalis
1048707 1048707 Mycoplasma pneumoniae Mycoplasma pneumoniae or or Chlamydia Chlamydia pneumoniae pneumoniae (5ndash10 of exacerbations)(5ndash10 of exacerbations)
bull Viral infections (one-third)Viral infections (one-third)bull No specific precipitant identified (20ndash35)No specific precipitant identified (20ndash35)
Symptoms amp SignsSymptoms amp Signs
bull bull 3 most common3 most commonbull CoughCough
bull Sputum productionSputum production
bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
EpidemiologyEpidemiology
gt70 of COLD-related health care gt70 of COLD-related health care expenditures go to emergency expenditures go to emergency department visits and hospital care department visits and hospital care (gt$10 billion annually in the US)(gt$10 billion annually in the US)
EpidemiologyEpidemiology
SexSexHigher prevalence inHigher prevalence in men men probably probably
secondary to smokingsecondary to smokingPrevalence of COLD among Prevalence of COLD among
women is increasing as the gender women is increasing as the gender gap in smoking rates has gap in smoking rates has diminisheddiminished
AgeAgeHigher prevalence with increasing Higher prevalence with increasing
ageagebull Dosendashresponse relationship between Dosendashresponse relationship between
cigarette smoking intensity and cigarette smoking intensity and decreased pulmonary functiondecreased pulmonary function
EpidemiologyEpidemiology
Risk FactorsRisk Factors
11 Cigarette smoking is a major risk Cigarette smoking is a major risk factorfactor
22 Cigar and pipe smokingCigar and pipe smoking33 Passive (secondhand) smokingPassive (secondhand) smoking
1048707 1048707 Associated with reductions in pulmonary Associated with reductions in pulmonary functionfunction
1048707 1048707 Its status as a risk factor for COLD Its status as a risk factor for COLD remains uncertainremains uncertain
Occupational exposures to dust and Occupational exposures to dust and fumes (eg cadmium)fumes (eg cadmium)bull Likely risk factorsLikely risk factors
bull The magnitude of these effects appears The magnitude of these effects appears substantially less important than the substantially less important than the effect of cigarette smokingeffect of cigarette smoking
Ambient air pollutionAmbient air pollutionbull The relationship of air pollution to COLD The relationship of air pollution to COLD
remains unprovenremains unproven
Genetic factorsGenetic factors
bull α1 antitrypsin (α1AT) deficiencyα1 antitrypsin (α1AT) deficiencybull Common M allele normal levelsCommon M allele normal levelsbull S allele slightly reduced levelsS allele slightly reduced levelsbull Z allele markedly reduced levelsZ allele markedly reduced levelsbull Null allele absence of α1AT (rare)Null allele absence of α1AT (rare)bull Lowest levels of α1AT are associated with Lowest levels of α1AT are associated with
incidence of COLD α1AT deficiency interacts incidence of COLD α1AT deficiency interacts with cigarette smoking to increase riskwith cigarette smoking to increase risk
Distributions of forced expiratory volume in 1 s (FEV1)values Distributions of forced expiratory volume in 1 s (FEV1)values in a generalin a generalpopulation sample stratified by pack-years of smoking population sample stratified by pack-years of smoking
EtiologyEtiologyCOLDCOLD
bull Causal relationship between cigarette Causal relationship between cigarette smoking and development of COLD smoking and development of COLD has been proven however the has been proven however the response varies considerably among response varies considerably among individualsindividuals
COLD exacerbationCOLD exacerbation
bull Bacterial infectionsBacterial infections1048707 1048707 Streptococcus pneumoniaeStreptococcus pneumoniae
1048707 1048707 Haemophilus influenzaeHaemophilus influenzae
1048707 1048707 Moraxella catarrhalisMoraxella catarrhalis
1048707 1048707 Mycoplasma pneumoniae Mycoplasma pneumoniae or or Chlamydia Chlamydia pneumoniae pneumoniae (5ndash10 of exacerbations)(5ndash10 of exacerbations)
bull Viral infections (one-third)Viral infections (one-third)bull No specific precipitant identified (20ndash35)No specific precipitant identified (20ndash35)
Symptoms amp SignsSymptoms amp Signs
bull bull 3 most common3 most commonbull CoughCough
bull Sputum productionSputum production
bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
EpidemiologyEpidemiology
SexSexHigher prevalence inHigher prevalence in men men probably probably
secondary to smokingsecondary to smokingPrevalence of COLD among Prevalence of COLD among
women is increasing as the gender women is increasing as the gender gap in smoking rates has gap in smoking rates has diminisheddiminished
AgeAgeHigher prevalence with increasing Higher prevalence with increasing
ageagebull Dosendashresponse relationship between Dosendashresponse relationship between
cigarette smoking intensity and cigarette smoking intensity and decreased pulmonary functiondecreased pulmonary function
EpidemiologyEpidemiology
Risk FactorsRisk Factors
11 Cigarette smoking is a major risk Cigarette smoking is a major risk factorfactor
22 Cigar and pipe smokingCigar and pipe smoking33 Passive (secondhand) smokingPassive (secondhand) smoking
1048707 1048707 Associated with reductions in pulmonary Associated with reductions in pulmonary functionfunction
1048707 1048707 Its status as a risk factor for COLD Its status as a risk factor for COLD remains uncertainremains uncertain
Occupational exposures to dust and Occupational exposures to dust and fumes (eg cadmium)fumes (eg cadmium)bull Likely risk factorsLikely risk factors
bull The magnitude of these effects appears The magnitude of these effects appears substantially less important than the substantially less important than the effect of cigarette smokingeffect of cigarette smoking
Ambient air pollutionAmbient air pollutionbull The relationship of air pollution to COLD The relationship of air pollution to COLD
remains unprovenremains unproven
Genetic factorsGenetic factors
bull α1 antitrypsin (α1AT) deficiencyα1 antitrypsin (α1AT) deficiencybull Common M allele normal levelsCommon M allele normal levelsbull S allele slightly reduced levelsS allele slightly reduced levelsbull Z allele markedly reduced levelsZ allele markedly reduced levelsbull Null allele absence of α1AT (rare)Null allele absence of α1AT (rare)bull Lowest levels of α1AT are associated with Lowest levels of α1AT are associated with
incidence of COLD α1AT deficiency interacts incidence of COLD α1AT deficiency interacts with cigarette smoking to increase riskwith cigarette smoking to increase risk
Distributions of forced expiratory volume in 1 s (FEV1)values Distributions of forced expiratory volume in 1 s (FEV1)values in a generalin a generalpopulation sample stratified by pack-years of smoking population sample stratified by pack-years of smoking
EtiologyEtiologyCOLDCOLD
bull Causal relationship between cigarette Causal relationship between cigarette smoking and development of COLD smoking and development of COLD has been proven however the has been proven however the response varies considerably among response varies considerably among individualsindividuals
COLD exacerbationCOLD exacerbation
bull Bacterial infectionsBacterial infections1048707 1048707 Streptococcus pneumoniaeStreptococcus pneumoniae
1048707 1048707 Haemophilus influenzaeHaemophilus influenzae
1048707 1048707 Moraxella catarrhalisMoraxella catarrhalis
1048707 1048707 Mycoplasma pneumoniae Mycoplasma pneumoniae or or Chlamydia Chlamydia pneumoniae pneumoniae (5ndash10 of exacerbations)(5ndash10 of exacerbations)
