Belgorod National Research University

CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
COPD
part 2

Lecturer:
Head of the Department of Faculty Therapy
 COPD
Medical management
 Give antibiotics to treat infection
 Give bronchodilators to relieve bronchospasm, reduce
airway obstruction, mucosal edema and liquefy
secretions.
 Chest physiotherapy and postural drainage to improve
pulmonary ventilation.
 Proper hydration helps to cough up secretions or
tracheal suctioning when the patient is unable to
cough.
 Steroid therapy if the patient fails to respond to more
conservative treatment.
 COPD
Medical management (cont…)
 Stop smoking
 Oxygenation with low concentration during the acute
episodes
 In asthma adrenaline ( epinephrine) SC if the
bronchospasm not relieved.
 Aminophylins IV if the above treatment does not help.
 IV corticosteroids for patients with chronic asthma or
frequent attack.
 Sedative or tranquilizers to calm the patient.
 Increase fluids intake to correct loss of diaphoresis and
inaccessible loss of hyperventilation.
 Intubations and mechanical ventilation if there is
respiratory failure.
 Objectives of COPD Management

• Prevent disease progression

• Relieve symptoms
• Improve exercise tolerance
• Improve health status
• Prevent and treat exacerbations
• Prevent and treat complications
• Reduce mortality
• Minimize side effects from treatment
 Tactics of treatment of COPD
SMOKING CESSATION,
EXCLUDE OCCUPATIONAL HAZARD

The period The period

of exacerbation of remission

Antibacterial
therapy Prevention
basic therapy
basic therapy
 Etiotropic treatment of chronic
bronchitis in the acute stage

Removal of noxious impurities in the air

breathed
Antibiotic therapy

6
 Pathogenetic treatment of chronic
bronchitis in the acute stage (1)

Effect on bronchial obstruction

Anti-inflammatory therapy
Improvement of pulmonary ventilation
Increased reactivity of the organism
 Pathogenetic treatment of chronic
bronchitis in the acute stage (2)
 Effect on bronchial obstruction:
expectorants: mucolytics, mukoregulyatory
 Bronchodilators
• Inhaled anticholinergics
• Inhaled β2-agonists
• Cholinolytics agonists + β2-inhalation
• Methylxanthines (theophylline and long-acting
derivatives
 Improved sanitation bronchoscopy
8
 Pathogenetic treatment of chronic
bronchitis in the acute stage (2)
 Anti-inflammatory therapy
- Fenspiride (Erespal)
- Corticosteroids?
 Improvement of pulmonary ventilation

- breathing exercises
- massage
- oxygen therapy
 Increased reactivity of the organism

- immunomodulators
- adaptogens
9
FORMS OF DRUG DELIVERY
INTO THE BRONCHI
Management Stage 0: At Risk for COPD

Characteristics Recommended
Treatment

• Chronic Avoidance of risk

symptoms factors:
- cough
- sputum Smoking cessation
• No spirometric Influenza vaccination
abnormalities
 Management Stage I: Mild COPD
Characteristics Recommended
Treatment

• FEV1/FVC < 70 % • Add Short-acting

• FEV1 > 80 % bronchodilator as
predicted needed
• With or without
symptoms
 Management of Stage II:
Moderate COPD
Characteristics Recommended
Treatment

• FEV1/FVC < 70% • Add regular tx with

• 50% < FEV1< 80% long-acting BD
• Pulmonary rehab
predicted
• With or without
symptoms
 Management of Stage III: Severe COPD
Characteristics Recommended
Treatment

• FEV1/FVC < 70% Add ICS if repeated

• 30% < FEV1 < 50% exacerbations
predicted
• With or without symptoms
 Management of Stage IV:
Very Severe COPD
Characteristics Recommended
Treatment

