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COPD

COPD. Tintinalli Chapter 73. COPD definition. Airflow limitation that is progressive and not fully reversible Abnormal inflammatory response to noxious particles or gases. Only major cause of death that is ↑ 85% chronic bronchitis Productive cough for >3 months x 2 yrs 15% emphysema

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COPD

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  1. COPD Tintinalli Chapter 73

  2. COPD definition • Airflow limitation that is progressive and not fully reversible • Abnormal inflammatory response to noxious particles or gases. • Only major cause of death that is ↑ • 85% chronic bronchitis • Productive cough for >3 months x 2 yrs • 15% emphysema • Destruction of bronchioles and alveoli

  3. Pathophysiology • Airway changes 2˚ to noxious stimuli • Increase in number and size of bronchial mucous glands • ↑ secretions • Acute and chronic airway inflammation • ↑ airway resistance • Breakdown in alveolar architecture • Hypoxemia 2˚ to V/Q mismatch

  4. Chronic Signs/Symptoms • Classic signs • Exertional dyspnea • Cough • Symptoms • Tachypnea • Accessory muscle use • Pursed lip exhaling • Decreased breath sounds • Wheezing upon exhalation • Prolonged exhalation • Barrel chest • Findings of right ventricular strain on EKG

  5. Acute Signs/Symptoms • Acute decompensation characterized by • Progressive hypoxemia • Tachypnea • Cyanosis • AMS • Increased work of breathing

  6. Diagnosis of chronic, compensated COPD • PFTs • Ratio FEV1:FVC < 70% • Indicates obstructive disease • Value of FEV1 • Indicates severity of disease • DLCO < 80% • Differentiates between chronic bronchitis and emphysema

  7. Diagnosis of acute exacerbations • Assess hypoxemia • Pulse ox • Assess hypercapnea/ acid-base disturbances • ABGs • Bedside PFTS if available • Often unreliable 2˚ to poor pt cooperation • Assess sputum • Look for changes in color, volume, and consistency • Culture • CXR • Look for underlying etiology

  8. Treatment • Chronic treatment • Lifestyle changes • #1 smoking cessation • Pulmonary rehab • Oxygen • Home O2 indicated for PaO2 < 55% or SaO2 < 88% • Meds • Do not reduce mortality, but provide symptomatic relief • Β2agonist, anticholinergics, +/- steroids

  9. Treatment • Acute treatment • Oxygen • Maintain SaO2 > 90% • Bronchodilator therapy • Β2agonist, anticholinergics, or combination therapy • Aerosolized tx preferred • When using Β2agonist in pt with known heart disease, consider placing on cardiac monitor

  10. Treatment (cont) • Corticosteroids • IV solumedrol 125mg • PO prednisone 60mg • Consider abx therapy if suspect infection • Appropriate tx based on whether pt is from nursing home/community • Consider NIPPV • BiPAP/CPAP • Indications for mechanical ventilation • Resp muscle fatigue • ABG signs of worsening resp acidosis • Declining mental status 2˚ to hypercapnea • Significant hypoxemia

  11. Exacerbation/Mortality • With each exacerbation pts never return to their baseline pulmonary ftn. • As a consequence pt mortality rises with each exacerbation regardless of therapeutic intervention.

  12. Disposition • Pt who fail to improve adequately or continue to deteriorate require hospitalization. • Pt stable for d/c to home should have the following • Adequate home O2 if needed • Bronchodilator txs • Short course of PO steroids • Abx if indicated • Secure follow up with PCP

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