bull Viral infections (one-third)Viral infections (one-third)bull No specific precipitant identified (20ndash35)No specific precipitant identified (20ndash35)
Symptoms amp SignsSymptoms amp Signs
bull bull 3 most common3 most commonbull CoughCough
bull Sputum productionSputum production
bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
AgeAgeHigher prevalence with increasing Higher prevalence with increasing
ageagebull Dosendashresponse relationship between Dosendashresponse relationship between
cigarette smoking intensity and cigarette smoking intensity and decreased pulmonary functiondecreased pulmonary function
EpidemiologyEpidemiology
Risk FactorsRisk Factors
11 Cigarette smoking is a major risk Cigarette smoking is a major risk factorfactor
22 Cigar and pipe smokingCigar and pipe smoking33 Passive (secondhand) smokingPassive (secondhand) smoking
1048707 1048707 Associated with reductions in pulmonary Associated with reductions in pulmonary functionfunction
1048707 1048707 Its status as a risk factor for COLD Its status as a risk factor for COLD remains uncertainremains uncertain
Occupational exposures to dust and Occupational exposures to dust and fumes (eg cadmium)fumes (eg cadmium)bull Likely risk factorsLikely risk factors
bull The magnitude of these effects appears The magnitude of these effects appears substantially less important than the substantially less important than the effect of cigarette smokingeffect of cigarette smoking
Ambient air pollutionAmbient air pollutionbull The relationship of air pollution to COLD The relationship of air pollution to COLD
remains unprovenremains unproven
Genetic factorsGenetic factors
bull α1 antitrypsin (α1AT) deficiencyα1 antitrypsin (α1AT) deficiencybull Common M allele normal levelsCommon M allele normal levelsbull S allele slightly reduced levelsS allele slightly reduced levelsbull Z allele markedly reduced levelsZ allele markedly reduced levelsbull Null allele absence of α1AT (rare)Null allele absence of α1AT (rare)bull Lowest levels of α1AT are associated with Lowest levels of α1AT are associated with
incidence of COLD α1AT deficiency interacts incidence of COLD α1AT deficiency interacts with cigarette smoking to increase riskwith cigarette smoking to increase risk
Distributions of forced expiratory volume in 1 s (FEV1)values Distributions of forced expiratory volume in 1 s (FEV1)values in a generalin a generalpopulation sample stratified by pack-years of smoking population sample stratified by pack-years of smoking
EtiologyEtiologyCOLDCOLD
bull Causal relationship between cigarette Causal relationship between cigarette smoking and development of COLD smoking and development of COLD has been proven however the has been proven however the response varies considerably among response varies considerably among individualsindividuals
COLD exacerbationCOLD exacerbation
bull Bacterial infectionsBacterial infections1048707 1048707 Streptococcus pneumoniaeStreptococcus pneumoniae
1048707 1048707 Haemophilus influenzaeHaemophilus influenzae
1048707 1048707 Moraxella catarrhalisMoraxella catarrhalis
1048707 1048707 Mycoplasma pneumoniae Mycoplasma pneumoniae or or Chlamydia Chlamydia pneumoniae pneumoniae (5ndash10 of exacerbations)(5ndash10 of exacerbations)
bull Viral infections (one-third)Viral infections (one-third)bull No specific precipitant identified (20ndash35)No specific precipitant identified (20ndash35)
Symptoms amp SignsSymptoms amp Signs
bull bull 3 most common3 most commonbull CoughCough
bull Sputum productionSputum production
bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Risk FactorsRisk Factors
11 Cigarette smoking is a major risk Cigarette smoking is a major risk factorfactor
22 Cigar and pipe smokingCigar and pipe smoking33 Passive (secondhand) smokingPassive (secondhand) smoking
1048707 1048707 Associated with reductions in pulmonary Associated with reductions in pulmonary functionfunction
1048707 1048707 Its status as a risk factor for COLD Its status as a risk factor for COLD remains uncertainremains uncertain
Occupational exposures to dust and Occupational exposures to dust and fumes (eg cadmium)fumes (eg cadmium)bull Likely risk factorsLikely risk factors
bull The magnitude of these effects appears The magnitude of these effects appears substantially less important than the substantially less important than the effect of cigarette smokingeffect of cigarette smoking
Ambient air pollutionAmbient air pollutionbull The relationship of air pollution to COLD The relationship of air pollution to COLD
remains unprovenremains unproven
Genetic factorsGenetic factors
bull α1 antitrypsin (α1AT) deficiencyα1 antitrypsin (α1AT) deficiencybull Common M allele normal levelsCommon M allele normal levelsbull S allele slightly reduced levelsS allele slightly reduced levelsbull Z allele markedly reduced levelsZ allele markedly reduced levelsbull Null allele absence of α1AT (rare)Null allele absence of α1AT (rare)bull Lowest levels of α1AT are associated with Lowest levels of α1AT are associated with
incidence of COLD α1AT deficiency interacts incidence of COLD α1AT deficiency interacts with cigarette smoking to increase riskwith cigarette smoking to increase risk
Distributions of forced expiratory volume in 1 s (FEV1)values Distributions of forced expiratory volume in 1 s (FEV1)values in a generalin a generalpopulation sample stratified by pack-years of smoking population sample stratified by pack-years of smoking
EtiologyEtiologyCOLDCOLD
bull Causal relationship between cigarette Causal relationship between cigarette smoking and development of COLD smoking and development of COLD has been proven however the has been proven however the response varies considerably among response varies considerably among individualsindividuals
COLD exacerbationCOLD exacerbation
bull Bacterial infectionsBacterial infections1048707 1048707 Streptococcus pneumoniaeStreptococcus pneumoniae
1048707 1048707 Haemophilus influenzaeHaemophilus influenzae
1048707 1048707 Moraxella catarrhalisMoraxella catarrhalis
1048707 1048707 Mycoplasma pneumoniae Mycoplasma pneumoniae or or Chlamydia Chlamydia pneumoniae pneumoniae (5ndash10 of exacerbations)(5ndash10 of exacerbations)
bull Viral infections (one-third)Viral infections (one-third)bull No specific precipitant identified (20ndash35)No specific precipitant identified (20ndash35)
Symptoms amp SignsSymptoms amp Signs
bull bull 3 most common3 most commonbull CoughCough
bull Sputum productionSputum production
bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Occupational exposures to dust and Occupational exposures to dust and fumes (eg cadmium)fumes (eg cadmium)bull Likely risk factorsLikely risk factors
bull The magnitude of these effects appears The magnitude of these effects appears substantially less important than the substantially less important than the effect of cigarette smokingeffect of cigarette smoking
Ambient air pollutionAmbient air pollutionbull The relationship of air pollution to COLD The relationship of air pollution to COLD
remains unprovenremains unproven
Genetic factorsGenetic factors
bull α1 antitrypsin (α1AT) deficiencyα1 antitrypsin (α1AT) deficiencybull Common M allele normal levelsCommon M allele normal levelsbull S allele slightly reduced levelsS allele slightly reduced levelsbull Z allele markedly reduced levelsZ allele markedly reduced levelsbull Null allele absence of α1AT (rare)Null allele absence of α1AT (rare)bull Lowest levels of α1AT are associated with Lowest levels of α1AT are associated with
