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COPD- Burden of Disease

COPD- Burden of Disease . Initial management of an acute exacerbation. Definition.

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COPD- Burden of Disease

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  1. COPD- Burden of Disease Initial management of an acute exacerbation Dr. David P. Breen

  2. Definition COPD is 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. Symptoms, functional abnormalities, and complications of COPD can all be explained on the basis on this underlying inflammation and the resulting pathology www.goldcopd.com Dr. David P. Breen

  3. Dr. David P. Breen

  4. Lung Function decline Dr. David P. Breen

  5. Spirometry is the GOLD Standard for the diagnosis of COPD Dr. David P. Breen

  6. Exacerbations of COPD • Acute exacerbations of COPD present as a worsening of a previously stable condition • Important symptoms include • Increased sputum purulence • Increased sputum volume • Increased dyspnoea • Increased wheeze • Chest tightness • Fluid retention Dr. David P. Breen

  7. Exacerbation • A new respiratory event or complication superimposed upon established disease • New events • Pneumonia • Pneumothorax • LVF/ Pulmonary Oedema • Lung Cancer • Upper airway Obstruction Dr. David P. Breen

  8. Acute exacerbation of COPD • Airflow Obstruction • Dyspnoea • Wheeze • Chest tightness • Respiratory Failure • Hypoxia • Dyspnoea, tachypnoea, cyanosis, confusion • Hypercapnia • Warm hands, dilated veins, tachycardia, bounding pulse, flapping tremor, chemosis, papilloedema, confusion, agitation • Cor pulmonale • Loud P2, RV (L Parasternal Heave), raised JVP, peripheral oedema • Infection • Increased sputum volume/purulence, fever, raised WCC Dr. David P. Breen

  9. Investigations • Full Blood Count • Renal Profile • Arterial Blood Gas • Chest X-Ray • Pneumonia • Bronchiectasis • Pneumothorax • LVF • Spirometry prior to discharge Dr. David P. Breen

  10. TREATMENT • Airflow Obstruction • Bronchodilators- Salbutamol, ipratropium • Corticosteroids • Respiratory Failure • See later • Cor Pulmonale • Daily weight, accurate input/output chart • Diuretics • Monitor renal function carefully • Infection • Antibiotics • physiotherapy Dr. David P. Breen

  11. Acute Respiratory Failure ABG Normal PO2 10.5-12.5 KPa Normal PCO2 4.5- 6.0 KPa Type 1 Failure PO2 PCO2 N or Type 2 Failure PO2 PCO2 Dr. David P. Breen

  12. Normally we breath mainly in response to raised PCO2 In Type 1 failure, this response is maintained High O2 is safe • In COPD, there is usually chronic CO2 retention The brain gets tired of responding to the raised PCO2 The main stimulus to breathe is then a decreased PO2 Dr. David P. Breen

  13. So, How much O2 should we give? Dr. David P. Breen

  14. In Type 2 Respiratory Failure PO2Hypoxic DriveSaO2O2 Delivery 7.5 maintained 90% adequate/good <7 maintained <90% poor 5.0 maintained <70% dangerously low 7.5 maintained 90% adequate/good >8 decreasing >90% good 10 very poor 95% good Dr. David P. Breen

  15. Therefore Look first at PO2 Maintain PO2 around 7.5-8.0 (SaO2 90-92%) Do not be afraid to give enough O2 to achieve this Do not push PO2 above this – very little extra delivery of O2 to all tissues and loss of hypoxic drive now becomes a problem Monitor PCO2 and clinical condition If PCO2 elevated or clinical condition poor Consider N.I.V Start with 24-28% and titrate upwards Monitor Sats and ABG Dr. David P. Breen

  16. But remember : Cigarettes are the main culprit!! Dr. David P. Breen

  17. Dr. David P. Breen

  18. Non-Invasive Ventilation: Dr. David P. Breen

  19. Selection Criteria • Respiratory distress • Moderate to severe dyspnoea • Accessory muscle use • Paradoxical movement of abdominal muscles • pH<7.35 with PaCO2>6kPa • Respiratory rate >25breaths/min • At least two criteria should be present Dr. David P. Breen

  20. Exclusion Criteria (Absolute) • Respiratory Arrest situation • Cardiorespiratory instability • Hypotension • Arrhythmia • Myocardial infarction • Uncooperative patient • Recent facial, oesophageal or gastric surgery Dr. David P. Breen

  21. Exclusion Criteria (Absolute) • Craniofacial trauma or burns • High aspiration risk • Absent gag reflex • Inability to manage secretions • Fixed anatomical abnormalities of the nasopharynx Dr. David P. Breen

  22. Relative Contraindications • Extreme anxiety • Massive obesity • Copious secretions • Adult Respiratory distress syndrome-ARDS • American Respiratory Care Foundation. Dr. David P. Breen

  23. Complications • Local damage related to mask/strap pressure • Gastric distension • Eye irritation • Sinus pain • Nasal congestion • Barotrauma • Air leaks • Adverse Haemodynamic effects rare • Nosocomial pneumonia rare Dr. David P. Breen

  24. Predicting Poor Outcome • Higher APACHE II score (15 Vs 20) • Acute physiological and chronic health evaluation • Lower pH in those who failed • 7.22 Vs 7.28 Ambrosino et al • Lower FVC • Presence of pneumonia • Soo Hoo et al Crit Care Med 1994 Dr. David P. Breen

  25. Suggested settings • NIPPY • Aim for IPAP of 20 • Normal breathing= 1sec insp, 2sec exp,will probably need to be shortened • Set trigger low eg. 0.5 = less effort required by patient • BIPAP • Suggest starting with IPAP 10 or 12 • May increase to 20 or higher • Suggest starting with EPAP of 4 • Never use less than EPAP of 4 = CO2 rebreathing • May increase EPAP to 6, seldom require higher Dr. David P. Breen

  26. Effectiveness • Significant decrease in mortality (9% Vs 29%) Brochard et al NEJM 1995 Dr. David P. Breen

  27. Effectiveness • Significant decrease in ICU length of stay (13 Vs 32 days) Wysocki et al Chest 1995 • Significant decrease in hospital length of stay (23 Vs 35 days) Brochard et al NEJM 1995 Dr. David P. Breen

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