Copd

based on 2020 GOLD guidelines,,

1. DR.BIPUL THAKUR KMCTH

2. Definition COPD is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.

3. COPD includes 1. Chronic bronchitis: is defines as chronic productive cough onmost days for at least 3 consecutive months in 2 successive years. 2.Emphysema: is defined as dilatation and destruction of air spaces distal to terminal bronchioles without obvious fibrosis.

4. EPIDEMIOLOGY Prevalence directly related to tobacco smoking and use of biomass fuel in low and middle income countries. Current estimates suggest that 80 million people worldwide suffer from moderate to severe disease. A/c to BOLD and other large scale epidemiological studies, it is estimated that no. of COPD cases was 384M in 2010 with global prevalence of 11.7% Globally around 3 million deaths occur annually With increasing prevalence and ageing , COPD prevalence expected to rise over next 40 years and by 2060 there may be 5.4 million deaths annually.

5. RISK FACTORS

6. Clinical features: Dyspnea: - Progressive over time - Characteristically worse with exercise - Persistent Cough: - May be Intermittent or may be unproductive - Recurrent Wheeze Chronic Sputum production: - May be dry or productive - Usually mucoid in nature - Mucopurulent during acute exacerbation

7. Physical signs: Inspection: - Barrel-shaped chest , Accessory respiratory muscle participate ,Prolonged expiration during quiet breathing. Expiration through pursed lips Paradoxical retraction of the lower interspaces during inspiration ( ie , hoover's sign) - Tripod Position

8. Tripod Position Patients with end-stage COPD may adopt positions that relieve dyspnea, such as leaning forward with arms outstretched and weight supported on the palms or elbows.

9. Palpation: Decreased vocal fremitus Percussion : - Hyper resonant - Depressed diaphragm, - Diminution of the area of absolute cardiac dullness.

10. Auscultation: - Vesicular with Prolonged expiration - Reduced breath sounds - The presence of wheezing during quiet breathing - Crackle can be heard if infection exist.

11. The presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD.

12. ABG: pH<7.3- sign of acute respiratory compromise Type II RF: Chronic Bronchitis Type I RF: Emphysema CBC: Polycythemia Hematocrit>50 Sputum examination: Streptococcus pneumonia Hemophilus influenzae M oraxella catarrhalis Klebsiella pneumonia

13. Chest x-ray-Chronic Bronchitis No apparent abnormality Or thickened and increased lung markings are noted. No apparent abnormality Or thickened and increased lung markings are noted.

14. Chest X-Ray - Emphysema Marked over inflation is noted with flattened and low diaphragm Intercostal space becomes widen A horizontal pattern of ribs A long thin heart shadow Decreased markings of lung peripheral vessels

15. CT(Computed tomography) Greater sensitivity and specificity for emphysema for evaluation of bullous disease

16. © 2020 Global Initiative for Chronic Obstructive Lung Disease

17. General: Exercise and management of Nutritional status Weight loss if obese Reduce exposure to noxious agents: 1.Smoking cessation : aided by Bupropion(Noradrenergic antidepressant), varenicline(Nicotinic receptor agonist antagonist) 2.Reduce Indoor and outdoor air pollution 3.Avoid dusty and smoke laden environment

18. Surgical Intervention Bulla: Bullectomy Lung volume reduction surgery Lung Transplantation

19. Acute exacerbation of COPD Is defined as any event in natural course of COPD characterized by a change in patient’s baseline dyspnoea , cough and/or sputum that is beyond normal day to day variations. Causes: 1.Infection 2.Air pollution 3.Cold

20. Management Initial treatment: 1. Position the patient up in bed 2. O2 therapy 3. If condition is not improving, intubation may be required Bronchodilator: 1. SABA: Nebulized Salbutamol 2.5mg every 20 min for initial 1-2 hr &/or 2. Short anticholinergic: Nebulized Ipratropium bromide 0.5mg &/or 3. IV Aminophylline: Failure of above treatment Loading dose:250mg IV in 20 min Maintenance dose: 0.5-0.7mg/kg/ hr in 1 ltr of saline at 2.4ml/kg/ hr

21. Antibiotics: 1. Outpatient: a. Doxycycline,cotrimoxazole or amoxiclav b. Hospitalized pt >65 yrs : give one of the newer FQs( Levoflox,Gemiflox,Moxiflox ) 2. Hosptalized : IV anibiotics : Azithro or FQs or 3 rd gen Cephalosporins 3. Severe exacerbations: 3 rd gen Cephalosporin + FQs or an aminoglycoside Antibiotics should cover S. pneumoniae, H. influenza, Legionella sp.

22. Steroids: Shortens recovery time, improve Lung function and hypoxia. Hydrocortisone 200mg IV repea 6-8 hrly or Methyl prednisolone1-2mg/kg IV 6hrly not to exceed 125mg : F/U with oral steroid: Presdnisolone 40-60mg/day in tapering dose Monitoring Mgso4 IV single dose : 1.2-2gm infused over 20 min Diuretics: In pts with gross Rt. Ventricular failure

23. NIPPV: 1.CPAP 2.BiPAP MOA: 1. Prevents airways to collapse and air trapping 2. Reduces need for ET intubation