incidence of COLD α1AT deficiency interacts incidence of COLD α1AT deficiency interacts with cigarette smoking to increase riskwith cigarette smoking to increase risk
Distributions of forced expiratory volume in 1 s (FEV1)values Distributions of forced expiratory volume in 1 s (FEV1)values in a generalin a generalpopulation sample stratified by pack-years of smoking population sample stratified by pack-years of smoking
EtiologyEtiologyCOLDCOLD
bull Causal relationship between cigarette Causal relationship between cigarette smoking and development of COLD smoking and development of COLD has been proven however the has been proven however the response varies considerably among response varies considerably among individualsindividuals
COLD exacerbationCOLD exacerbation
bull Bacterial infectionsBacterial infections1048707 1048707 Streptococcus pneumoniaeStreptococcus pneumoniae
1048707 1048707 Haemophilus influenzaeHaemophilus influenzae
1048707 1048707 Moraxella catarrhalisMoraxella catarrhalis
1048707 1048707 Mycoplasma pneumoniae Mycoplasma pneumoniae or or Chlamydia Chlamydia pneumoniae pneumoniae (5ndash10 of exacerbations)(5ndash10 of exacerbations)
bull Viral infections (one-third)Viral infections (one-third)bull No specific precipitant identified (20ndash35)No specific precipitant identified (20ndash35)
Symptoms amp SignsSymptoms amp Signs
bull bull 3 most common3 most commonbull CoughCough
bull Sputum productionSputum production
bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Genetic factorsGenetic factors
bull α1 antitrypsin (α1AT) deficiencyα1 antitrypsin (α1AT) deficiencybull Common M allele normal levelsCommon M allele normal levelsbull S allele slightly reduced levelsS allele slightly reduced levelsbull Z allele markedly reduced levelsZ allele markedly reduced levelsbull Null allele absence of α1AT (rare)Null allele absence of α1AT (rare)bull Lowest levels of α1AT are associated with Lowest levels of α1AT are associated with
incidence of COLD α1AT deficiency interacts incidence of COLD α1AT deficiency interacts with cigarette smoking to increase riskwith cigarette smoking to increase risk
Distributions of forced expiratory volume in 1 s (FEV1)values Distributions of forced expiratory volume in 1 s (FEV1)values in a generalin a generalpopulation sample stratified by pack-years of smoking population sample stratified by pack-years of smoking
EtiologyEtiologyCOLDCOLD
bull Causal relationship between cigarette Causal relationship between cigarette smoking and development of COLD smoking and development of COLD has been proven however the has been proven however the response varies considerably among response varies considerably among individualsindividuals
COLD exacerbationCOLD exacerbation
bull Bacterial infectionsBacterial infections1048707 1048707 Streptococcus pneumoniaeStreptococcus pneumoniae
1048707 1048707 Haemophilus influenzaeHaemophilus influenzae
1048707 1048707 Moraxella catarrhalisMoraxella catarrhalis
1048707 1048707 Mycoplasma pneumoniae Mycoplasma pneumoniae or or Chlamydia Chlamydia pneumoniae pneumoniae (5ndash10 of exacerbations)(5ndash10 of exacerbations)
bull Viral infections (one-third)Viral infections (one-third)bull No specific precipitant identified (20ndash35)No specific precipitant identified (20ndash35)
Symptoms amp SignsSymptoms amp Signs
bull bull 3 most common3 most commonbull CoughCough
bull Sputum productionSputum production
bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Distributions of forced expiratory volume in 1 s (FEV1)values Distributions of forced expiratory volume in 1 s (FEV1)values in a generalin a generalpopulation sample stratified by pack-years of smoking population sample stratified by pack-years of smoking
EtiologyEtiologyCOLDCOLD
bull Causal relationship between cigarette Causal relationship between cigarette smoking and development of COLD smoking and development of COLD has been proven however the has been proven however the response varies considerably among response varies considerably among individualsindividuals
COLD exacerbationCOLD exacerbation
bull Bacterial infectionsBacterial infections1048707 1048707 Streptococcus pneumoniaeStreptococcus pneumoniae
1048707 1048707 Haemophilus influenzaeHaemophilus influenzae
1048707 1048707 Moraxella catarrhalisMoraxella catarrhalis
1048707 1048707 Mycoplasma pneumoniae Mycoplasma pneumoniae or or Chlamydia Chlamydia pneumoniae pneumoniae (5ndash10 of exacerbations)(5ndash10 of exacerbations)
bull Viral infections (one-third)Viral infections (one-third)bull No specific precipitant identified (20ndash35)No specific precipitant identified (20ndash35)
Symptoms amp SignsSymptoms amp Signs
bull bull 3 most common3 most commonbull CoughCough
bull Sputum productionSputum production
bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
EtiologyEtiologyCOLDCOLD
bull Causal relationship between cigarette Causal relationship between cigarette smoking and development of COLD smoking and development of COLD has been proven however the has been proven however the response varies considerably among response varies considerably among individualsindividuals
COLD exacerbationCOLD exacerbation
bull Bacterial infectionsBacterial infections1048707 1048707 Streptococcus pneumoniaeStreptococcus pneumoniae
1048707 1048707 Haemophilus influenzaeHaemophilus influenzae
1048707 1048707 Moraxella catarrhalisMoraxella catarrhalis
1048707 1048707 Mycoplasma pneumoniae Mycoplasma pneumoniae or or Chlamydia Chlamydia pneumoniae pneumoniae (5ndash10 of exacerbations)(5ndash10 of exacerbations)
bull Viral infections (one-third)Viral infections (one-third)bull No specific precipitant identified (20ndash35)No specific precipitant identified (20ndash35)
Symptoms amp SignsSymptoms amp Signs
bull bull 3 most common3 most commonbull CoughCough
bull Sputum productionSputum production
bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
COLD exacerbationCOLD exacerbation
bull Bacterial infectionsBacterial infections1048707 1048707 Streptococcus pneumoniaeStreptococcus pneumoniae
1048707 1048707 Haemophilus influenzaeHaemophilus influenzae
1048707 1048707 Moraxella catarrhalisMoraxella catarrhalis
1048707 1048707 Mycoplasma pneumoniae Mycoplasma pneumoniae or or Chlamydia Chlamydia pneumoniae pneumoniae (5ndash10 of exacerbations)(5ndash10 of exacerbations)
bull Viral infections (one-third)Viral infections (one-third)bull No specific precipitant identified (20ndash35)No specific precipitant identified (20ndash35)
Symptoms amp SignsSymptoms amp Signs
bull bull 3 most common3 most commonbull CoughCough
bull Sputum productionSputum production
bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Symptoms amp SignsSymptoms amp Signs
bull bull 3 most common3 most commonbull CoughCough
bull Sputum productionSputum production
bull Exertional dyspnea frequently of long Exertional dyspnea frequently of long durationduration
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
signs and symptomssigns and symptoms Dyspnea at restDyspnea at rest Prolonged expiratory phase andor expiratory wheezing Prolonged expiratory phase andor expiratory wheezing
on lung examinationon lung examination Decreased breath soundsDecreased breath sounds Barrel chestBarrel chest Large lung volumes and poor diaphragmatic excursion Large lung volumes and poor diaphragmatic excursion