• FEV1/FVC < 70% • Long-term oxygen therapy

• Treatment of complications
• FEV1 < 30% predicted • Consider surgical options
or presence of
respiratory failure or
right heart failure
16
17
 Surgical Treatments
• Bullectomy: In carefully selected patients, this
procedure is effective in reducing dyspnea and
improving lung function (Evidence C)
• Lung Volume Reduction Surgery
• Lung Transplantation: In appropriately selected
patients, improves quality of life and functional
capacity (Evidence C). Criteria for referral:
FEV1<35% predicted PaO2<55-60mm Hg,
PaCO2>50 mm Hg, and secondary pulmonary
hypertension
Manage Stable COPD: Bronchodilators
• Bronchodilator medications are central to the
symptomatic management of COPD. They are given
on an as-needed basis or on a regular basis to prevent
or reduce symptoms.
– Alleviate symptoms
– Improve exercise tolerance
– Improve quality of life
– Decrease the incidence of exacerbations
– Decrease hyperinflation
• Inhaled therapy is preferred
 Manage Stable COPD: Bronchodilators
• Beta2-agonists: increase cyclic adenosine
monophosphate levels and promote airway smooth-
muscle relaxation
– Short acting: Albuterol (Proventil)
– Long acting: Salmeterol (Serevent) and
Formoterol fumarate (Foradil)
• Anticholinergics: block muscarinic receptors
– Short acting: Ipratropium bromide (Atrovent)
– Long acting: Tiotropium bromide (Spiriva)
• Combination: (Combivent, DuoNeb)
 Manage Stable COPD: Bronchodilators
• Phosphodiesterase Inhibitors: increase intracellular cyclic
adenosine monophosphate levels within airway smooth
muscle
– 3rd line agent
– Improves respiratory muscle function, stimulates the
respiratory center, decreases dyspnea, and enhances
activities of daily living
– Toxic side effects: tachyarrhythmias, nausea,
vomiting, seizures
– Monitoring should include intermittent serum level
measurements: target range 8-12mcg/mL
 Inhaled Steroids (ICS) in Stable COPD
• Glucocorticoids act at multiple points within the
inflammatory cascade.
• Regular treatment with ICS does not modify the long-
term decline in FEV1.
• Appropriate for symptomatic COPD patients with an
FEV1 < 50% and repeated exacerbations (Stage III and
IV).
• ICS reduce frequency of exacerbations and improve
health status (Evidence A).
• ICS combined with long-acting b2-agonist more
effective than individual components.
 Steroids in Stable COPD
• GOLD guidelines recommend a trial of 6 weeks to 3
months of ICS to identify subset of patients who may
benefit.
• Short course of oral steroids is a poor predictor of
long-term response to ICS.
• Long-term treatment with oral steroids is NOT
recommended (Evidence A):
– No evidence of long-term benefit
– Major side effects: skin damage, cataracts,
diabetes, osteoporosis, secondary infection,
psychosis, fluid retention
 Other pharmacologic treatments
• Vaccines: Influenza vaccine reduces serious illness
and death in COPD patients by 50%. Pneumococcal
vaccine is recommended every 5 years although data
in COPD patients is lacking.
• Other anti-inflammatory agents: Cromolyn,
nedocromil, and leukotriene inhibitors have not been
adequately tested in patients with COPD
Other pharmacologic treatments
• Alpha-1 Antitrypsin Augmentation Therapy: young
patients with severe deficiency and established
emphysema
• Antibiotics are not recommended other than in
treating infectious exacerbations (Doxycycline,
amoxicillin, macrolide, fluoroquinolones)
• Mucolytic agents: not recommended
• Antioxidants (N-acetylcysteine) may reduce the
frequency of exacerbations
• Antitussives: contraindicated in stable COPD
because cough is protective
• Comprehensive pulmonary rehabilitation
programs have been shown to improve all of
the following EXCEPT:
• A. Measured FEV1
• B. Respiratory symptoms
• C. 6-Minute walk test
• D. Need for outpatient care and inpatient
hospitalizations
• E. Symptoms of anxiety, depression, and lack
of well-being
 Pulmonary Rehabilitation in Stable COPD
• All COPD-patients benefit from exercise
training programs, improving with respect to
both exercise tolerance and symptoms of
dyspnea and fatigue (Evidence A).
• The minimum length of an effective rehab
program is 2 months; the longer the better
(Evidence B).
• Comprehensive pulmonary rehabilitation
program includes exercise training, nutrition
counseling, and education.
 Manage Stable COPD: Oxygen
• The long-term administration of oxygen (> 15 hours
per day) to patients with chronic respiratory failure
(Stage IV) has been shown to increase survival
(Evidence A).
• Oxygen administration reduces hematocrit, pulmonary
artery pressures, dyspnea, and rapid eye movement
related hypoxemia during sleep.
• Tailor prescription to patient: source, method of
delivery, duration of use, flow rate at rest, during
exercise, and sleep
 The indications for oxygen therapy
 PaO 2 <55 mm Hg or SaO2 <88% at rest
 PaO 2 <56-59 mm Hg or SaO2 = 89% in the
presence of CCP and / or erythrocytosis
(hematocrit> 55%)
"Situational" oxygen therapy is indicated for:
 PaO 2 <55 mm Hg or SaO2 <88% during
exercise
 PaO 2 <55 mm Hg or SaO2 <88% during sleep
 Long-term oxygen therapy
is not indicated in patients
with moderate hypoxia
(PaO 2> 60 mmHg)

