Lecture on treatment of chronic obstructive pulmonary disease (COPD)

2021-08-10 11:57 PM

Treatment of chronic obstructive pulmonary disease (COPD) includes management of stable-COPD patients and treatment of the COPD exacerbations.

Treatment of chronic obstructive pulmonary disease (COPD)

Treatment of chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD) is a restrictive disease of lungs (obstructive lung disease).

Treatment of chronic obstructive pulmonary disease (COPD) includes management of stable-COPD patients and treatment of the COPD exacerbations.

Management of patients with stable-COPD

Purpose

Improve the quality of life (relieve symptoms, improve lung function).

Reduce frequency and severity of exacerbations.

Slows disease progression and prolongs life.

Patient education

Sign of commitment to quitting smoking.

Background information on chronic obstructive pulmonary disease.

Drugs and their use.

How to handle exacerbations at home, recognize severe signs to go to medical facilities.

Treatment according to the stage of disease

I: Minor Illness

II: Average

III: Severe illness

IV: Severely

FEV1/FVC < 0.7

FEV1 > 80%

FEV1/FVC < 0.7

50% £ FEV1 < 80%

FEV1/FVC < 0.7

30% £ FEV1 < 50%

FEV1/FVC < 0.7


FEV1 < 30% or FEV1 < 50% with chronic respiratory failure

Avoid risk factors, get flu shot

Add a short-acting bronchodilator (as needed)

 

Add one or more long-acting bronchodilators

Rehabilitation of respiratory function

 

 

Add inhaled corticosteroids if exacerbations repeat (every year)

 

 

 

Add prolonged oxygen if there is chronic respiratory failure

Consider surgery

SABAs (short-acting b2-agonists) have a duration of 4-6 hours, LABAs (long-acting b2-agonists) has a duration of 8-12 hours, and long-acting anticholinergics can last for more than 24 hours.

Other drugs (not yet widely used due to low effectiveness, being studied, or only used in some cases).

Vaccines: Influenza vaccines, pneumococcal polysaccharide vaccine… can reduce the incidence of community-acquired pneumonia in COPD patients over 65 years old with FEV1 < 40%.

Alpha-1 antitrypsin.

Antibiotics: often used in acute exacerbations.

Long sputum: effective only in a small number of patients with thick mucus.

Antioxidant agents: N-acetylcysteine.

Immunomodulators: reduce the frequency and severity of exacerbations.

Anti-cough.

Vasodilators: to improve pulmonary arterial hypertension, thereby reducing right ventricular afterload, increasing cardiac output, and increasing peripheral perfusion.

Sedative.

Non-drug treatment

Rehabilitation:

Motor.

Nutrition.

Extended oxygen at home:

Indications: patients with stage IV COPD presenting with:

Pa02 < 55 mmHg or Sa02 < 88% with or without hypercapnia.

Pa02 from 55-60 mmHg or Sa02 <88%, with evidence of pulmonary hypertension, peripheral edema, congestive heart failure, polycythemia vera.

The oxygen supply device should be a mask (facemask) or a nasal cannulae, Fi02 from 24-35%, at least 15 hours/day.

Assisted ventilation.

Surgical treatment:

Bullectomy.

Lung volume reduction surgery.

Lung transplantation.

Treatment of COPD exacerbations

Define

A COPD exacerbation is a sudden worsening of a stable condition: increased dyspnea; increased cough; and/or increased sputum production, causing the patient to change his or her usual treatment regimen.

Diagnostic criteria for exacerbations

When there are 2 out of 3 following criteria: increased dyspnea, increased sputum volume, purulent sputum.

Or have 1 of the 3 criteria above and at least one of the following signs: upper respiratory tract infection in the past 5 days, fever without other causes, increased wheezing, increased cough, pulse, increased respiratory rate 20 % from the base value.

Differential diagnosis

The differential diagnosis of COPD exacerbations should include pneumonia, pulmonary embolism, pneumothorax or pleural effusion, heart failure, arrhythmias, chest trauma, side effects of sedatives or beta-blockers.

Assess the severity of the exacerbation

If at least 2 criteria are present in the history or 1 criterion on physical examination, which is the most severe, then classify it as that level.

Signs

Mild

medium

Heavy

Anamnesis:

Comorbid diseases(*)

Levels in the last 3 years

COPD severity

 

are not

< 1 time/year

Phase I

 

There may be

1 time/year

Phase II

 

Yes

> 1 time/year

Stage III-IV

Physical signs:

Sense


Breathing rate (times/minute)

Contraction of accessory respiratory muscles

Maximum blood pressure


Remaining symptoms after initial treatment

 

Normal


< 30

Mild

Normal


Over

 

Normal

30 - 35

medium

Normal

Few left

 

Consciousness disorder


> 35 or < 18

Heavy

< 90mmHg


Not responding or increasing

(*): Comorbidities are often associated with poor prognosis in acute exacerbations, including congestive heart failure, coronary artery disease, diabetes, liver failure, and renal failure.

Indications for hospitalization

Indications for admission:

Significant increase in symptoms, especially dyspnea even at rest.

Severe stage COPD.

New symptoms appear cyanosis, peripheral edema, arrhythmia.

Symptoms do not respond completely to outpatient treatment.

Presence of high-risk comorbidities including pneumonia, heart failure, arrhythmia, diabetes, liver failure, kidney failure.

Diagnosis uncertain.

Inability to care for themselves or lack of family support.

Indications for ICU admission:

Severe respiratory failure is unresponsive to initial treatment.

Confusion (confusion, coma).