as assessed by percussionas assessed by percussion Use of accessory muscles of respirationUse of accessory muscles of respiration Pursed lip breathing (predominantly emphysema)Pursed lip breathing (predominantly emphysema) Characteristic tripod sitting position to facilitate the Characteristic tripod sitting position to facilitate the
actions of the sternocleidomastoid scalene and actions of the sternocleidomastoid scalene and intercostal musclesintercostal muscles
Cyanosis visible in lips and nail bedsCyanosis visible in lips and nail beds
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Systemic wastingSystemic wasting1048707 1048707 Significant weight lossSignificant weight loss1048707 1048707 Bitemporal wastingBitemporal wasting1048707 1048707 Diffuse loss of subcutaneous adipose tissueDiffuse loss of subcutaneous adipose tissue
Paradoxical respirationParadoxical respiration1048707 1048707 Inward movement of the rib cage with inspiration Inward movement of the rib cage with inspiration
(Hoovers sign) in some patients(Hoovers sign) in some patients
Pink puffers are patients with predominant Pink puffers are patients with predominant emphysemamdashno cyanosis or edema with emphysemamdashno cyanosis or edema with decreased breath soundsdecreased breath sounds
Blue bloaters are patients with predominant Blue bloaters are patients with predominant bronchitismdashcyanosis and edemabronchitismdashcyanosis and edema1048707 1048707 Most patients have elements of eachMost patients have elements of each
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Advanced disease signs of cor Advanced disease signs of cor pulmonalepulmonale
1048707 1048707 Elevated jugular venous distentionElevated jugular venous distention
1048707 1048707 Right ventricular heaveRight ventricular heave
1048707 1048707 Third heart sound Third heart sound
1048707 1048707 Hepatic congestionHepatic congestion
1048707 1048707 AscitesAscites
1048707 1048707 Peripheral edemaPeripheral edema
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Differential DiagnosisDifferential Diagnosis11 Congestive heart failureCongestive heart failure22 AsthmaAsthma33 BronchiectasisBronchiectasis44 Obliterative bronchiolitisObliterative bronchiolitis55 PneumoniaPneumonia66 TuberculosisTuberculosis77 AtelectasisAtelectasis88 PneumothoraxPneumothorax99 Pulmonary embolismPulmonary embolism
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
ConsiderationsConsiderations11 COLD is present only if chronic airflow COLD is present only if chronic airflow
obstruction occursobstruction occurs1048707 1048707 Chronic bronchitis without chronic airflow Chronic bronchitis without chronic airflow
obstruction is not COLDobstruction is not COLD
22 AsthmaAsthma1048707 1048707 Reduced forced expiratory volume in 1 second Reduced forced expiratory volume in 1 second
(FEV1) in COLD seldom shows large responses (FEV1) in COLD seldom shows large responses (gt30) to inhaled bronchodilators although (gt30) to inhaled bronchodilators although improvements up to 15 are commonimprovements up to 15 are common
1048707 1048707 Asthma patients can also develop chronic (not fully Asthma patients can also develop chronic (not fully reversible) airflow obstructionreversible) airflow obstruction
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
33 Problems other than COLD should Problems other than COLD should be suspected when hypoxemia is be suspected when hypoxemia is difficult to correct with modest levels difficult to correct with modest levels of supplemental oxygenof supplemental oxygen
44 Lung cancerLung cancer1048707 1048707 Clubbing of the digits is Clubbing of the digits is notnot a sign of a sign of
COLDIn patients with COLD COLDIn patients with COLD development of lung cancer is the most development of lung cancer is the most likely explanation for newly developed likely explanation for newly developed clubbingclubbing
ConsiderationsConsiderations
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Chronic BronchitisChronic Bronchitis
Chronic lower airway inflammationChronic lower airway inflammation
bull Increased bronchial mucus Increased bronchial mucus productionproduction
bull Productive coughProductive cough Urban male smokers gt 30 years oldUrban male smokers gt 30 years old
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Chronic BronchitisChronic Bronchitis
Mucus swelling interfere with ventilationMucus swelling interfere with ventilation Increased COIncreased CO22 decreased 0 decreased 022
CyanosisCyanosis occurs occurs earlyearly in disease in disease Lung disease overworks right ventricleLung disease overworks right ventricle Right heart failure occursRight heart failure occurs RHF produces peripheral edemaRHF produces peripheral edema
Blue Bloater
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
EmphysemaEmphysema
Loss of elasticity in small airwaysLoss of elasticity in small airways Destruction of alveolar wallsDestruction of alveolar walls Urban male smokers gt 40-50 years oldUrban male smokers gt 40-50 years old
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
EmphysemaEmphysema
Lungs lose elastic recoil Lungs lose elastic recoil Retain CORetain CO22 maintain near normal O maintain near normal O22
CyanosisCyanosis occurs occurs latelate in disease in disease Barrel chest (increased AP diameter) Barrel chest (increased AP diameter) Thin wastedThin wasted Prolonged exhalation through pursed lipsProlonged exhalation through pursed lips
Pink Puffer
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
COPD ManagementCOPD Management
OxygenOxygenbull Monitor carefullyMonitor carefully
bull Some COPD patients may Some COPD patients may experience respiratory depression on experience respiratory depression on high concentration oxygenhigh concentration oxygen
Assist ventilations as neededAssist ventilations as needed
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Diagnostic ApproachDiagnostic Approach
Initial assessmentInitial assessment11 History and physical examination (Signs amp History and physical examination (Signs amp
Symptoms)Symptoms)
22 Pulmonary function testing to assess Pulmonary function testing to assess airflow obstructionairflow obstruction
33 Radiographic studiesRadiographic studies
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Assessment of exacerbationAssessment of exacerbation11 HistoryHistory
1048707 1048707 FeverFever
1048707 1048707 Change in quantity and character of sputumChange in quantity and character of sputum
1048707 1048707 ill contactsill contacts
1048707 1048707 Associated symptomsAssociated symptoms
1048707 1048707 Frequency and severity of prior Frequency and severity of prior exacerbationsexacerbations
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Assessment of exacerbation Assessment of exacerbation 22 Physical examinationPhysical examination
1048707 1048707 TachycardiaTachycardia1048707 1048707 TachypneaTachypnea1048707 1048707 Chest examinationChest examination
1048707 1048707 Focal findingsFocal findings1048707 1048707 Air movementAir movement1048707 1048707 SymmetrySymmetry1048707 1048707 Presence or absence of wheezingPresence or absence of wheezing1048707 1048707 Paradoxical movement of abdominal wallParadoxical movement of abdominal wall1048707 1048707 Use of accessory musclesUse of accessory muscles
1048707 1048707 Perioral or peripheral cyanosisPerioral or peripheral cyanosis1048707 1048707 Ability to speak in complete sentencesAbility to speak in complete sentences1048707 1048707 Mental statusMental status
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
33 Radiographic studiesRadiographic studies1048707 1048707 Chest radiography focal findings (pneumonia Chest radiography focal findings (pneumonia