Oxygen Concentrator (OXYLIFE), for the

production of oxygen from ambient air.
Lancet 2003;362:1053-61
• A 59 year old male presents with worsening
shortness of breath. He was diagnosed with
COPD several years ago and was told to wear
oxygen at home. However, he doesn’t feel
like he needs it. He continues to exercise for
several minutes a day on the treadmill and
does pull-ups. In the office, his O2 sats are
83% on room air so he is admitted to the
hospital. T 98.9 HR 103 R 24 BP 142/82
Sats 91% on 6 L oxymizer. His weight is 144
lbs at 68 inches. He has temporal wasting. He
has supraclavicular fullness, jugular venous
distension to the jaw, a prominent P2 on
cardiac exam. He has poor air movement
• Pulmonary function tests: FEV1/FVC 28.6%
FEV1 0.51 L 18% predicted; FVC 1.8L 52%
predicted. With albuterol, his FVC increases
to 2.07 L, a 14% improvement. His TLC is
151% predicted. His RV is 359% predicted.
• How would you rate his severity of disease?
• How should this patient be treated?
• What (if any) bronchodilators would you use?
• Is there any role for inhaled corticosteroids?
• What about systemic corticosteroids?
• Any other beneficial interventions?
 True or False
• COPD is a disease process limited to the
lungs. _______
• COPD is the only disease in which mortality
rates have been rising over the past several
decades. _________

36
 Symptoms
• Increased breathlessness, wheezing, chest tightness
• Increased cough and sputum
• Change in color and/or tenacity of sputum
– An increase in sputum volume and purulence points to a
bacterial cause
• Nonspecific complaints: fever, malaise, fatigue,
depression, confusion

37
 Assessment of severity of
exacerbation
• Peak flow <100 L/min or FEV1 <1.0 L
indicates severe exacerbation
• ABG
• CXR
• EKG
• D-dimer, spiral CT
• Sputum culture
 Manage Exacerbations: Key Points
• Inhaled bronchodilators
(Beta2-agonists and/or
anticholinergics),
theophylline, and systemic,
preferably oral,
glucocortico-steroids are
effective for the treatment
of COPD exacerbations
(Evidence A).
• 80% of AECB are
infectious. Environmental
factors and medication
nonadherence are 20%.
 Manage Exacerbations: Key Points

• Noninvasive intermittent positive pressure

ventilation (NIPPV) in acute exacerbations
improves blood gases and pH, reduces in-
hospital mortality, decreases the need for
invasive mechanical ventilation and intubation,
and decreases the length of hospital stay
(Evidence A).
 NIPPV
• Selection criteria:
– Moderate to severe dyspnea with use of accessory muscles and
paradoxical abdominal motion
– Moderate to severe acidosis and hypercapnia
– Respiratory frequency >25/min
• Exclusion criteria:
– Respiratory arrest
– Cardiovascular instability
– Somnolence, impaired mental status, uncooperative patient
– High aspiration risk
– Viscous or copious secretions
– Recent facial or gastroesophageal surgery
– Craniofacial trauma
– Extreme obesity
• He is admitted to 5500. How should he be
treated? The nurse calls you because the
patient is poorly responsive. T 98.6 HR 125 R
16 BP 110/65 Sats 92% on 50% face mask.
Patient is barely arousable by sternal rub.
What do you want to do now?
• Which of the following is NOT true about this
patient?
• A. His inpatient mortality rate is 25%.
• B. If he survives this hospitalization, he is
likely to be readmitted within 6 months.
• C. This is the ideal time to discuss code status
with the patient’s family.
• D. The patient’s five year mortality is 70%.
• Retrospective study of 57 patients with COPD
admitted to the ICU with a COPD
exacerbation
• 90% intubated
• In-hospital mortality 24.5%
• Median survival 26 months
• Mortality rate at 5 years 69.6%
• Chest 2005; 128:518-24
 etiology and pathogenesis
【 classification of respiration failure mechanism 】
respiratory failure

ventilatory gas exchange

disorders disorders
restrictive ventilatory

obstructive ventilatory

diffusion disorders

ventilation-perfusion
mismatching
disorders

disorders
46
47
48
49
51
 COPD
Preventive measures
 To prevent irritation and infection of the
airways, instruct the patient to:

 Avoid exposure to cigarette, pipe, and cigar

smoke as well as to dusts and powders.

 Avoid use of aerosol sprays.

 Stay indoors when the pollen count is high.

 Stay indoors when temperature and humidity

are both high
 COPD
Preventive measures (cont…)
 Use air conditioning to help decrease
pollutants and control temperature

 Avoid exposure to persons known to have

colds or other respiratory tract infection

 Avoid enclosed, crowded areas during cold and

flu season.

 Obtain immunization against influenza and

streptococcal pneumonia.
 COPD
Preventive measures (cont…)
 To ensure prompt, effective treatment
of a developing respiratory infection,
instruct the patient to do the following:-

 Report any change in sputum color

character, increased tightness of the
chest, increased dyspnea, or fatigue.

 Call the physician if ordered antibiotics

do not relieve symptoms within 24
hours.
THANK YOU FOR YOUR
ATTENTION