Severe hypoxemia (Pa02 < 40 mmHg) and/or severe C02 elevation (PaC02 > 60 mmHg) and/or severe respiratory acidosis (pH < 7.25) despite oxygen delivery and noninvasive ventilation.

Hemodynamically unstable.

Treatment

Oxygen therapy:

It is recommended to start with a low dose of 1-2 liters/minute.

Arterial blood gases should be checked after 30-60 minutes, ensuring PaO2 >60 mmHg or SaO2 >90% without hypercapnia or acidosis. The Venturi mask is a more accurate oxygen delivery device than a nasal cannula but is difficult for patients to tolerate.                                                                        

Treatment with bronchodilators:

Start with stimulant medications b2 agonists inhaled, if the delayed response can incorporate anticholinergic group.

In severe exacerbations, oral or intravenous administration of methylxanthine should be considered, with close monitoring of serum theophylline concentrations to avoid adverse drug effects.

Glucocorticosteroids:

Oral or intravenous glucocorticosteroids are recommended for the treatment of COPD exacerbations in the hospital. Dosage: 30-40 mg of prednisolone/day for 10-14 days, long-term treatment is not recommended because of low efficacy but increased risk of side effects.

Indications for antibiotics:

Acute exacerbations have all 3 symptoms: increased dyspnea, increased sputum volume, and purulent sputum.

An exacerbation has 2 out of 3 symptoms above if purulent sputum is one of the two symptoms.

Severe COPD exacerbations requiring mechanical ventilation.

Guidelines for antibiotic treatment:

Group A: mild exacerbation.

Bacteria: H.influenzae, S.pneumonia, M.catarrhalis, Chlamydia pneumonia, Viruses.

Oral: b-lactam (penicillin, ampicillin/amoxicillin), Tetracycline, Trimethoprim/Sulfamethoxazole.

Alternative antibiotics: b-lactam/anti- b-lactamase, Macrolides, 2nd and 3rd generation Cephalosporins, Ketolides (Telithromycin).

Group B: moderate exacerbation.

Group A and: Group resistant to b-lactamase, penicillin-resistant S.pneumoniae.

Viking: Enterobacteriaceae K.pneumonia, E.coli, Proteus.

Oral: b-lactam/anti- b-lactamase (Co-amoxiclav).

Alternative antibiotics: Fluoroquinolones (Gemifloxacin, Levofloxacin, Moxifloxacin).

Parenteral route: b-lactam/anti- b-lactamase (Co-amoxiclav, ampicillin/sulbactam). 2nd and 3rd generation cephalosporins. Fluoroquinolones.

Group C: severe exacerbation.

Bacteria: there are risk factors for P.aeruginosa infection.

Oral: High-dose fluoroquinolones.

Parenteral route: High-dose, b-lactam fluoroquinolones are effective against P.aeruginosa.

Mechanical ventilation:

Noninvasive Intermittent Positive Pressure Ventilation (NIPPV):

Specified:

The patient has at least 2 of the following symptoms.

Moderate-severe dyspnea with use with accessory respiration and paradoxical abdominal movement.

Breathing rate > 25 breaths/min.

pH £7.35 and/or PaCO2 > 45 mmHg.

Contraindications:

Have any of the following symptoms.

Stop breathing.

Cardiovascular instability (hypotension, arrhythmia, myocardial infarction).

Uncooperative patient, psychotic.

High risk of inhalation, excessive mucus secretion.

Recent facial or gastrointestinal surgery.

Nasopharyngeal abnormalities.

Traumatic brain injury.

Burn.

Too obese.                                                                         

Invasive Mechanical Ventilation (IMV: Invasive Mechanical Ventilation):

Specified:

When one of the following signs is present:

Severe hypoxemia PaO2 < 40 mmHg or pH < 7.25 and/or PaCO2 > 60 mmHg.

Breathing rate > 35 breaths/min.

Stop breathing.

Comatose.

Cardiovascular complications: hypotension, shock, heart failure

Other complications: metabolic disorders, sepsis, pneumonia, pulmonary embolism, barotrauma, large pleural effusion.

NIPPV failure or contraindication to NIPPV.

Specific treatment of COPD exacerbations

Treatment

Mild COPD exacerbations (1)

Moderate COPD exacerbation (2)

Severe COPD exacerbations (3)

Bronchiectasis

Ipratropium and/or SABA as MDI/NEB as needed

Consider taking a LABA in combination

Ipratropium and/or SABA as MDI/NEB/ every 4-6 hours 

Consider taking a LABA in combination

Ipratropium and/or SABA as MDI/NEB/ every 2-4 hours

Consider taking a LABA in combination

Corticosteroid

Oral Prednisolone 30-40 mg /dayx10-14 days

Consider using ICS

Take 30-40 mg of Prednisolone/day x 7-10 days. If no response, Methylprednisolone 40mg IV every 8 hours for 3 days, then switch to oral medication for 7-10 days

Consider ICS or NEB

Methylprednisolone 40mg IV/every 8 hours x N1 ®N3; then switch to oral medication for 7-10 days

Consider ICS or NEB

Antibiotic

 

See antibiotic section

Oxy

 

Give oxygen if SaO2 <90%

Breathe oxygen by blood gas

Ventilator if indicated

Discharge criteria

The need for short-acting bronchodilators by inhalation should not exceed 6 times/day.

The patient can walk around the room.

Do not wake up with difficulty breathing.

Clinically stable for 24 hours.

Arterial blood gases are stable for 24 hours.

Patients and family members know how to take the medicine correctly.

Completed home care and monitoring plan (nursing, oxygen concentrator, dietitian).

Related articles:

Obstructive lung disease

Restrictive disease of lungs

Chronic obstructive pulmonary disease (COPD): Severe respiratory