atelectasis)atelectasis)
44 Arterial blood gasesArterial blood gases1048707 1048707 HypoxemiaHypoxemia1048707 1048707 HypercapniaHypercapnia
55 Hospitalization recommended forHospitalization recommended for1048707 1048707 Respiratory acidosis and hypercarbiaRespiratory acidosis and hypercarbia1048707 1048707 Significant hypoxemiaSignificant hypoxemia1048707 1048707 Severe underlying diseaseSevere underlying disease1048707 1048707 Living situation not conducive to careful Living situation not conducive to careful
observation and delivery of prescribed treatmentobservation and delivery of prescribed treatment
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
ABG and oximetryABG and oximetry Although not sensitive they may Although not sensitive they may
demonstrate resting or exertional hypoxemiademonstrate resting or exertional hypoxemia Blood gases provide additional information Blood gases provide additional information
about alveolar ventilation and acidndashbase about alveolar ventilation and acidndashbase status by measuring arterial PCO 2 and pHstatus by measuring arterial PCO 2 and pHbull Change in pH with PCO 2 is 008 units10 mmHg Change in pH with PCO 2 is 008 units10 mmHg
acutely and 003 units10 mmHg in the chronic acutely and 003 units10 mmHg in the chronic statestate
10487071048707
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Laboratory TestsLaboratory Tests11 Elevated hematocrit suggests chronic hypoxemiaElevated hematocrit suggests chronic hypoxemia22 Serum level of α1AT should be measured in some Serum level of α1AT should be measured in some
patientspatientso Presenting at le 50 years of ageo Presenting at le 50 years of ageo Strong family historyo Strong family historyo Predominant basilar diseaseo Predominant basilar diseaseo Minimal smoking historyo Minimal smoking historyo Definitive diagnosis of α1AT deficiency requires PI type o Definitive diagnosis of α1AT deficiency requires PI type
determinationdetermination1048707 1048707 Typically performed by isoelectric focusing of serum which reflects Typically performed by isoelectric focusing of serum which reflects
thethegenotype at the PI locus for the common alleles and many of the rare genotype at the PI locus for the common alleles and many of the rare
PIPIallelesalleles1048707 1048707 Molecular genotyping can be performed for the common PI alleles Molecular genotyping can be performed for the common PI alleles
(M S(M Sand Z)and Z)
33 Sputum gram stain and culture (for COLD exacerbation)Sputum gram stain and culture (for COLD exacerbation)
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
ImagingImagingbull bull Chest radiographyChest radiography
bull Emphysema obvious bullae paucity of Emphysema obvious bullae paucity of parenchymal markings or hyperlucencyparenchymal markings or hyperlucency
bull Hyperinflation increased lung volumes Hyperinflation increased lung volumes flattening of diaphragmflattening of diaphragm
ndash Does not indicate chronicity of changesDoes not indicate chronicity of changes
bull bull Chest CTChest CTbull Definitive test for establishing the Definitive test for establishing the
diagnosis of emphysema but not diagnosis of emphysema but not necessary to make the diagnosisnecessary to make the diagnosis
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Diagnostic ProceduresDiagnostic ProceduresPulmonary function testsspirometryPulmonary function testsspirometry
bull Chronically reduced ratio of FEV1 to forced vital Chronically reduced ratio of FEV1 to forced vital capacity (FVC)capacity (FVC)ndash In contrast to asthma the reduced FEV1 in COLD In contrast to asthma the reduced FEV1 in COLD
seldom shows large responses (gt30) to inhaled seldom shows large responses (gt30) to inhaled bronchodilators although improvements up to 15 bronchodilators although improvements up to 15 are commonare common
bull Reduction in forced expiratory flow ratesReduction in forced expiratory flow ratesbull Increases in residual volumeIncreases in residual volumebull Increases in ratio of residual volume to total Increases in ratio of residual volume to total
lung capacitylung capacitybull Increased total lung capacity (late in the Increased total lung capacity (late in the
disease)disease)bull Diffusion capacity may be decreased in patients Diffusion capacity may be decreased in patients
with emphysemawith emphysema
ElectrocardiographyElectrocardiography bull may detect signs of ventricular hypertrophmay detect signs of ventricular hypertroph
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
ClassificationClassification
GOLD stageGOLD stageClassification based on pathologic Classification based on pathologic
typetype
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
GOLD stageGOLD stage00
1048707 1048707 Severity at riskSeverity at risk1048707 1048707 Symptoms chronic cough sputum productionSymptoms chronic cough sputum production1048707 1048707 Spirometry normalSpirometry normal
II1048707 1048707 Severity mildSeverity mild1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 ge 80 predictedSpirometry FEV1FVC lt 07 and FEV1 ge 80 predicted
IIII1048707 1048707 Severity moderateSeverity moderate1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 50ndash80 predictedSpirometry FEV1FVC lt 07 and FEV1 50ndash80 predicted
IIIIII1048707 1048707 Severity severeSeverity severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry FEV1FVC lt 07 and FEV1 30ndash50 predictedSpirometry FEV1FVC lt 07 and FEV1 30ndash50 predicted
IVIV1048707 1048707 Severity very severeSeverity very severe1048707 1048707 Symptoms with or without chronic cough or sputum productionSymptoms with or without chronic cough or sputum production1048707 1048707 Spirometry Spirometry
FEV1FVC lt 07 and FEV1 lt 30 predicted FEV1FVC lt 07 and FEV1 lt 30 predicted or or FEV1 lt 50 predicted with respiratory failure or signs of right heart failureFEV1 lt 50 predicted with respiratory failure or signs of right heart failure
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Treatment Approach Treatment Approach GeneralGeneral
bull Only 2 interventions have been demonstrated Only 2 interventions have been demonstrated to influence the natural historyto influence the natural history1048707 1048707 Smoking cessationSmoking cessation
1048707 1048707 Oxygen therapy in chronically hypoxemic patientsOxygen therapy in chronically hypoxemic patients
bull All other current therapies are directed at All other current therapies are directed at improving symptoms and decreasing improving symptoms and decreasing frequency and severity of exacerbationsfrequency and severity of exacerbations
bull Therapeutic response should determine Therapeutic response should determine continuation of treatmentcontinuation of treatment
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
BronchodilatorsBronchodilators
bull Used to treat symptomsUsed to treat symptoms
bull The inhaled route is preferredThe inhaled route is preferred
bull Side effects are less than with parenteral Side effects are less than with parenteral deliverydelivery
bull Theophyllline various dosages and Theophyllline various dosages and preparations typical dose 300ndash600 mgd preparations typical dose 300ndash600 mgd adjusted based on levelsadjusted based on levels
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Anticholinergic agentsAnticholinergic agentsbull Trial of inhaled anticholinergics is recommended in Trial of inhaled anticholinergics is recommended in
