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Lecture on treatment of chronic obstructive pulmonary disease (COPD)
Treatment of chronic obstructive pulmonary disease (COPD) includes management of stable-COPD patients and treatment of the COPD exacerbations.
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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
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I: Minor Illness |
II: Average |
III: Severe illness |
IV: Severely |
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FEV1/FVC < 0.7 FEV1 > 80% |
FEV1/FVC < 0.7 50% £ FEV1 < 80% |
FEV1/FVC < 0.7 30% £ FEV1 < 50% |
FEV1/FVC < 0.7
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Avoid risk factors, get flu shot Add a short-acting bronchodilator (as needed) |
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Add one or more long-acting bronchodilators Rehabilitation of respiratory function |
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Add inhaled corticosteroids if exacerbations repeat (every year) |
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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.
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Signs |
Mild |
medium |
Heavy |
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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 |
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Physical signs: Sense
Contraction of accessory respiratory muscles Maximum blood pressure
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Normal
Mild Normal
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Normal 30 - 35 medium Normal Few left |
Consciousness disorder
Heavy < 90mmHg
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(*): 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
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Treatment |
Mild COPD exacerbations (1) |
Moderate COPD exacerbation (2) |
Severe COPD exacerbations (3) |
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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 |
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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 |
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Antibiotic
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See antibiotic section |
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Oxy |
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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:
Chronic obstructive pulmonary disease (COPD): Severe respiratory