ASTHMA/ COPD

CASE

• En. M, a 38 years old Malay gentleman from Pasir Tumboh • Construction worker ≈ 20 years• Smoker – 20cigarettes/ day for 22 years (22 packs/ year)• Came to A&E on 27th August 2010 with complaint of severe

breathlessness since early morning (≈3 am).– Sudden onset– Not relieve by MDI salbutamol ( X 3 doses)– Not able to speak– a/w wheezing and productive cough– No altered in conscious level– Slight better after given neb at A&E

• Since 3 months ago– Noted have on and off SOB and productive cough during early morning, a/w

wheezing. Day time – better/ asymptomatic– Tolerable and not affecting his daily activities

• Similar complaint ≈ 2 weeks ago– Treat as AEBA secondary to pneumonia– Was well on the day of discharge– MDI Combivent 20 mcg BD

MDI Salbutamol 200 mcg PRNMDI Beclomethasone dipropionate 100 mcg TDS

• No heart failure symptoms• No chest pain• No significant LOA/ LOW• No family history of asthma and atopy• House – good ventilation

• O/E– Vital sign

– General

– Specific examⁿ of lung

CHRONIC OBSTRUCTIVE PULMONARY DISEASE(COPD)1. Guidelines of the Global Initiative for Chronic Obstructive Lung

Disease (GOLD) global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease.

2. CPG on the Management of COPD

• Definition– A disease state characterized by airflow limitation

that is not fully reversible.

– The airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases.

COPD stage

Severity Classification by postbronchodilatorspirometricvalues

Classification by symptoms anddisability

I Mild FEV1/FVC < 0.70FEV1 > 80% predicted

Chronic cough + sputum production

II Moderate FEV1/FVC < 0.7050% ≤ FEV1 < 80% predicted

Shortness of breath on exertion

III Severe FEV1/FVC < 0.7030% ≤ FEV1 < 50% predicted

Greater SOB, reduce exercise capacity, repeated exacerbation which have impaired on patient’s quality of life

IV Very severe FEV1/FVC < 0.70FEV1 < 30% predicted orFEV1 < 50% predicted pluschronic respiratory failure

Chronic respi failureQuality of life very appreciably impaired and exacerbation maybe life threatening.

Management of AECOPD

ims:– Relieve symptoms and airflow obstruction

– Maintain adequate oxygenation

– Treat any co-morbid conditions that may contribute to the respiratory deterioration or treat any precipitating factor such as infection

Management of Stable COPD

Aims:– Preventing disease progression– Reducing frequency and severity of exacerbation– Improving exercise tolerance– Improving lung function and general health– Improving patient’s symptoms, e.g. dyspnoea,

cough and tiredness.– Improving quality of life– Reducing mortality.

• The overall approach to managing stable COPD should be characterized by a stepwise increase in the treatment, depending on the severity of the disease

• 3 components– Patient education

– Pharmacological treatment

– Non-pharmacological treatment

• Pharmacological treatment

• Patient education– Improve patients’ skills, ability to cope with illness

and health status

– Smoking• Smoking cessation is the single most effective and cost

effective intervention in most people to reduce the risk of developing COPD and stop its progression. All smokers should be offered smoking cessation interventions.

• Pharmacological– None of the existing medications for COPD has

been shown to modify the long-term decline in lung function that is the hallmark of this disease. Therefore, pharmacotherapy for COPD is used to decrease symptoms and/or complications.

– Bronchodilators• Bronchodilator medications are central to the

symptomatic management of COPD

• They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms

• Beta2-agonists

Anticholinergics

Methylxanthines

Combination therapy

•Availability•Individual response in terms of symptoms relief and side effects

β2-agonist

• Short acting– Salbutamol = inhaler,oral (pill),injection– Terbutaline = inhaler,oral (pill),injection– Levalbuterol = inhaler,nebulizer– Fenoterol = inhaler, nebulizer,oral (syrup)

• Long acting– Formoterol = inhaler,nebulizer– Arformoterol = nebulizer– Salmeterol = inhaler– The duration of action of LABAs is 12 hours or longer

as compared to 4 hours in SABAs.

Side effect

• Fine tremor• Nervous tension• Headache• Muscle cramp• Palpitation• Tachycardia• Arrythmia• Peripheral vasodilation• MI

• Paradoxical bronchospasm (occ severe)•Urticaria •Angioedema•Hypotension•Collapse•Hypokalaemia (high doses)•Disturbance of sleep and behaviour

ANTICHOLINERGIC/ANTIMUSCARINIC

• Short acting– Ipratropium bromide = inhaler,nebulizer

– Oxitropium bromide = inhaler,nebulizer

Long acting– Tiotropium = inhaler

• Mechanism of Action: Ipratropium is a bronchodilator which is a competitive inhibitor of muscarinic cholinergic receptors.

• Act on the muscarinic receptors by blocking their bronchoconstrictor effects and reducing mucus secretions.

Side effect

• Most common– Dry mouth

• Less common– Nausea– Headache

• Rarely– Constipation– Tachycardia– Palpitation– Paradoxical bronchospasm– Urinary retention– Blurred vision– Angle closure glaucoma– Hypersensitivity

reaction(Rash, urticaria, angioedema,pruritus)

Methylxanthines

• Aminophylline – oral,injection

• Theophylline – oral

• relaxation of bronchiole smooth muscle, effects on T-cells & eosinophils, increased mucociliary clearance (all via increase in cAMP)

Side effects

–Tachycardia,palpitation,nausea, GI disturbance, headache, CNS stimulation, insomnia, arrhythmia, convulsion,

–*allergy to ethylenediamine can cause urticaria ,erythema and exfoliative dermatitis

MOA

• Mechanism of Action: inhibition of phosphodiesterase, which results in an increase in cAMP.

• relax the smooth muscle of the bronchi and pulmonary blood vessels.

– Glucocorticosteroids• Regular treatment with inhaled glucocorticosteroids does not

modify the long term decline in FEV1 but has been shown to reduce frequency of exacerbations

• Combination therapy (inhaled glucocorticosteroids + LABA) is more effective than individual components.

• Long term treatment with oral glucocoticosteroids is not recommended

• Inhaled – Beclomethasone– Budesonide– Fluticasone– Triamcinolone

Systemic– Prednisone– methylprednisolone

• Mechanism of Action: – They are anti-inflammatory agents– inhibit the production of cytokines, an effect which reduces

eosinophil infiltration, inhibits macrophage and eosinophil function

– decreases mediator cells in the epithelium, reduces vascular permeability, and reduces the production of leukotrienes.

• Side effects– Osteoporosis– Premature cataract– Muscle weakness and wasting– Diabetes mellitus – Hypertension.– Peptic ulcer– Psychosis– Cushing syndrome

• Others– Vaccines

• Influenza vaccine• Reduce serious illness and death in 50% of patient

– Antibiotics • Not recommended except for treatment of infectious

exacerbations and other bacterial infections– Mucolytics agent

• Patient with viscous sputum may benefit but used are not recommended

– Antitussive• Regular used contraindicated in stable COPD

• Non-pharmacological– Rehabilitation – exercise training, nutrition

counseling, education

– Oxygen therapy – LTOT for patient with chronic respiratory failure

– Surgical intervention – bullectomy and lung transplantation