symptomatic patientssymptomatic patientsbull Side effects are minorSide effects are minorbull Improve symptoms and produce acute improvement Improve symptoms and produce acute improvement
in FEVin FEVbull Do not influence rate of decline in lung functionDo not influence rate of decline in lung functionbull Ipratropium bromide (short-acting anticholinergic) Ipratropium bromide (short-acting anticholinergic)
(Atrovent)(Atrovent)1048707 1048707 Inhaled 30-min onset of action 4-h durationInhaled 30-min onset of action 4-h duration1048707 1048707 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2 Atrovent metered-dose inhaler 18 μg per inhalation 1ndash2
inhalations qidinhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Tiotropium (long-acting anticholinergic) Tiotropium (long-acting anticholinergic) (Spiriva)(Spiriva)1048707 1048707 Spiriva powder via handihaler 18 μg per Spiriva powder via handihaler 18 μg per
inhalation 1 inhalation qdinhalation 1 inhalation qdSymptomatic benefitSymptomatic benefit Long-acting inhaled β-agonists such as Long-acting inhaled β-agonists such as
salmeterol have benefits similar to salmeterol have benefits similar to ipratropium bromideipratropium bromide1048707 1048707 More convenient than short-acting agentsMore convenient than short-acting agents
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Addition of a β-agonist to inhaled anticholinergic Addition of a β-agonist to inhaled anticholinergic therapy provides incremental benefittherapy provides incremental benefitbull Side effectsSide effects
1048707 1048707 TremorTremor
1048707 1048707 TachycardiaTachycardia
Salmetrol (Serevent)Salmetrol (Serevent)1048707 1048707 Powder via diskus 50-μg inhalation every 12 hPowder via diskus 50-μg inhalation every 12 h
Formoterol (Foradil)Formoterol (Foradil)1048707 1048707 Powder via aerolizer 12-μg inhalation every 12 hPowder via aerolizer 12-μg inhalation every 12 h
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Albuterol (short-acting β-agonist) (Proventil Albuterol (short-acting β-agonist) (Proventil HFA Ventolin HFA Ventolin Proventil)HFA Ventolin HFA Ventolin Proventil)1048707 1048707 Metered-dose inhaler (or in nebulizer Metered-dose inhaler (or in nebulizer
solution) 180-μg inhalation every 4ndash6 h as solution) 180-μg inhalation every 4ndash6 h as neededneeded
Combined β-agonistanticholinergic Combined β-agonistanticholinergic albuterolipratropium (albuterolipratropium (Combivent)Combivent)1048707 1048707 Metered-dose inhaler (also available in Metered-dose inhaler (also available in
nebulizer solution) 120 mcg21 μg per nebulizer solution) 120 mcg21 μg per inhalation 1ndash2 inhalations qidinhalation 1ndash2 inhalations qid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Inhaled glucocorticoidsInhaled glucocorticoidsbull Reduce frequency of exacerbations by 25ndash30Reduce frequency of exacerbations by 25ndash30bull No evidence of a beneficial effect for the regular use of No evidence of a beneficial effect for the regular use of
inhaled glucocorticoids on the rate of decline of lung inhaled glucocorticoids on the rate of decline of lung function as assessed by FEV1function as assessed by FEV1
bull Consider a trial in patients with frequent exacerbations Consider a trial in patients with frequent exacerbations (ge2 per year) and those who demonstrate a significant (ge2 per year) and those who demonstrate a significant amount of acute reversibility in response to inhaled amount of acute reversibility in response to inhaled bronchodilatorsbronchodilators
bull Side effectsSide effects1048707 1048707 Increased rate of oropharyngeal candidiasisIncreased rate of oropharyngeal candidiasis
1048707 1048707 Increased rate of loss of bone densityIncreased rate of loss of bone density
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Specific TreatmentsSpecific TreatmentsStable-phase COLD Stable-phase COLD pharmacotherapypharmacotherapy
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
OxygenOxygen
11 Supplemental O2 is the only therapy demonstrated to Supplemental O2 is the only therapy demonstrated to decrease mortalitydecrease mortality
22 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 In resting hypoxemia (resting O2 saturation lt 88 or lt 90 with signs of pulmonary hypertension or right heart failure) with signs of pulmonary hypertension or right heart failure) the use of O2 has been demonstrated to significantly affect the use of O2 has been demonstrated to significantly affect mortalitymortality
33 Supplemental O2 is commonly prescribed for patients with Supplemental O2 is commonly prescribed for patients with exertional hypoxemia or nocturnal hypoxemiaexertional hypoxemia or nocturnal hypoxemia1048707 1048707 The rationale for supplemental O2 in these settings is The rationale for supplemental O2 in these settings is
physiologically sound but benefits are not well substantiatedphysiologically sound but benefits are not well substantiated
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
bull Beclomethasone (QVAR)Beclomethasone (QVAR)1048707 1048707 Metered-dose inhaler 40ndash80 μgspray 40ndash160 μg bidMetered-dose inhaler 40ndash80 μgspray 40ndash160 μg bid
bull Budesonide (Pulmicort)Budesonide (Pulmicort)1048707 1048707 Powder via Turbuhaler 200 μgspray 200 μg inhaled bidPowder via Turbuhaler 200 μgspray 200 μg inhaled bid
bull Fluticasone (Flovent)Fluticasone (Flovent)1048707 1048707 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440 Metered-dose inhaler 44 110 or 220 μgspray 88ndash440
μg inhaled bidμg inhaled bid
bull Triamcinolone (Azmacort)Triamcinolone (Azmacort)1048707 1048707 Metered-dose inhaler via built-in spacer 100 μgspray Metered-dose inhaler via built-in spacer 100 μgspray
100ndash400 μg inhaled bid100ndash400 μg inhaled bid
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Parenteral corticosteroidsParenteral corticosteroids Long-term use of oral glucocorticoids is not recommendedLong-term use of oral glucocorticoids is not recommended Side effectsSide effects
1048707 1048707 Osteoporosis fractureOsteoporosis fracture1048707 1048707 Weight gainWeight gain1048707 1048707 CataractsCataracts1048707 1048707 Glucose intoleranceGlucose intolerance1048707 1048707 Increased risk of infectionIncreased risk of infection
Patients tapered off long-term low-dose prednisone (~10 Patients tapered off long-term low-dose prednisone (~10 mgd) did not experience any adverse effect on the mgd) did not experience any adverse effect on the frequency of exacerbations quality of life or lung functionfrequency of exacerbations quality of life or lung function
On average patients lost ~45 kg (~10 lb) when steroids On average patients lost ~45 kg (~10 lb) when steroids were withdrawnwere withdrawn
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
TheophyllineTheophylline Produces modest improvements in expiratory Produces modest improvements in expiratory
flow rates and vital capacity and a slight flow rates and vital capacity and a slight improvement in arterial oxygen and carbon improvement in arterial oxygen and carbon dioxide levels in dioxide levels in moderatemoderate to severe COPD to severe COPD
Side effectsSide effects1048707 1048707 Nausea (common)Nausea (common)
1048707 1048707 TachycardiaTachycardia
1048707 1048707 TremorTremor
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Other agentsOther agents
11 N-acetyl cysteineN-acetyl cysteine1048707 1048707 Used for its mucolytic and antioxidant Used for its mucolytic and antioxidant
(current clinical trials) properties(current clinical trials) properties
22 Intravenous α1AT augmentation therapy Intravenous α1AT augmentation therapy for patients with severe α1AT deficiencyfor patients with severe α1AT deficiency
33 AntibioticsAntibiotics1048707 1048707 Long-term suppressive or rotating Long-term suppressive or rotating
antibiotics are not beneficialantibiotics are not beneficial
Specific TreatmentsSpecific TreatmentsStable-phase COLD pharmacotherapyStable-phase COLD pharmacotherapy
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Smoking cessationSmoking cessation All patients with COLD should be strongly urged to quit All patients with COLD should be strongly urged to quit
and educated about the benefit of cessation and risks and educated about the benefit of cessation and risks of continuationof continuation
Combining pharmacotherapy with traditional supportive Combining pharmacotherapy with traditional supportive approaches considerably enhances the chances of approaches considerably enhances the chances of successful smoking cessationsuccessful smoking cessation1048707 1048707 BupropionBupropion1048707 1048707 Nicotine replacement (gum transdermal inhaler nasal spray)Nicotine replacement (gum transdermal inhaler nasal spray)1048707 1048707 The US Surgeon General recommendation is for all smokers The US Surgeon General recommendation is for all smokers
considering quitting to be offered pharmacotherapy in the considering quitting to be offered pharmacotherapy in the absence of any contraindicationabsence of any contraindication
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
General medical careGeneral medical care
11 Annual influenza vaccineAnnual influenza vaccine
22 Polyvalent pneumococcal vaccine is Polyvalent pneumococcal vaccine is recommended although proof of recommended although proof of efficacy in COLD patients is not efficacy in COLD patients is not definitivedefinitive
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Pulmonary rehabilitationPulmonary rehabilitation
bull Improves health-related quality of life Improves health-related quality of life dyspnea and exercise capacitydyspnea and exercise capacity
bull Rates of hospitalization are reduced Rates of hospitalization are reduced over 6 to 12 monthsover 6 to 12 months
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Lung volume reduction surgeryLung volume reduction surgeryProduces symptomatic and functional benefit in Produces symptomatic and functional benefit in
selected patientsselected patients1048707 1048707 EmphysemaEmphysema1048707 1048707 Predominant upper lobe involvementPredominant upper lobe involvement
ContraindicationsContraindications1048707 1048707 Significant pleural disease (pulmonary artery systolic Significant pleural disease (pulmonary artery systolic
pressure gt45 mm Hg)pressure gt45 mm Hg)1048707 1048707 Extreme deconditioningExtreme deconditioning1048707 1048707 Congestive heart failureCongestive heart failure1048707 1048707 Other severe comorbid conditionsOther severe comorbid conditions1048707 1048707 FEV1 lt 20 of predicted and diffusely distributed FEV1 lt 20 of predicted and diffusely distributed
emphysema on CT or diffusing capacity for CO lt20 of emphysema on CT or diffusing capacity for CO lt20 of predicted (due to increased mortality)predicted (due to increased mortality)
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Lung transplantationLung transplantation COLD is the leading indicationCOLD is the leading indication CandidatesCandidates
1048707 le1048707 le65 years65 years
1048707 1048707 Severe disability despite maximal medical therapySevere disability despite maximal medical therapy
1048707 1048707 No comorbid conditions such as liver renal or No comorbid conditions such as liver renal or cardiac diseasecardiac disease
1048707 1048707 Anatomic distribution of emphysema and presence of Anatomic distribution of emphysema and presence of pulmonary hypertension are not contraindicationspulmonary hypertension are not contraindications
Unresolved issues include whether single- or Unresolved issues include whether single- or double-lung transplantation is preferreddouble-lung transplantation is preferred
Specific TreatmentsSpecific TreatmentsStable-phase COLD nonpharmacologic therapiesStable-phase COLD nonpharmacologic therapies
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
exacerbation of COPDexacerbation of COPD
The goals of emergency therapyThe goals of emergency therapy correct tissue oxygenationcorrect tissue oxygenation alleviate reversible bronchospasmalleviate reversible bronchospasm treat the underlying etiology of the treat the underlying etiology of the
exacerbation exacerbation
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Administer controlled Administer controlled oxygen therapy oxygen therapy
correct or prevent life-threatening correct or prevent life-threatening hypoxemia PaO2 greater than 60 hypoxemia PaO2 greater than 60 mm Hg or an SaO2 greater than 90 mm Hg or an SaO2 greater than 90 percent percent
Improvement after administration of Improvement after administration of supplemental oxygen may take 20 supplemental oxygen may take 20 to 30 min to achieve a steady state to 30 min to achieve a steady state
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
B 2-AgonistsB 2-Agonists and and anticholinergic anticholinergic agents are first-line therapies in the agents are first-line therapies in the management of acute severe management of acute severe COPD COPD
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
CORTICOSTEROIDSCORTICOSTEROIDS
short course (7 to 14 days) of systemic short course (7 to 14 days) of systemic steroids appears more effective than steroids appears more effective than placebo in improving FEV1 in acute placebo in improving FEV1 in acute severe exacerbations of COPDsevere exacerbations of COPDbull role in mild-to-moderate exacerbations role in mild-to-moderate exacerbations bull Hyperglycemia is the most common Hyperglycemia is the most common
adverse effectadverse effect
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
ANTIBIOTICSANTIBIOTICS
All current guidelines recommend antibiotics if there is evidence All current guidelines recommend antibiotics if there is evidence of infection of infection bull change in change in volume of sputumvolume of sputum and increased and increased purulence of sputumpurulence of sputum
benefits are more apparent in more severe exacerbationsbenefits are more apparent in more severe exacerbations
Antibiotic choices should be directed at the most common Antibiotic choices should be directed at the most common pathogens known to be associated with COPD exacerbationpathogens known to be associated with COPD exacerbationbull Streptococcus pneumoniae Haemophilus influenzaeStreptococcus pneumoniae Haemophilus influenzae and and
Moraxella catarrhalisMoraxella catarrhalis
duration of treatment(3 to 14 days )duration of treatment(3 to 14 days )
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
METHYLXANTHINESMETHYLXANTHINES
theophylline and aminophyllinetheophylline and aminophylline severe exacerbation when other therapy severe exacerbation when other therapy
has failed or in patients already using has failed or in patients already using methylxanthines who have subtherapeutic methylxanthines who have subtherapeutic drug levelsdrug levels
The bronchodilation effect of The bronchodilation effect of aminophylline is limitedaminophylline is limited
therapeutic range is narrowtherapeutic range is narrow
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
IV loading dose IV loading dose 5 to 6 mgkg5 to 6 mgkg usually required to obtain an initial usually required to obtain an initial serum concentration of 8 to serum concentration of 8 to 12 macgmL12 macgmL
In patients who regularly use theophylline In patients who regularly use theophylline a mini-loading dose should be administereda mini-loading dose should be administered (target concentrationndashcurrently assayed concentration) x (target concentrationndashcurrently assayed concentration) x
volume of distribution (ie 05 times ideal body weight in liters)volume of distribution (ie 05 times ideal body weight in liters)bull target concentration should be between 10 and 15 macgmLtarget concentration should be between 10 and 15 macgmL
IV maintenance infusion rate is 02 to 08 mgkg ideal body IV maintenance infusion rate is 02 to 08 mgkg ideal body weight per h weight per h
lower maintenance rates (congestive heart failure or hepatic lower maintenance rates (congestive heart failure or hepatic insufficiency )insufficiency )
raise maintenance rates in patients with higher clearance rates raise maintenance rates in patients with higher clearance rates such as smokers such as smokers
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Summary for ED Summary for ED Management Management
Assess severity of symptom Assess severity of symptom Administer controlled oxygen therapy Administer controlled oxygen therapy Perform arterial blood gasPerform arterial blood gas
bull measurement after 20ndash30 min if SaO2 measurement after 20ndash30 min if SaO2 remains lt90 or if concerned about remains lt90 or if concerned about symptomatic hypercapniasymptomatic hypercapnia
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Administer bronchodilators Administer bronchodilators B2-agonists andor anticholinergic agents by B2-agonists andor anticholinergic agents by
nebulization or MDI with spacernebulization or MDI with spacer
Consider adding intravenous methylxanthine Consider adding intravenous methylxanthine if neededif needed
Add corticosteroids ( Oral or intravenous)Add corticosteroids ( Oral or intravenous) Consider antibiotics Consider antibiotics
bull If increased sputum volume change in sputum If increased sputum volume change in sputum color fever or suspicion of infectious etiology of color fever or suspicion of infectious etiology of exacerbationexacerbation
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Laboratory evaluation Laboratory evaluation Chest x-ray Chest x-ray CBC with differential CBC with differential Electrolytes Electrolytes Arterial blood gases Arterial blood gases ECG as neededECG as needed
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
At all times hellip At all times hellip
Monitor Monitor fluid fluid balance balance Consider subcutaneous Consider subcutaneous heparinheparin
(venous thrombosis prophylaxis) (venous thrombosis prophylaxis) Identify and treat associated conditions Identify and treat associated conditions
(eg heart failure arrhythmias) (eg heart failure arrhythmias) Closely monitor condition of the patientClosely monitor condition of the patient
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Indications for Invasive Indications for Invasive Mechanical Ventilation Mechanical Ventilation
Severe dyspnea with use of accessory Severe dyspnea with use of accessory muscles and paradoxical abdominal motionmuscles and paradoxical abdominal motion
Respiratory frequency gt35 breaths per minRespiratory frequency gt35 breaths per min Life-threatening hypoxemia PaO2 lt50 mm Life-threatening hypoxemia PaO2 lt50 mm
Hg (lt53 kPa) or PaO2FIO2 lt200 mm HgHg (lt53 kPa) or PaO2FIO2 lt200 mm Hg Severe acidosis (pH lt725) and hypercapnia Severe acidosis (pH lt725) and hypercapnia
(PaCO2 gt60 mm Hg or gt80 kPa)(PaCO2 gt60 mm Hg or gt80 kPa) Respiratory arrestRespiratory arrest Somnolence impaired mental statusSomnolence impaired mental status Cardiovascular complications (hypotension Cardiovascular complications (hypotension
shock heart failure)shock heart failure) NIPPV failureNIPPV failure
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Indications for ICUIndications for ICU
Severe dyspnea that responds inadequately Severe dyspnea that responds inadequately to initial emergency therapyto initial emergency therapy
Confusion lethargy comaConfusion lethargy coma Persistent or worsening hypoxemia Persistent or worsening hypoxemia
PaO2 lt50 mm Hg (lt67 kPa)PaO2 lt50 mm Hg (lt67 kPa) Severe or worsening hypercapnia Severe or worsening hypercapnia
PaCO2 gt70 mm Hg (gt93 kPa)PaCO2 gt70 mm Hg (gt93 kPa) Severe or worsening respiratory acidosis Severe or worsening respiratory acidosis
(pH lt730) despite supplemental oxygen and (pH lt730) despite supplemental oxygen and NIPPVNIPPV
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Indications for Hospital Indications for Hospital Admission Admission
Marked increase in intensity of symptoms such as Marked increase in intensity of symptoms such as sudden development of resting dyspneasudden development of resting dyspnea
Severe background of COPDSevere background of COPD Onset of new physical signs (eg cyanosis peripheral Onset of new physical signs (eg cyanosis peripheral
edema)edema) Failure of exacerbation to respond to initial medical Failure of exacerbation to respond to initial medical
managementmanagement Significant comorbiditiesSignificant comorbidities Newly occurring arrhythmiasNewly occurring arrhythmias Diagnostic uncertaintyDiagnostic uncertainty Older ageOlder age Insufficient home supportInsufficient home support
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
discharge to homedischarge to home
(1)(1) adequate supply of home oxygen if adequate supply of home oxygen if neededneeded
(2)(2) adequate and appropriate adequate and appropriate bronchodilator treatmentbronchodilator treatment
(3)(3) short course of oral corticosteroidsshort course of oral corticosteroids
(4)(4) a follow-up with their physician a follow-up with their physician
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
Spacer Devices for Spacer Devices for Metered Dose InhalersMetered Dose Inhalers
Spacer devices have a chamber Spacer devices have a chamber that receives the aerosol before that receives the aerosol before it is inhaledit is inhaled They serve two They serve two functionsfunctions aa) ) to overcome difficulties in to overcome difficulties in coordinating the timing of the coordinating the timing of the inhaler actuation and inhalation inhaler actuation and inhalation
bb) ) to slow down the speed of to slow down the speed of delivery of the aerosol into the delivery of the aerosol into the mouth so that less of the drug mouth so that less of the drug impacts in the throatimpacts in the throat
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection
PreventionPrevention
bull bull SmokingSmoking prevention or prevention or cessationcessationbull bull Prevention of exacerbationsPrevention of exacerbations
bull Long-term suppressive antibiotics are not Long-term suppressive antibiotics are not beneficialbeneficial
bull Inhalation glucocorticoids should be Inhalation glucocorticoids should be considered in patients with frequent considered in patients with frequent exacerbations or in patients with an exacerbations or in patients with an asthmatic componentasthmatic component
bull bull VaccinationVaccination against influenza and against influenza and pneumococcal infectionpneumococcal infection